Costochondritis

What you get told is that costo or Tietze’s is a "mysterious inflammation" of the joints where your ribs hinge onto your breastbone - it has no known cause, it’ll settle down in a few weeks, and take these anti-inflammatory medications.

There is no medical research evidence supporting any of those statements.  The existing published medical research actually shows that most costochondritis will last at least a year - or more.  No-one has ever (by 2022) done a clinical trial to see if anti-inflammatories or steroid shots into the rib joints actually help costo.  If you’re reading this, it’s probably because the standard medical approaches haven’t fixed you.

Neither have the vast array of non-medical suggestions - turmeric, Vitamin D, CBD oil, omega-3, etc.  Certainly, if you take or inject enough medications they’ll dampen some pain, and if your body is healthier because of the non-medical supplements, then it’ll handle inflammation and pain better.

But all these treatments don’t help much, or don’t work at all; and anyway don’t last. There’s a very clear reason why.  None of them, medical and non-medical, actually treat the CAUSE of the costo pain, so they all miss the point.

This is easy to follow.  Think of your ribs like bucket handles, hinged at the front onto your breastbone and at the back onto your spine.  The ribs lift up and down with every breath you take, and also move as you twist and move around. 

Now, if the posterior rib joints (where the ribs hinge onto your spine) are frozen solid and not moving, then the more delicate joints where the ribs hinge onto your breastbone HAVE to work excessively, just to let you breathe.  This is unequivocal.

So they 'give', strain, get irritated, then get locally inflamed - and there’s your costochondritis.  It is NOT a "mysterious inflammation" arriving out of a clear blue sky only at a few specific rib joints for no reason - of course it isn't. 

If the joints where the ribs join onto your breastbone are strained and inflamed enough to produce obvious swelling (just like a swollen sprained ankle) then it gets called Tietze’s Syndrome.  And they never get a rest, as long as you keep breathing.

That's why you get the sharp stabbing pains and clicking and popping with costo - as the rib joints on your breastbone 'give' with movement.  These are NOT symptoms you get from inflammation, which is silent and constant.  They indicate a mechanical strain problem, not an inflammatory one.  It's a lot like spraining your ankle, only at the little rib joints on your breastbone.  It hurts!

This explanation is the only, repeat only, one which makes sense of why you get such specific pain just at the rib joints on the breastbone and nowhere else in the body. It’s supported by the best published medical research on treating costo - a recent (2017) US paper by Zaruba and Wilson. 

It explains why you often get breathless with costo - you can't inhale fully if your rib joints can't move.  It explains why you get sore lying down - the pressure of your mattress or floor on your rib cage means the front rib joints strain further.  It fits with the known anatomy and physiology.  It's sensible - and it makes treatment logical, effective and quick.  It is NOT a mystery.

Just to be clear, a 1994 American Medical Association paper by Disla et al showed there was no significant difference in inflammation levels in the blood (ESR test) between a group of costo patients and a group without costo.  That's conclusive - costo is NOT an auto-immune systemic inflammation, no matter what you've been told.  That's why treating it like one doesn't work.

So there's no point in going on a mystical quest for the magic medication which will somehow disappear this "mysterious inflammation" that nobody understands - it doesn't exist.   What you have to do is free up the frozen rib machinery around the back, and the straining rib joints on the breastbone can settle down.  Cheeringly, this is a straightforward physiotherapy-type problem - it's not difficult.

We were staggered to discover that most of the rest of the world doesn't understand this, and doesn't fix costochondritis.

This is pretty common, and there are various reasons: impact on the rib cage (including car crashes), much coughing (which is a surprisingly strong percussive impact on the rib joints), straining (especially from dips in the gym), and twisting (especially golf). 

Coughing and rib cage muscle spasm during COVID-19 is a major recent (2020) cause. The rib joints also commonly get quietly tight with asthma, ankylosing spondylitis and scoliosis.  

Chest surgery like a thoracotomy (especially a sternal split) puts a MASSIVE strain on the rib joints as the ribs are cranked apart to allow the surgery, and they will commonly scar and freeze afterwards. 

Scoliosis surgery straightens and fuses the spine, and can leave immobile rib joints in its wake.  (These are not fused, and can be freed up). 

Costo is also a commonly a problem from chest binding.  The constriction freezes up the rib cage joints round the back, which sets off the strain and pain at the rib joints on the breastbone.   We think anyone doing this should also be using a Backpod to keep the rib joints round the back free.

The big increase in costocondritis in recent years is caused by the iHunch.  This is the huge surge in upper back pain, neck pain and headache driven by people hunching over laptops, tablets and smartphones.  As the hunching spinal joints tighten and freeze, so too do the rib joints - setting off the costo pain around the front when they get tight enough. 

See our iHUNCH page for a good explanation and how we sort it out.  We developed the Backpod and its simple home programme primarily to combat this huge problem.

Rib pain in pregnancy is common.  In a tight rib cage where the back rib joints can't move, as the baby bulge increases the strain will come more and more onto the rib joints on the breastbone.  It can stay like that even after the baby is born - until those tight joints are freed up again.

Almost everyone with costo has some pain around the middle back and/or side as well, most commonly between the spine and the shoulder blade(s).  This is why - it’s from the tight or immobile rib joints round the back.  It's not an unusual extra - it's the basis of most costo.  It's just that everyone focuses on the worse, scarier pain round the front.

This isn't conclusive (no single test for costo is) but is a good indicator that you have this locking rib problem at the back driving your costo pain on your chest.  It works best if your chest pain is mostly one-sided.

Sit squarely back on a desk, table or bench; knees apart and locked onto the edge, so you're upright and stable.  Get someone to take hold of your shoulders and rotate your torso to each side.  Normal range would be about 90˚, with your shoulders coming to roughly a right angle with the front edge of the desk. 

Your torso rotating easily round to 90˚ would usually mean that all your thoracic spine and rib joints are gliding fully (although if you're naturally really flexible or hypermobile (e.g. with Ehlers-Danlos syndrome) you could still have some joints not moving).

If you can't rotate as far towards the side you get your costo pain on, then that will be because some of your rib and spinal joints round your back can't move at all.  This makes the rib joints on your breastbone move much more to compensate.  So they strain, usually click and pop, 'give', get locally inflamed and painful.

So what you’ve got is NOT a "mysterious inflammation" which nobody understands.  It's a straightforward musculoskeletal frozen joint problem which is usually not difficult to sort out.  It's the direct cause of most costo. 

If you don't fix it, then NO treatment for general inflammation or just for the specific pain on your breastbone is going to fix your costo - because the tight joints round your back will just keep driving the strain and pain at your front.  

This lack of joint movement will not show on X-ray, CAT or MRI scans, because these are essentially still photos, and cannot show whether the joints can move or are frozen solid.

You can be tight in both directions, as is often the case with costochondritis on top of asthma, ankylosing spondylitis, chest surgery or the iHunch, where the rib cage is generally tight and restricted.

This is perfectly logical - you free up the tight rib machinery around your back and sides which is causing the overuse strain and pain of the rib joints on your breastbone.  This is quite quick and not difficult - it's basic New Zealand manual physiotherapy.  It's MUCH easier than trying to heal a "mysterious inflammation" that nobody understands.

How to do it is explained in detail in our YouTube video ‘How to fix (most) costochondritis and Tietze’s Syndrome chest pain; Part (2)’. 

As well as freeing up the posterior rib hinges, you may need some massage and stretches for the tight muscles - and a Backpod.

The essential core of fixing most costo and Tietze’s is freeing up the tight and frozen posterior rib hinges.  As far as we can tell, there isn’t anything other than the Backpod that will do this effectively - for clear technical reasons. 

Foam rollers are the next best thing, but their long cylindrical shape spreads the load so you can’t get much stretch pressure onto the rib joints.  Swiss balls are too wide and rolled towels are too squashy.  All balls and rollers are unstable, so your muscles can’t relax when you’re on them - this limits the stretch.

The Backpod's stable peaked form, shape, size and construction are exactly designed from 30 years of New Zealand physiotherapy expertise to give the best possible stretch for tight rib and thoracic spine joints.  You can bang stuck joints temporarily free with manipulation, but they don’t stay free unless you also stretch the tough, tight collagen material around them - hence the Backpod.

For one young woman’s report on using the Backpod, see Samantha Wayne’s YouTube video (2018) ‘Costochondritis / The Backpod’.  After a year of debilitating costochondritis, she was pain-free in three weeks on the Backpod, and back in the gym after that.

This is the usual response with costo and Tietze’s - feeling obviously better in the first week, and 90% better in three weeks.  That’s the timing you’d expect with freeing up a frozen joint problem - it’s in the real world.  It isn't instant - it takes time to stretch the tight stuff, just like it would to stretch a tight hamstring muscle, say.

Of course it can vary, but freeing up tight joints essentially isn’t difficult - MUCH easier than searching for a non-existent magic potion to somehow disappear a "mysterious inflammation" of no known cause.  Regardless of what you've been told, the "mysterious inflammation" idea is not evidence based - we've gone back over the published medical research and looked.

For an overview of what the research actually says, see our YouTube video: 'Costochondritis and Tietze's Syndrome: the published medical research.'  

Lying back on the Backpod uses your own upper body weight to quietly stretch tight and frozen rib joints and tight and hunched middle back joints.  DO please follow the instructions in the detailed user guide - this comes as a 31-page booklet with the Backpod, or download or view it here.   Some Backpods sold in the EU and UK do not include this full user guide in the box.  These are the best detailed instructions on how to use the Backpod.

With costochondritis, make sure you also use the Backpod positioned slightly to the side of the spine over the curve of the ribs, to quietly stretch free the tightened rib joints. 

Using it positioned under the midline of the spine will stretch a tightened upper back hunch, and you’ll probably need to do this too.  Usually 10 minutes once a day, changing position every minute or so, is all that’s needed for an effective stretch.  For a video on how to use the Backpod, click here.

If this sounds simple - essentially it is.  All you're doing is using your upper body weight focused over the Backpod to effectively stretch tight rib and spinal joints.  It's like stretching tight hamstrings - if you do that for 10 minutes daily for a few weeks, sure they'll get freer.

The published medical research conclusively shows that costochondritis is NOT a general systemic or auto-immune inflammation - no matter what you’ve been told by your doctors, specialists or the popular medical sites. 

A 1994 research paper in the American Medical Association Archives of Internal Medicine by Disla et al found no higher inflammation levels in the blood samples of a group of costochondritis patients compared to a group without costochondritis.  This is conclusive.  That’s why just treating it like an inflammation does not work and does not fix it.

Yes, this is nuts.  The ‘-itis’ ending of the word ‘costochondritis’ means 'inflammation’.  That term started to be used for the problem back in the 1960s, for no justified reason - it used to just be called ‘chest wall pain’.  To busy doctors, it seemed like the word 'costochondritis' explained what the problem actually is, so they treated it like that.  And most still do.

The research confirms this is the wrong approach.  Of course it is - why should a general systemic inflammation (like rheumatoid arthritis or ankylosing spondylitis) cause such specific pain just at some rib joints on your breastbone and nowhere else in your body?  That just doesn’t make sense.

There IS some localised inflammatory response where your rib joints are straining onto your breastbone.  This is just like spraining your ankle and it then swelling up, or like getting a blister on your heel because of tight footware - it’s a normal body response to strain and injury. 

But it’s not a “mysterious inflammation” arriving for no apparent reason from a clear blue sky.  The rib joints round your front are moving excessively and straining simply because the rib joints round your back can’t move.

Anti-inflammatory diets, medications, and even steroid shots can help things a bit.  If you get your body's inflammation levels down generally, then that takes some of the heat out of the specific straining rib joints on your breastbone.  Also, if you have coeliac disease then a gluten-free diet will help, and if you're low in Vitamin D then correcting that with supplements will help that. 

But none of these things on their own will fix the ongoing straining at the specific rib joints on your breastbone - you do that by freeing up the tight rib joints around the back which are causing it. 

Cheeringly, this isn't usually difficult to do - it's a bog standard normal New Zealand manual physiotherapy problem with a clear treatment approach.  It's clearly supported by the existing, already published medical research on costo.  And it's MUCH easier than trying to find the magic pill or potion that will somehow miraculously disappear this "mysterious inflammation" that nobody understands.

I’ve been asked by the British Medical Journal (Australian office) to submit a paper reassessing costochondritis.  Lord knows it’s needed.  I've also been lecturing on costochondritis to the doctors at various medical conferences and hospital Accident & Emergency departments (EDs) in New Zealand.  I'm part of a multi-disciplinary group of doctors, cardiologists and physiotherapists in New Zealand running a  randomised controlled trial comparing the usual medical anti-inflammatory approach with our New Zealand manual physiotherapy approach. 

We’ve now surveyed the published medical literature on costochondritis, and two things stand out:

(1) The published medical research conclusively shows that costochondritis is NOT a systemic or auto-immune inflammation - no matter what you’ve been told by your doctors, specialists, the popular medical sites or popular patient sites and groups.  A research paper on costo in an ED published in 1994 in the American Medical Association Archives of Internal Medicine by Disla et al found no higher inflammation levels in the bloods of a group of costochondritis patients compared to a group without costochondritis.  That’s why just treating it like an inflammation does not work and does not fix it. 

The only reason it's called an inflammation at all is because of the adoption of the term 'costochondritis' for it back in the 1960s: the '-itis' ending means 'inflammation'.  There is no medical research basis for the term whatsoever - the problem was also called various other things including simply 'chest wall pain.'  Calling the actual problem by a name which implies it's an inflammation sends doctors and patients alike off down the wrong road for treating it - it is simply incorrect.

(2) The single best published piece of research evidence on how to fix costochondritis is from Zaruba and Wilson (2017) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5455195/ ), who fixed eight chronic costochondritis patients by freeing up their tight thoracic spine and rib joints.  This is only a case series of eight patients, but it is better than anything else so far published in English (as at August, 2019).  It is further supported by several individual case studies which essentially demonstrated exactly the same thing. 

All of these entirely conform with and support our New Zealand manual physiotherapy understanding of costochondritis - that it is essentially strain at the rib joints on the sternum, because the rib joints round the back can’t move, and that you fix it by freeing these up again.

We’ve put up an easy-to-follow YouTube video explaining what we found in the research, called ‘Costochondritis and Tietze’s Syndrome: The published medical research on how to fix them.’  The link is https://youtu.be/t8k2LCLeR24  There is also a pdf of the detailed text to go with the video near the bottom of this page.

Doctors (and physiotherapists) are supposed to practice 'evidence-based medicine', where what you tell the patient is supported by actual published medical research.   Telling the costochondritis patient that what they have is a mysterious inflammation that will respond to anti-inflammatory medications, and will anyway settle down soon, is simply wrong - according to the research and our New Zealand manual physiotherapy experience.  And also according to my personal experience of fixing costochondritis on patients over my 30 years as a physiotherapist, including completely fixing my own costo 30 years ago. 

Yes, this is a crazy situation.  The doctors are not uncaring or malicious.   But they are busy, and simply passing on the standard popular medical view of what costochondritis is and how to fix it - and this is incorrect.

So you are unlikely to find a doctor or specialist who will fix your costo for you.  It's up to you - you are the one in pain.  Cheeringly, it's a logical physiotherapy-type problem and not particularly difficult.  Good luck with the work.

Steve August (B.A.,Dip.Physio.).