What is costochondritis?
Your ribs do not meet your sternum bone to bone. The top seven attach through short strips of cartilage called the costal cartilages, and those cartilage joints, the costochondral and costosternal junctions, let the ribcage flex a little as you breathe and take some of the force out of a hit to the chest.
Costochondritis is inflammation of one or more of those junctions. Inflamed cartilage gives you a sharp, sometimes stabbing pain at the front of the chest, right where a rib meets the sternum, and it can be strong enough that you think you are having a heart attack or that you have broken something. The joint is irritated rather than broken, and it quietens down as the inflammation does.
Ribs 2–5
Where it sits
One side is the usual story, though it can take in both.
1–12 weeks
How long it lasts
Most of it settles well inside that, and if it is still sharp after six to eight weeks, get it looked at again.
Contact
Why it comes back
The pressing and the collisions that set it off the first time will set it off again.
How it happens in rugby
Those junctions sit at the very front of your chest, which is about the most exposed place on your body in contact. A few things in rugby set them off:
- A shoulder driven into your sternum in a front-on tackle compresses the cartilage joints all at once, and the chest takes the whole of the collision with nothing in front of it
- Rucks and mauls squeeze the chest between bodies, so the rib and sternum junctions take the same stress over and over, and props and hookers get the scrum version of it load after load through a match
- Bench press, incline press and push-ups load the chest while the ribcage is held slightly compressed, so a heavy pressing block can irritate the junctions on its own, and stacking it on top of contact training gives them no chance to calm down
- Coughing hard through a chest infection or a bout of flu does the same job without anyone touching you, so you can pick this up in the middle of winter having played nothing at all
- Twisting the torso sharply or reaching overhead under load shears across the cartilage, and that is enough on its own to start it
What does it feel like?
Once you know what you are looking for, it is a fairly recognisable pattern:
| Feature | Costochondritis presentation |
|---|---|
| Where it hurts | Sharp and well localised, right where a rib meets the sternum, usually on one side and sometimes on both |
| The kind of pain | Stabbing, sharp or aching, and you can usually put one finger on the exact point of it |
| What sets it off | Deep breaths, coughing, sneezing, bench press and push-ups, twisting, and any direct pressure on the spot |
| Pressing on the spot | Press firmly on the affected rib and sternum junction and the exact pain comes back, which is the hallmark sign and the thing that separates it from cardiac pain |
| At rest | Fades to a dull ache or goes altogether when you are still, then comes back sharp the moment you move or press on it |
| In bed | Lying on that side hurts, and so does rolling over, because your own bodyweight presses down on the inflamed junction |
Costochondritis vs Tietze syndrome
Tietze syndrome is the close relative that gets mixed up with costochondritis, and the difference you can actually see is swelling. In Tietze the affected junction swells enough that you can spot the lump and feel it under your fingers, while costochondritis hurts without changing the shape of anything. One rib is the usual story with Tietze, most often the second or third, where costochondritis can take in several. Treatment is the same either way and neither one is dangerous, though a visible lump on your chest is more frightening to look at and can take longer to go down.
How is it managed?
Costochondritis settles by itself, so managing it is mostly about keeping the pain down and staying off whatever keeps stirring it up:
- Back off the things that reproduce the sharp pain, so bench pressing, push-ups, contact on the chest and deep rotational work all come out for now, but keep your conditioning and everything below the waist going, because sitting still for a fortnight is not the treatment either
- Ice wrapped in a towel over the sore spot, fifteen to twenty minutes at a time and three or four times a day, takes the edge off in the first few days after it comes on
- If your doctor is happy for you to take them, a short course of NSAIDs such as ibuprofen or naproxen brings the inflammation and the pain down. Follow the dosing on the packet and eat something with them
- Loosen the guarding that builds up around a sore area with gentle chest and thoracic work, a doorway stretch or an extension over a foam roller, and stop the moment any of it brings the sharp pain back
- One to six weeks is the usual run of it, and some cases go on for months, generally the ones where the aggravating activity never actually stopped, so pushing through the pain buys you nothing
Returning to rugby
Symptoms decide when you go back, because nothing here is knitting together the way a fracture does. The cartilage is irritated rather than broken, so the way through looks like this:
Remove the triggers
1–2 weeks
Drop the pressing exercises and stay out of chest contact, but keep training your legs, your pulling work and your conditioning. Ice and anti-inflammatory medication as you need them. You should feel the pain starting to settle inside the first week once the triggers are gone.
Reintroduce pressing gradually
2–4 weeks
Begin with light pressing, wall push-ups or an incline dumbbell press with almost nothing on it. If that stays pain-free, move on to standard push-ups and a light bench over the following week. You are looking for the load your chest tolerates without complaint, then raising it a bit at a time.
Return to contact
3–6 weeks
Once pressing is pain-free at training loads, bring contact back in slowly with tackle bags, light wrestling and pad work. If the chest stays quiet through that, go to full contact in training and then into a match. A padded chest guard is worth wearing through the transition, for the protection and for how much easier it makes the first few hits.
When to be concerned
Costochondritis itself is not dangerous, but a few things should send you back to a doctor rather than waiting it out:
- Pain that is still there after six to eight weeks of modifying what you do is worth investigating properly, because a stress fracture of the sternum, slipping rib syndrome or pain referred from your thoracic spine can all look like this
- If the swelling at the junction does not go down, that points to Tietze syndrome, and rarely to something else, so ask about imaging
- Sore junctions on both sides at once, alongside fatigue or joint pain elsewhere in the body, can be a sign of an inflammatory condition such as rheumatoid arthritis or ankylosing spondylitis, and that needs a proper workup rather than rest
- Repeat flare-ups off almost no force suggest something structural underneath, and slipping rib syndrome is worth asking about by name