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Thoracic and Chest Wall Pain

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About Thoracic and Chest Wall Pain

Thoracic and chest wall pain refers to mechanical musculoskeletal pain arising from the mid-back (T1-T12), rib articulations, and anterior chest wall, including the costovertebral, costotransverse, costosternal, and associated soft tissue structures. These conditions may occur independently or together and are frequently associated with neck or shoulder symptoms. Pain may develop from acute overload, sustained or awkward postures, movement-related irritation, or without a clearly identifiable cause.

Thoracic and chest wall pain occur across the lifespan and are not uncommon in adults. Many people experience recurrent episodes, and some report limitations in daily activities. Most cases are benign and self-limiting; however, symptoms can be distressing and warrant careful assessment to rule out non-musculoskeletal causes.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Thoracic and Chest Wall Pain Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent
  • Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
  • Key Aspects:
    • Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
    • Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time. 
    • Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
      • Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
      • Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
    • Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.
3. Health History
  • Apply cultural awareness and trauma-informed care principles.
  • Sociodemographic information: Age, gender, sex, race/ethnicity.
  • Main complaint: Description of pain including:
    • Location: T1- T12 posteriorly, thoracic outlet to the diaphragmatic margin anteriorly; costovertebral, costotransverse, and costosternal regions.
    • Associated symptoms: E.g., neck, shoulder, or low back pain; stiffness; movement-related pain; breathing-related discomfort.
    • Timing and course: E.g. acute onset, recurrent episodes, symptoms ≥ 3 months, night pain, morning stiffness, symptoms with activity or rest.
  • Body systems review: Cardiopulmonary, gastrointestinal, renal, neurologic, musculoskeletal, dermatologic.
  • Health, lifestyle, and history: Past medical conditions (e.g., infections, cancer, osteoporosis, inflammatory spondyloarthropathies), medications (e.g., anticoagulants), supplements, injuries, hospitalizations, surgeries, diet, exercise habits, sleep, footwear, work/school environment, and relevant activities.
  • Social determinants of health: Employment, financial strain, caregiving responsibilities, education, nutrition, housing, access to care, experiences of discrimination, social isolation, domestic violence, and child maltreatment.
  • Previous treatments and responses: Effectiveness and any adverse effects.
  • Beliefs and expectations: Patient understanding of their condition, concerns, expectations for treatment, and preferred care approaches.
  • Flag considerations: Identify red, orange, and yellow flags for potential referrals.

​​Outcomes Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

  • Pain: Use pain scales (e.g., NRS) and diagrams.
  • Function and Participation: Evaluate impact on daily activities (PSFS, WHODAS).
  • Recovery: Use self-rated recovery scales.
  • Quality of life: Assess using tools such as SF-12.
  • Work/school status: Monitor return to activities.
  • Sleep quality: Assess using tools such as PSQI.
  • Individual goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely).
  • Patient feedback: Gatherand integrate patient experience and satisfaction.
4. Red Flags : Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

  • Traumatic fracture: Acute onset with a plausible mechanism.
  • Pathological fracture: May be present with night pain, unexplained weight loss, night sweats, fever, chills or other constitutional symptoms.
  • Fragility fracture: Sudden onset following a low-force or minimal-trauma mechanism.

ACTION: Refer to appropriate medical provider:

  • Inflammatory arthritides: Consider conditions such as rheumatoid arthritis, reactive arthritis,  Reiter’s, or psoriatic arthritis, particularly when accompanied by prolonged morning stiffness (>30 minutes), peripheral joint symptoms, or enthesitis (e.g., heel pain).
  • Non-musculoskeletal presentation: Signsor symptoms suggestive of cardiac, vascular, pulmonary, renal, gastrointestinal, or dermatological conditions (e.g., blisters/ vesicles), any presentation not better explained by a musculoskeletal condition.
5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.
  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)
6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
  • Social: Lack of family/social support, limited connections.
  • Socioeconomic: Employment status, financial stress, litigation/compensation.
  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.
  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

  • Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
  • Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)

7. Physical Examination
  • Observation: Assess visible abnormalities, asymmetries, postural patterns, breathing mechanics, and functional movements. Observe gait, transitional movements, and any pain-related guarding or rigidity.
  • Range of motion (ROM): Assess active, passive, and resisted thoracic, cervical and lumbar movements in flexion, extension, lateral flexion, and rotation.
  • Palpation: Examine the thoracic and chest wall for regional and segmental tenderness, including costovertebral, costotransverse, and costosternal joints. Assess peri-articular soft tissues for tone, swelling, warmth, trigger points, or tissue texture changes. 
  • Neurological examination: Perform when neurological symptoms are reported or when radicular pain, sensory changes, weakness, or gait disturbance raises suspicion of neurological involvement. 
  • Special/Orthopedic Tests: Perform as clinically indicated.
  • Advanced Diagnostics: Imaging is not routinely recommended for thoracic or chest wall pain in the absence of red flags. Consider imaging when: serious underlying pathology is suspected (e.g., fracture, infection, cancer, inflammatory arthropathy), or
    surgical intervention is being considered.

8. Clinical Presentations and Diagnostic Considerations for Thoracic and Chest Wall Pain

The diagnosis is based on the presence of pain arising from musculoskeletal structures of the thoracic or chest wall, after excluding conditions better explained by non-MSK pathology. A diagnosis of musculoskeletal thoracic or chest wall pain may be made when the following considerations are met:

  • Pain location: Symptoms are experienced between T1–T12 posteriorly and/or from the thoracic outlet to the diaphragmatic margin anteriorly, including costovertebral, costotransverse, or costosternal regions.
  • Provocation or reproduction of symptoms: Pain is reproduced by movement, load, palpation, or mechanical provocation of thoracic or chest wall structures.
  • Identifiable musculoskeletal source (when present): A specific structure or region (e.g., thoracic joints, rib articulations, soft tissue) can reasonably account for the symptoms.
  • Non-specific presentation: A specific structure cannot be identified, but the pain pattern and clinical findings are most consistent with musculoskeletal disorder.
  • Exclusion of non-MSK causes: Symptoms are not better explained by cardiac, pulmonary, gastrointestinal, dermatologic, or other systemic conditions (see Red Flags).
9. Conservative Treatment Considerations for Thoracic and Chest Wall Pain

Approach to Treatment

The treatments outlined in this section reflect core domains of care consistently identified across high-quality clinical practice guidelines and established clinical practices. These include interventions shown to improve patient-important outcomes such as pain, function, and quality of life. Management plans should be tailored to the individual’s needs, goals, and preferences, taking into account clinical presentation, response to care, and contextual factors.

Not all domains need to be included in every care plan or at every stage of recovery. Clinicians are expected to apply professional judgment in selecting the most relevant components based on the clinical context.

This pathway is not prescriptive, nor does it list every possible intervention. Readers are encouraged to consult individual guidelines for specific treatment protocols, dosage, and condition-specific considerations.

While a range of other interventions may be in use, such as passive physical modalities, these have mixed or limited evidence of clinical benefit and are therefore not recommended for routine use. If applied, such therapies should be used as adjuncts to the core, evidence-based components of care, and not as standalone treatment.

  1. Manual Therapy (Southerst et al., 2015)
    • Manual therapy (e.g., mobilization or manipulation) may be considered as part of a broader care plan to improve pain and function in people with recent-onset thoracic pain.
  2. Multimodal Care (Southerst et al., 2015)
    • Multimodal care may include manual therapy, soft tissue techniques, exercise, heat/ice, and advice. It may be integrated into a broader care plan to improve pain and function for recent-onset musculoskeletal thoracic or chest wall pain.
  3. Exercise 
    • Exercise is a component of conservative management for thoracic and chest wall pain. Programs may include mobility exercises, postural training, strengthening, stabilization, and functional movement retraining. Exercise can be tailored to individual needs and may be delivered through supervised or self-directed programs. Incorporating exercise into a broader care plan may help improve pain, function, and participation in daily activities.
10. Risk and Prognostic Factors for Thoracic Pain

Risk and prognostic factors for thoracic and chest wall pain vary across age groups and often reflect a combination of biomechanical, psychosocial, and contextual influences.

Common Associated Factors (Briggs et al., 2009):

  • Adolescents: Postural changes associated with backpack use, backpack weight, female sex, presence of other musculoskeletal symptoms, and mismatched furniture (e.g., chair height at school).
  • Adults: Concurrent musculoskeletal symptoms and difficulty performing activities of daily living.

Common Risk Factors (Briggs et al., 2009):

  • Adolescents: Poor mental health and transitional stages through adolescence.

Common Prognostic Factors (Briggs et al., 2009):

  • Adults: Biomechanical loading, concurrent musculoskeletal pain, and psychosocial factors ( e.g., fear of movement, stress, low mood).

Prognosis (Southerst et al., 2015):

  • Musculoskeletal anterior chest wall pain, including conditions such as costochondritis, is typically benign and self-limiting; however, recurrent episodes are common. 
11. Ongoing Follow-up
  • Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
  • Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
  • Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
  • Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
  • Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
  • Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.
12. Criteria for Discharge
  • Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
  • Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
  • Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
  • Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
  • Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

References