Chronic Chest & Chest-Wall Pain

With that said: many people live with genuine, persistent chest and upper-back pain that isn't their heart, go undiagnosed, and suffer needlessly. Chest pain can come from any structure in the chest and upper back — muscle, nerve, joint, cartilage, bone — as well as from arthritis, old fractures, infection, and more. Here are the chest-wall causes a pain specialist sees most.

Costochondritis and Tietze's syndrome

The most common chest-wall culprits are inflammation of the cartilage joining the ribs to the breastbone. Both cause pain over the sternum that can be alarming — it sometimes mimics heart pain, radiating toward the arm and jaw — and both worsen with coughing and deep breathing.

Tietze's syndrome usually appears before age 40, typically at the second or third rib (a few inches above the nipple), where the cartilage feels tender and visibly swollen. It usually resolves on its own. Costochondritis tends to occur in older adults, affects several rib levels, and is tender without swelling. Both respond to anti-inflammatory medication and, when needed, corticosteroid injections.

Costovertebral arthritis

Arthritis isn't only a hands-and-hips problem — any joint can be affected, including where the ribs meet the spine (costovertebral joints) and the spinal joints themselves. This produces aching chest and upper-back pain that can be treated like other arthritic joint pain.

Slipping rib syndrome

First described in 1922, this causes pain in the lower rib cage, usually after trauma. The cartilage at the end of a lower rib separates from its normal attachment and rides up over the rib above, sometimes with a palpable or audible click. Treatment is local injections and, when necessary, surgery to remove the slipping cartilage.

Nerve-related and post-surgical chest pain

Some of the most treatable — and most often missed — chest pain is nerve pain:

Shingles (herpes zoster) breaks out in the chest about half the time, causing a painful, hypersensitive rash in a band on one side, where even clothing hurts. Pain persisting beyond 4–6 weeks becomes postherpetic neuralgia, which can last a lifetime — and early antiviral treatment dramatically lowers that risk. This matters enormously: treat facial or chest shingles as early as possible. (See our full Shingles & Postherpetic Neuralgia page — and note the shingles vaccine now prevents most cases.)

Post-thoracotomy syndrome — pain wrapping around the chest after lung surgery (for cancer, emphysema, and other conditions), from damage to an intercostal nerve running beneath a rib. A series of intercostal nerve blocks, along with medications, electrical stimulation, and other blocks, can help.

Post-mastectomy pain syndrome — a tight, sharp pain in the breast, armpit, shoulder, and upper arm after breast surgery, from injury to the intercostobrachial nerve. Patients often hold the arm close to the body for relief. Nerve blocks, medications, electrical stimulation, and physical therapy all have roles. (See our page on breast-related pain.)

Cancers — why persistent chest pain gets evaluated

Most chest-wall pain is benign, but persistent unexplained pain is taken seriously because a minority of cases signal something more. A Pancoast tumor at the top of the lung (in a small share of lung cancers) can press on the nerve bundle to the arm, causing pain in the shoulder, shoulder blade, arm, and hand, sometimes with a droopy eyelid, unequal pupils, or hoarseness. Breast cancer is usually painless until it involves ribs, bone, or nerves. This is precisely why a careful evaluation — rather than reassurance alone — matters for chest pain that won't resolve.

Posture and structural causes

The chest and upper back are also stressed by kyphosis — rounding of the upper spine — and by the forward-leaning posture it creates, which strains chest and upper-back muscles. Compression fractures of the spine (often from osteoporosis) produce localized pain and can drive progressive kyphosis. (See our Kyphosis page.) And in women, heavy breasts are a common, overlooked cause of chest, shoulder, neck, and upper-back pain — often highly treatable without surgery. (See our page on breast-related pain.)

How chest-wall pain is treated

Once cardiac and other serious causes are excluded, chest-wall pain generally responds well to a targeted, non-opioid approach: anti-inflammatory medication, precisely placed injections (costochondral, intercostal, and other nerve blocks), nerve-pain medications for the neuropathic causes, posture correction, and physical therapy. The key, as always, is finding the true source — chest pain has many, and they need different treatments.

If you have chronic chest or upper-back pain your doctor hasn't been able to pin down, call Newport Pain Management at (949) 759-8400.