Thoracic and Chest Wall Pain

• 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.

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.

• 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.

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).

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.

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.