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- Fibromyalgia and Itching: Why It Happens, What the Science Actually Says, and What You Can Do About It - 9 September 2026
- Hypermobility in Children: Growing Pains, the Beighton Score, and What Actually Helps - 15 August 2026
This article is part of our comprehensive guide to living with fibromyalgia.
Costochondritis is a local problem at the small joints where your ribs meet your breastbone, and it gets diagnosed by somebody pressing on those joints and reproducing your pain, once everything dangerous has been ruled out first [1][2]. Fibromyalgia is a different animal altogether, and the two can certainly turn up in the same person, but the link between them is a good deal looser than the internet would have you believe. Among those arriving at hospital with costochondritis, only a small minority meet the criteria for fibromyalgia, although getting on for half have widespread pain of some kind [3]. So, the two are genuinely related, they just aren’t related in the way the phrase fibro chest pain usually implies.
What’s far better evidenced, and far more useful if you’re the one sat there with the sore ribs, is the overlap between fibromyalgia and hypermobility [4][5]. And a decent chunk of the chest pain that gets handed the costochondritis label in bendy people is probably mechanical trouble at the rib joints rather than inflamed cartilage [1][6][7], and that distinction isn’t academic at all, as it changes what actually helps.
What Costochondritis Actually Is
Costochondritis, which also gets called costosternal syndrome or anterior chest wall syndrome, is irritation of the cartilage joining the ribs to the sternum [2][8]. The tenderness is reproducible when somebody presses on the affected junctions, it usually sits somewhere between the second and the fifth, it’s often on both sides of the breastbone, and there’s genuinely nothing to see: no swelling, no redness, no heat [1][2]. Tietze’s syndrome is the one with visible swelling, and it typically involves a single junction rather than a run of them [1].
Now, the word inflammation is doing a great deal of work in that first sentence, and it’s worth being straight about it. The cause of costochondritis is poorly understood, and in most cases nobody can point at anything specific [2], so it’s usually called idiopathic, which is medicine’s polite way of saying we don’t know.
Where a trigger does turn up it’s usually mechanical or infective, as heavy lifting, repetitive upper body movement, a strenuous stint of something new, and a proper hacking cough all show up as precipitants [8][9][10]. Recent chest infections get linked to it too, and severe cases have been described in children after COVID [8][11]. After heart surgery that goes through the breastbone, roughly a third are left with it, and women about twice as often as men [12]. In children, low vitamin D and low folate have both been associated with it, which is an association in children rather than a treatment anybody has tested in adults [13][14][15]. And rarely the cartilage is genuinely infected, with published cases involving the sternum itself and one where tuberculosis turned up wearing a costochondritis costume [10][16].
There’s no test for it, as in no bloods, no scan, no ECG finding, so it’s a diagnosis you arrive at by ruling other things out [1][2][8]. And the uncomfortable part of that, which doesn’t get said often enough, is that chest pain you can reproduce by pressing on the chest doesn’t rule out a heart attack, as a small proportion of those with reproducible chest wall tenderness were having one [2][3]. So, “it’s only costochondritis” is where you finish rather than where you start, and anybody offering it before the cardiac workup is doing it backwards.
It turns up most often in the forties, and among those arriving at emergency departments with it, the large majority are women [1][3]. In children and teenagers it accounts for a meaningful slice of all chest pain, which is worth knowing if you’ve got a bendy teenager who keeps getting sent home [1].
What It Feels Like
The pain gets described as sharp, aching or pressure like, and sometimes as dull, stabbing or burning, which is a wide enough range that the description on its own doesn’t really tell you much [2][8]. What’s more consistent is what makes it worse, as a deep breath, a cough, moving the upper body, exercise and stress all reliably wind it up [2][1][8].
Some people, younger ones especially, don’t report a discrete pain at all, and describe tightness or not being able to get a full breath instead [1]. Others get it radiating into the back or the abdomen, and in some it creeps up into the neck and shoulder [17][18]. Severe episodes can arrive with nausea, breathlessness and enough distress to call an ambulance [19].
Fear of a heart attack is a standard feature of this, for the person and for the family around them [1], and that’s your nervous system doing precisely the job it evolved to do. The fact that it turns out to be cartilage in the end, doesn’t make the first hour of it any less unpleasant.
Does Costochondritis Cause Fatigue
Not directly, no. Fatigue isn’t an inflammatory feature of costochondritis, and there’s nothing about irritated rib cartilage that would flatten you on its own [2][20].
Indirectly is a different answer though, as where costochondritis becomes chronic or atypical, meaning it doesn’t settle the way the textbooks promise, it comes with reduced energy, real functional limits and a psychological load [2][8][20]. When those living with it were asked what actually restricted their lives, a lack of energy came up alongside not being able to exercise and not being understood by the people around them [20].
Most cases settle within a few weeks [1][8], though a subset run for months, and some past a year [8][20]. Over half of those seen in emergency with it were still reporting chest pain twelve months later, which is a fair distance from the self limiting story most people get handed at the door [3].
So, the fatigue looks like a downstream thing rather than a symptom of the condition itself: months of pain, sleep broken by pain at night, and the low grade stress of a symptom that keeps making you wonder about your heart [20][1]. Which is more than enough to account for it, without the cartilage having to be involved at all.
One thing to keep in mind though. New or worsening fatigue, alongside chest pain that isn’t improving, is a reason to go back rather than to settle in with it. Chest pain confidently put down to costochondritis has turned out to be something else entirely, and rising fatigue was the flag that prompted the rethink [18].
Is There Really a Connection With Fibromyalgia
There is, but it’s looser than the way it usually gets told, so start with the direct evidence, such as it is. Among those with costochondritis in an emergency setting, only a small minority met fibromyalgia criteria, while getting on for half had widespread pain of some kind [3]. In an older group who had chest pain and perfectly clean coronary arteries, both fibromyalgia and costochondritis were more common than you’d expect by chance, and yet the two almost never sat in the same person [21].
Put those together and you get overlap, but not the tight one to one relationship the phrase fibro costochondritis tends to suggest. Musculoskeletal causes do account for a large share of chest pain that turns out not to be cardiac, and both conditions sit comfortably on that list, which is probably where a lot of the conflation starts [22][23][24].
Now, fibromyalgia makes chest pain of its own, and that’s where most of the confusion lives. Several of the classic tender points sit in the anterior chest wall, including near the second rib and at the pectoral origin just to the side of the costochondral junction [21][25]. A tender spot an inch off the joint isn’t the same thing as a tender joint, and it doesn’t behave the same way, but it’s an easy thing to conflate when somebody prods your chest and you wince.
Worth remembering too that fibromyalgia is itself diagnosed by description and by exclusion, with no gold standard test sitting behind it [26], and one recurring complaint is how readily the label gets applied to things that aren’t it [27][26]. So chest wall tenderness in fibromyalgia isn’t automatically costochondritis, and it’s genuinely worth having somebody localise the pain properly rather than accepting a label at the door.
The Overlap With Hypermobility
The connection this area is genuinely confident about isn’t costochondritis and fibromyalgia at all, it’s fibromyalgia and hypermobility. Most of those carrying an hEDS or HSD diagnosis also carry a fibromyalgia one, and the figures come out high across the board even though they vary a lot between the groups looked at [4]. In one large specialist clinic, over half had both [5]. Coming at it from the other direction, in a group with fibromyalgia or ME/CFS, most met the older hypermobility criteria and a smaller number met the 2017 criteria for hEDS, and how hypermobile somebody was predicted how severe their pain and fatigue were [28].
What the two groups report is close to identical, as chronic pain, fatigue, anxiety, dysautonomia and sleep problems turn up in both [29][30], and in registry data both come with widespread pain, low vitality and a heavy functional burden [31].
There’s also a plausible sequence here, and it’s one that’s been described rather than proven. Pain starts local, driven by lax tissue, repeated small injuries and joints that keep travelling further than they should, and over years it broadens out into something that meets the description of fibromyalgia [32][33][34]. Which would mean a proportion of fibromyalgia diagnoses are sitting on top of unrecognised hypermobility, and that’s a conclusion several groups have reached independently [28][35][36][37].
Ribs, Laxity, and Slipping Rib Syndrome
If you’re bendy and your chest hurts, there’s a mechanical explanation that gets missed a lot of the time, and it’s worth knowing the name of it. Slipping rib syndrome is what happens when the front ends of the lower costal cartilages are too mobile (a rare case of medicine calling something exactly what it is). They sublux, they irritate the nerve running underneath, and the result is pain that often clicks or catches [1][6]. It gets confused with costochondritis constantly, and the tells are usually the click and the location, as slipping rib sits lower down the chest wall than the second to fifth junctions do.
That confusion has been documented, as a hypermobile gymnast with persistent clicking chest pain was labelled with costochondritis first, before the mobile costal cartilage was identified and, after that, hypermobile EDS [6]. Recurrent rib subluxations and pain on breathing in both turn up among the chest manifestations described in EDS, with costochondritis itself sitting on the same list [7].
And some of it isn’t inflammation in any meaningful sense, as in one instance of chest pain brought on by chest flies, the pain was focal and there was swelling visible on ultrasound, but the working diagnosis was mechanical dysfunction at the sternocostal joint, and it improved almost completely with mobility and stabilisation work rather than with anti inflammatories [38].
Nobody has directly tested how often classic parasternal costochondritis is actually driven by connective tissue laxity though [2]. The mechanism gets proposed a great deal more often than it gets measured, and the broader tissue work in hypermobility is still mostly generic rather than chest specific [34][39]. So, treat it as a good reason to have your ribs looked at, rather than as a settled explanation for why they hurt.
Why Fibromyalgia Makes the Same Chest Hurt More
Fibromyalgia turns the gain up. The system carrying nociceptive input from the tissues, and the parts of the cord and brain that process it, become more responsive, so the relationship between what’s going on in the tissue and how much it hurts comes apart [40][41][42][43]. That’s central sensitisation, and it’s probably the single most useful idea in this whole area.
In practice it means two things for chest pain. Less pressure is needed before something registers as painful, so a mildly irritated joint can feel a great deal worse than the state of the joint would suggest. And the usual clinical logic, press here and tell me how bad it is, gets considerably less informative, because the answer is now telling you as much about the system as about the rib [41][44].
This isn’t hypothetical in the hypermobile population either, as generalised hyperalgesia and sensory testing changes consistent with sensitisation have been found in joint hypermobility syndrome and the hypermobility type of EDS [45], and in adolescents with HSD or hEDS, alongside higher fatigue [46]. And where two painful conditions sit in the same person, each tends to worsen the other through the same shared machinery [47].
The proposed sequence, and it is a proposal rather than a demonstration, is that steady nociceptive input from joints that keep moving too far is what drives the sensitisation in the first place [5][45]. It fits, it makes mechanistic sense, and nobody has shown it directly, which is roughly the state of play for most of the good ideas in hypermobility research.
When anti inflammatories stop working on chest pain that started out responding to them, it doesn’t mean the pain has gone imaginary, or that the inflammation was never there in the first place. It usually means the dominant driver has shifted from the chest wall to the way the whole system is handling the input, and that needs a different tool rather than a higher dose [44][18].
Breathing and the Chest Wall
Your ribs are joints, and they have a job, which is to move every few seconds for the whole of your life, so breathing mechanics are unusually relevant to chest wall pain, and it’s the part that almost never gets picked up after a normal cardiac workup [48].
The fibromyalgia findings here are among the more solid in this whole area. Chest expansion, inspiratory pressure and maximal voluntary ventilation are all measurably reduced compared with people who don’t have it [49], and women with fibromyalgia breathe faster and shallower with less thoracic movement, which pushes the work onto the accessory muscles of the chest and neck rather than the diaphragm [50][51].
Upper chest breathing flattens the diaphragm and leans on the intercostals, and it’s a common default in chronic pain generally [52]. Among those with moderate to extreme central sensitisation, the large majority had a disordered breathing pattern, and how disordered it was tracked with how much pain they were in [52].
Hypermobility brings its own version of this, as breathlessness on exertion in this group is multifactorial, with altered chest proprioception, autonomic contribution and structural rib problems all in the mix, on top of whatever the cartilage happens to be doing [53][54].
Now, all of that is association. Nobody has shown that a breathing pattern causes costochondritis, and it would be very easy to overstate this into something it genuinely isn’t. What it is, is a plausible loading story for the chest wall, and it’s one of the few things around here that happens to be treatable. Inspiratory muscle training improves respiratory muscle function in hypermobile EDS [53], and breathing retraining over five weeks improved musculoskeletal pain complaints and end tidal CO2 at three months, in a small early piece of work, so take that as a hint rather than a result [55].
What Actually Helps
First, and this really isn’t a formality, get the heart ruled out properly, as a chest wall that’s tender to press doesn’t mean the pain is coming from the chest wall [2][3].
After that, the honest position is that the treatment evidence for costochondritis is thin to the point of embarrassment. There are no good trials of any of it, and most of what gets recommended is recommended because it’s always been recommended [2].
– Anti inflammatories: Reasonable for a short run while a genuinely irritated joint settles down, and they’re the standard first move alongside rest and staying off whatever sets it off [1][9]. They’re a much poorer bet for fibromyalgia itself, where the evidence is thin enough that they’re generally not recommended at all [56].
– Rib and soft tissue work: Manual work on the ribs, soft tissue mobilisation and graded exercise have cleared persistent chest wall pain in published cases, including ones that had been going on for well over six months [8][57]. That evidence is low certainty and mostly individual, so it’s a reasonable thing to try rather than a reliable thing to expect.
– Acupuncture: A small handful of people with costochondritis reported large improvements in pain, which is a hint and not much more [19]. In fibromyalgia, massage and myofascial work show some benefit at low certainty [58], and what people actually report about these treatments is decidedly mixed [59].
– Steroid injection: Proposed for pain that won’t settle, and its effectiveness is unproven [1].
– Exercise, education and graded loading: This is where fibromyalgia specific care has the better evidence behind it, and it outperforms leaning on anti inflammatories [40][58][56]. It’s also the least appealing thing to read when your chest hurts, which is fair enough really.
A more useful question than which treatment is which problem you’ve actually got, and you can get a surprisingly long way on three observations.
– Focal and reproducible: Tenderness sitting right on the rib joints, worse with a deep breath and with upper body movement, points at the chest wall itself [21][2].
– Widespread and amplified: Pain in a lot of places, fatigue, poor sleep, and tenderness that doesn’t map neatly onto any structure, points at sensitisation doing most of the work [21][40][42].
– Clicking and moving: A rib that feels like it shifts, pain lower down the chest wall, a click or a catch, particularly in somebody bendy, points at rib mechanics rather than cartilage [1][6].
Most people reading this will recognise more than one of those, and that’s normal rather than confusing, as the two things run together a great deal of the time.
In our opinion, and this is us rather than the literature talking, the thing that gets neglected most is a chest that’s been held still for months because moving it hurt. A rib cage that hasn’t moved properly since spring, is a rib cage getting steadily worse at its job, and there’s a fair argument that gentle, varied, graded movement through the thoracic spine and ribs does two jobs at once: it gives the joints something better to do, and it gives the system better information about where those joints actually are. That’s the direction the mechanical cases point in [38][8], and it’s how we work in the studios, but nobody has run the trial and we’re not going to pretend otherwise.
What Nobody Knows Yet
Quite a lot, honestly. Nobody knows how often costochondritis in a hypermobile person is actually being driven by connective tissue laxity, because that specific question has been proposed repeatedly and tested almost not at all [2]. Nobody has run a decent trial of any treatment for costochondritis either, so every recommendation above rests on tradition, small numbers, or reasoning from mechanism [2]. The chest specific work in hypermobility barely exists, and what’s there is mostly extrapolated from how lax tissue behaves in other joints [34][39]. And whether breathing retraining does anything for chest wall pain specifically, in this population specifically, is untested [55][48].
What you can do with that is limited, but it isn’t nothing. Get the dangerous things excluded, find out whether you’re actually hypermobile, get somebody to localise the pain rather than label it, and treat a chest that’s been guarded for months as a mechanical problem worth addressing as well as a painful one.
The Fibro Guy
