Thoracic and Chest Wall Pain

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada, 2018).
• Patient and contextual information: age; sex and gender when clinically relevant; language and communication needs; occupation or school; caregiving; sport and recreation; and activities, roles and cultural or community practices important to the patient.

Primary concerns

• Context and onset: sudden or gradual onset; recent trauma, fall, forceful exertion, lifting, coughing, respiratory illness or procedure; prior episodes; surgery; training or workload change; and whether symptoms are improving, stable, fluctuating or worsening.
• Location and pattern: posterior thoracic, paraspinal, interscapular, rib, flank, sternal, parasternal or other chest-wall location; radiation around the trunk or into the neck, shoulder, arm or abdomen; duration, severity, irritability and pattern over the day and night.
• Aggravating and relieving factors: thoracic, neck, shoulder or trunk movement; posture; lifting, pushing, pulling or overhead activity; breathing, coughing, sneezing or swallowing; meals; exertion; rest; sleep position; and response to pressure or palpation.
• Associated symptoms and participation: shortness of breath, cough, haemoptysis, palpitations, sweating, nausea, dizziness, fainting, fever, chills, unexplained weight change, fatigue, rash, abdominal or urinary symptoms, numbness, tingling, band-like trunk symptoms, weakness, gait change, bowel or bladder change; and effects on sleep, self-care, work, school, caregiving, recreation and exercise.
• Body systems review: constitutional and infectious; cardiovascular and vascular; respiratory; neurological; gastrointestinal; renal and genitourinary; musculoskeletal and bone health; skin; breast or chest tissue when relevant; mental health; and reproductive systems. Pursue findings indicated by the presentation.
• Health, lifestyle and history: cardiovascular, pulmonary, vascular, gastrointestinal, renal, neurologic, inflammatory, infectious, cancer and bone-health conditions; previous thoracic, chest, rib, neck or shoulder injury; surgery, hospitalization or chest procedure; current medications and supplements, including anticoagulants and systemic corticosteroids; allergies; physical activity, sleep, nutrition, smoking, alcohol or substance use; and family history relevant to cardiovascular, aortic, clotting, inflammatory or bone disease.
• Social determinants of health: work or school demands and supports, caregiving, income, housing, food security, transportation, safety, discrimination, social support and access to primary, emergency, diagnostic and rehabilitation care when these may shape health, care or participation (Public Health Agency of Canada, 2026).
• Previous care and responses: advice, rehabilitation, medication, injection, imaging, investigations or self-management tried; what helped or did not help; adverse effects; and reasons care was difficult to use or continue.
• Patient perspective: understanding of the problem, priorities, preferences, cultural context, concerns, expectations, confidence, previous experiences of care and what meaningful improvement would look like.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant. Reassess if the symptom pattern or general health changes.

Outcome measures

• Use a small set that reflects the patient’s goals and is practical to repeat. Record a baseline and reassess often enough to guide decisions.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: WHOQOL-BREF when it fits the clinical question.
• Symptoms and participation: a pain or symptom rating, meaningful activity tolerance, sleep, work or school, caregiving, breathing-related activity and the patient’s own assessment of change when relevant.
• Individual goals: agree on patient-defined goals and how progress will be recognized.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change safety, the working presentation, care or referral. Adapt the pace, positioning and extent of examination to the patient’s symptoms, comfort, consent and abilities.

• Consent, dignity and comfort: explain each step and obtain ongoing consent. Before examining the anterior chest wall, discuss why it is relevant and provide choices about draping, positioning, a support person or chaperone, and areas the patient does not want examined. Stop or modify the examination when requested.
• Observation and general assessment: general appearance, breathing effort and pattern, posture, gait, transfers, guarding, asymmetry, swelling, bruising, rash, deformity and use of supports. Measure temperature, pulse, blood pressure, respiratory rate or oxygen saturation when cardiac, vascular, pulmonary, infectious or other systemic concern makes them relevant.
• Movement and range of motion: active thoracic flexion, extension, rotation and side-bending; cervical, lumbar, shoulder or rib-cage movement when relevant; movement quality, symptom response and tolerance to repeated or sustained positions.
• Breathing and cough response: observe comfortable and deeper breathing, rib-cage movement, cough and speech tolerance when clinically relevant. Stop and arrange medical assessment when findings raise cardiopulmonary concern.
• Neurological examination when indicated: trunk sensation by dermatome; superficial abdominal reflexes and inspection or testing for focal truncal or abdominal wall weakness when thoracic nerve-root involvement is suspected; limb motor performance, sensation and reflexes; gait, balance and coordination; and upper motor neuron findings such as hyperreflexia, clonus or an extensor plantar response when cord involvement is possible (Mostert et al., 2024).
• Provocation and regional tests: active, resisted or length tests for trunk, shoulder girdle and respiratory muscles; rib or chest-wall loading and selected orthopaedic tests only when they may change the working presentation or plan. Interpret findings with the rest of the assessment.
• Palpation: assess relevant thoracic vertebrae, ribs, sternum, costochondral regions and soft tissues for focal bony tenderness, swelling, warmth or symptom reproduction when this contributes to the differential. Reproducing chest pain by palpation does not exclude a serious cardiac or pulmonary cause (Mott et al., 2021).
• Functional assessment: select tasks tied to the patient’s goals, such as sitting, standing, walking, reaching, lifting, pushing, pulling, carrying, rolling in bed, work simulation, caregiving, sport or breathing-related activity.
• Regional and differential examination: assess the neck, shoulder, lumbar spine, abdomen, vascular or cardiopulmonary system only when the history indicates and within competence and scope. Refer when a medical examination or investigation is needed.
• Imaging: uncomplicated acute thoracic back pain without red flags, myelopathy or radiculopathy does not usually need initial imaging. Refer earlier when cancer, infection, immunosuppression, trauma, fracture or myelopathy is suspected. Nontraumatic focal chest-wall pain follows a different imaging pathway, particularly with suspected malignancy, infection, inflammation or prior chest intervention; coordinate imaging when the result is likely to change care (American College of Radiology, 2024; American College of Radiology, 2021).
• Reassessment: repeat the findings and functional tasks needed to review progress, adverse effects, the working presentation and any change requiring medical assessment or referral.

Working clinical presentations

• Use these as working descriptions after appropriate safety screening. Presentations can overlap or change, and local tenderness or movement-related pain does not establish one tissue source or exclude a serious non-musculoskeletal condition (Mott et al., 2021; Gulati et al., 2021).
• Non-specific musculoskeletal thoracic pain: thoracic or interscapular pain and activity limitation with movement-, posture- or load-related features and no evidence of a specific condition requiring different management. Descriptive joint, myofascial or postural terms can communicate findings but do not establish a confirmed pain source.
• Musculoskeletal chest-wall or costochondral pain: localized rib, sternal, parasternal, costochondral or costosternal pain reproduced by relevant movement, breathing, coughing or local pressure after cardiac, pulmonary, vascular and other causes have been addressed. Costochondritis is one possible working presentation; focal swelling or atypical features require further assessment (Mott et al., 2021; American College of Radiology, 2021).
• Thoracic or chest-wall strain pattern: recent symptoms associated with lifting, pushing, pulling, sport, forceful coughing or another plausible load, with local movement or resisted-muscle provocation and no fracture, organ injury or other serious cause.
• Thoracic radicular pattern and radiculopathy: radicular symptoms can include band-like pain, paresthesia, allodynia or numbness around the back, chest, flank, abdomen or breast in a thoracic dermatomal pattern. These symptoms do not by themselves establish thoracic radiculopathy. Radiculopathy is supported by corresponding neurological findings; dermatomal sensory loss, truncal or abdominal wall weakness or bulging, or absent or asymmetric superficial abdominal reflexes may be present. Record whether findings are stable or progressive and assess for cord involvement (Mostert et al., 2024).
• Persistent or recurrent thoracic or chest-wall pain: not a separate pain source. Revisit the differential and the interaction of symptoms, sleep, distress, confidence, work or caregiving demands, other musculoskeletal pain, social conditions, access and prior response.
• Alternative or overlapping presentation: findings may point to neck, shoulder, scoliosis, inflammatory, bone-health, neurologic, cardiopulmonary, gastrointestinal, renal, skin, breast or other chest-tissue conditions. Refer or coordinate care when needs extend beyond the clinician’s role.

Base care on the working clinical presentation, safety, goals, preferences, culture, access, other health conditions and observed response. Evidence supporting the non-specific exercise and hands-on options below comes from musculoskeletal thoracic and chest-wall presentations and does not establish effectiveness for thoracic radiculopathy (Southerst et al., 2015; Waqas et al., 2023; Mostert et al., 2024).

Education, self-management and participation

• Explanation and reassurance: explain the assessment, what serious causes have been addressed, the working presentation and remaining uncertainty in plain language. Validate the symptoms without implying that posture, stress or one tissue finding fully explains them.
• Self-management and participation: agree on realistic ways to manage symptom changes and continue or resume sleep, self-care, work, school, caregiving, recreation and community roles. Temporary task or workstation changes can support participation while capacity is rebuilt.
• Safety net: reinforce the chest, breathing, neurologic, infectious and trauma-related changes that require earlier reassessment or emergency care.

Protection and optimal loading

• Recent strain or costochondral irritation: short-term modification of clearly aggravating lifting, pushing, pulling, direct pressure or other tasks can form part of care while comfortable movement and daily activity continue. Progress load using symptom response, task demands and patient confidence (Mott et al., 2021).
• Bone or tissue vulnerability: avoid forceful loading or manual procedures and arrange further assessment when fracture, osteoporosis-related injury, cancer, infection, inflammatory disease, anticoagulation-related bleeding or another contraindication is suspected.

Physical activity and exercise

• Non-specific musculoskeletal thoracic or chest-wall presentations: options include thoracic and shoulder-girdle mobility, trunk and upper-body strength or endurance, aerobic activity, breathing-related movement and task-specific practice. Match type, amount and progression to the presentation, goals, capacity, irritability and response (Southerst et al., 2015; Waqas et al., 2023).
• Thoracic radicular pattern or radiculopathy: a monitored trial of individualized physical activity or exercise can form part of conservative care when serious or progressive causes have been addressed. Current evidence does not identify an effective program; type and progression reflect the suspected cause, symptom response and serial neurological findings (Mostert et al., 2024).
• Graded return: use pacing, planned breaks, gradual exposure or temporary accommodations when these help the patient resume valued activities without prolonged restriction.

Hands-on and symptom-relieving care

• Non-specific musculoskeletal thoracic or chest-wall presentations: thoracic or rib mobilization, manipulation and soft-tissue techniques can form part of a monitored plan. Identify the intended purpose and reassess the response; avoid forceful manual procedures when fracture, serious pathology or another contraindication is suspected (Southerst et al., 2015; Waqas et al., 2023).
• Thoracic radiculopathy: current evidence does not establish the effectiveness of a specific hands-on approach. When hands-on care addresses a coexisting musculoskeletal presentation, document that purpose separately and monitor neurological findings (Mostert et al., 2024).
• Symptom-relieving options: heat or cold, comfortable positioning, relaxation or breathing strategies, supports and temporary ergonomic changes can be tried when safe and useful to the patient. Monitor skin tolerance, breathing and activity effects (Southerst et al., 2015; Mott et al., 2021).
• Cultural and traditional approaches: culturally grounded, traditional, spiritual or community-based approaches identified by the patient can be included when safe, within scope and coordinated with the patient’s chosen practitioners.

Psychological, social and interdisciplinary support

• Psychologically informed care: supportive communication and behavioural strategies within competence can help when fear, distress, trauma, sleep or coping is affecting recovery. Coordinate mental-health care when needs extend beyond scope.
• Social and occupational support: workplace, school, caregiving, financial, transportation, housing, safety or access barriers can be addressed through practical accommodations, community resources or another appropriate professional when possible.
• Interdisciplinary care: coordinated medical, rehabilitation, occupational, psychological or social care can fit persistent disabling symptoms, complex comorbidity, substantial participation restrictions or diagnostic needs that one clinician cannot address.

Medication and procedural shared care

• Medication review: review current use, intended benefit, adverse effects, interactions and relevant gastrointestinal, renal, cardiovascular or bleeding risk. Medication selection, prescribing and dosing remain with an authorized prescriber or pharmacist. For costochondral pain, available analgesic and topical options have limited direct evidence (Mott et al., 2021).
• Procedural or specialist care: medical or specialist assessment can form part of shared care when imaging, injection, surgical opinion, cancer or infection management, inflammatory-disease care, fracture care or another procedure may change management.

Monitoring and reassessment

• Agree on a reassessment point based on the presentation, safety, goals, care being tried, patient needs and access rather than a fixed visit schedule.
• • Repeat the small outcome set recorded at baseline and review symptoms, breathing-related activity, movement and load tolerance, functioning, participation, benefits, adverse effects, treatment burden and progress toward patient-defined goals. When a thoracic radicular pattern or radiculopathy is present, repeat relevant dermatomal sensation, truncal motor or superficial abdominal reflex findings, and gait or upper motor neuron findings when indicated.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit Red Flags, the working presentation, differential diagnosis, imaging, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: the course depends on the presentation and direct evidence is limited. Recent costochondral pain often settles with conservative care; thoracic radiculopathy varies with its cause and neurological course. Use the individual’s observed change rather than a promised timeline (Mott et al., 2021; Mostert et al., 2024).
• Factors associated with a less favourable course: reliable physical prognostic factors for thoracic pain have not been established. Persistent or worsening symptoms, neurological change, other health conditions and barriers to participation still warrant reassessment because they may change care, but they are not validated predictions of outcome (Begum et al., 2026).
• Potential supports for recovery: confidence in safe movement, feasible self-management and activity progression, supportive relationships and workplaces, useful accommodations, access to coordinated care and progress toward meaningful activities may support recovery.
• Discussing prognosis: describe uncertainty in plain language, ask what the patient wants to know, and update the outlook using repeated outcomes and the observed course. Do not treat a prognostic factor, imaging finding or screening score as a fixed prediction.