Pain guide · Back pain
Pain in or behind the breastbone (sternum) most often comes from the chest wall: the joints where the ribs meet the breastbone (costochondritis) or a strained muscle. Reflux, anxiety, the lungs and the heart can be felt there too, and pain you can press on doesn't rule out the heart, so chest pain always needs checking first.
Call 999 for chest pain that is sudden, tight, heavy or like pressure, spreads to your arm, neck, jaw or back, or comes with breathlessness, sweating or feeling sick, and call 999 or go to accident and emergency (A&E) after a serious accident such as a car crash; for chest pain that comes and goes, see a general practitioner (GP) or call the National Health Service's 111 line (NHS 111). Once a clinician has checked your chest, this guide explains what helps (ibuprofen if it suits you, heat, easing off what brings it on, and gentle movement), how to sleep, and gives a three-stage plan back to pressing, lifting and sport, with 3D demos.
Exercise is for pain that has been checked or is clearly mild and settling.
Location narrows the likely causes; it does not diagnose.
Get it checked first: the warning signs above say how fast. The rest of this map is for pain a clinician has already looked at.
Often costochondritis, once a clinician has thought about the heart and lungs.
Read: Costochondritis →A visible, tender swelling over one upper rib joint beside the breastboneUsually Tietze syndrome: see a GP.
Read: Costochondritis →Usually the chest wall, which this guide covers.
Possibly painful xiphoid syndrome, which usually settles with time and painkillers.
See a GP if it grows, is hard and doesn't move, is painful, red or hot, or lasts more than 2 weeks, as the NHS advises for any lump.
The sternoclavicular joint. Red and hot with a fever, chills or night sweats needs checking the same day.
Read: Collarbone pain →After a car crash, a fall or a blow to the chestA bruised or broken breastbone, often with other injuries: 999 or A&E after a serious accident. Our rib injury guide covers bruised and broken ribs.
Read: Rib injury →The chest muscles towards the armpit, sore when you push or reachA chest muscle strain.
Read: Chest muscle pain →A pop at the front of the armpit or chest during a press or a dipA possible torn pec: get it checked the same day.
Read: Pec strain or tear →Heartburn and acid reflux. If food sticks or you're losing weight, see a GP.
Possibly the heart: call 999.
Possibly angina: get help from NHS 111.
Possibly pericarditis: an urgent GP appointment or NHS 111.
A chest infection or pleurisy: an urgent GP appointment or NHS 111.
Read: Rib pain →Shingles: see a pharmacist, ideally within 3 days of the rash.
Possibly a panic attack, once other causes have been considered.
Lasting pain is common, but a wound that is getting more painful or red, or leaking, needs the care team.
Our middle back pain guide maps the back.
Read: Middle back pain →The breastbone (sternum) has an upper part, a long body and a small lower tip (the xiphoid process). The first rib is joined firmly to the upper part, the next ribs meet the breastbone through flexible cartilage at small joints down each side, and the collarbones meet its top at the sternoclavicular joints. Because the ribs move with every breath and every arm movement, pain from these joints changes with breathing, twisting, reaching and pressing.
In general practice, the chest wall is the commonest single cause of chest pain: 24.5% to 49.8% across 6 good-quality studies of about 3,900 people, against 13.8% to 16.1% for heart and circulation problems (1.5% to 3.6% for a heart attack or a closely related emergency), 10.3% to 18.2% for the lungs, 9.5% to 18.2% for anxiety and other psychological causes, and 5.6% to 9.7% for the gut. In Swiss general practice, chest wall pain affected people of all ages, men and women equally. In German general practice, it was felt behind the breastbone in 52.0% of people who had it and on the left in 69.2%, often both.
Costochondritis was found in 30% of 122 people with chest pain in one emergency department, 69% of them women. The NHS links it with a chest injury, repetitive upper-body movements like lifting, coughing a lot and infection. Broken breastbones are uncommon and mostly follow car crashes and falls.
In an emergency department, 6% of people diagnosed with costochondritis were having a heart attack, against 28% of those without it. A review of the chest pain history found that pain which is stabbing, worse breathing in, changes with position or can be brought on by pressing makes a heart attack less likely, and pain spreading to the shoulders or arms, or brought on by effort, more likely, but no part of the history can rule it out without tests. In Swiss general practice, chest wall pain sat alongside heart disease in 19 of 300 people. That is why the NHS sends suspected costochondritis to NHS 111, and why this guide's map comes after the warning signs, never instead of them.
Most studies count the breastbone in with the rest of the chest wall. In one Swiss cohort, 20% of 195 chest wall syndromes at a single spot were on the midline: 14.4% on the breastbone itself, 2.6% on its upper part and 3.1% at its lower tip. Those figures come from that one cohort.
An American review lists arthritis of the joint between the upper part and the body of the breastbone, and painful xiphoid syndrome (tenderness at the lower tip), among chest wall conditions; in a Dutch series of 5 people with long-lasting pain at the lower tip, an injection helped 1, and removing the tip relieved the 4 who had it. At the top, the sternoclavicular joint can be sprained, usually in high-energy accidents or contact sport, or get arthritis, and infection there is rare: about 1% of joint infections, in a review of 180 cases.
The NHS says costochondritis pain may be worse lying down; heartburn is worse after eating, lying down and bending over; pericarditis is worse lying down, especially on the left side, and better leaning forward; and after a bruising blow, the NHS advises sleeping more upright for the first few nights. Turning over in bed also moves the rib joints beside the breastbone (our reading of how they work).
Broken breastbones made up 0.84% of 568,399 adult trauma admissions in the Netherlands, mostly from car crashes (48%) and falls (28%), often with broken ribs (51%), spinal fractures (36%) or bruised lungs (18%), and with an injury to the heart in 9.5%. In a Greek hospital series of 45 broken breastbones with no other injuries, all from car crashes and 91% in people wearing seat belts, the average hospital stay was under 2 days, with no heart complications or deaths.
No NHS page covers a bruised breastbone, so this guide borrows the NHS's advice for bruised or broken ribs, which usually get better by themselves within 2 to 6 weeks.
The NHS says it usually takes 2 to 3 months to recover fully from heart bypass surgery, with no heavy lifting for 3 months, and the surgical team's limits come first. Lasting pain is common, in two separate groups of patients. In a survey across 11 rehabilitation centres by an Italian team, 35.3% had pain at 3 months, 26.8% at a year and 19.8% at 3 years, in three different groups of about 315 people. At one centre, 39.7% of 174 people had pain at or around the incision at 6 months, and 9.6% of 146 at 7 years.
A wound that is getting more painful or red, bleeding or leaking pus, a high temperature or palpitations need the care team.
Clinicians check the heart first: an American review suggests an electrocardiogram (ECG) for anyone over 35, anyone at risk of heart disease and anyone with heart or lung symptoms, and a chest X-ray when there is a fever, a cough, swelling or other lung findings; computed tomography (CT) can show problems in the rib cartilage. No test confirms chest wall pain: it is diagnosed once other causes have been considered, and the National Institute for Health and Care Excellence (NICE) asks clinicians to explain when chest pain isn't coming from the heart.
After a car crash, a broken breastbone shows on X-ray or CT; in the Greek series, people whose ECG, heart blood tests and chest X-ray were normal needed no further tests. NICE asks for a suspected cancer referral for difficulty swallowing, and from 55 for weight loss with pain at the top of the tummy, reflux or indigestion. A swollen sternoclavicular joint with a fever needs a scan to look for infection.
The NHS says costochondritis usually gets better on its own, over a few weeks to several months. In Swiss general practice, the outlook at a year was good, but chest wall pain came back in half; in Germany, 55.4% still had some chest pain at 6 months; and of 21 people followed after costochondritis in an emergency department, 11 still had chest pain at a year, only a third of them with definite costochondritis. Bruised or broken ribs usually heal within 2 to 6 weeks; no source we read gives a time for the breastbone. No one can promise a timescale.
The NHS asks you to get help from NHS 111 if you think you have costochondritis, so that chest pain can be checked for more serious causes. NICE asks clinicians to explain when chest pain isn't from the heart and to consider the gut, the gullet and the chest wall once angina is unlikely, and an NHS emergency department leaflet tells people that most chest pain isn't heart-related, naming reflux, chest wall strains, anxiety and the lungs. The Swiss authors argue that a clear chest wall diagnosis reassures people more than just being told a serious disease has been ruled out.
No treatment for costochondritis has been tested in a trial. The NHS suggests anti-inflammatory painkillers such as ibuprofen, and a steroid injection or local anaesthetic for very bad pain that doesn't get better over time. American family medicine reviews add simple painkillers, heat, cutting back the activities that bring it on, treating a cough that keeps it going, and reassurance.
In 115 people with sudden chest wall pain first seen at a hospital heart unit, 4 weeks of chiropractic care, including spinal manipulation, did better than a self-management session on some measures at 4 and 12 weeks, with no difference at a year. People knew which treatment they had, which can colour results like these.
No exercise programme has been tested in a trial for breastbone or chest wall pain. One small look back at people with long-standing costochondritis reported less pain with a stretching programme than in similar people who didn't stretch, but it was small and its figures were inconsistent. The plan here borrows breathing, walking and gentle movement from our costochondritis and chest muscle pain guides, and it is our suggestion, not a tested treatment.
In a trial of 40 people with Tietze syndrome, adding a 3-week course of steroid tablets to anti-inflammatories brought pain scores down further than anti-inflammatories alone (by 65.4% against 46.7% at 3 weeks); that is a doctor's decision. Painful xiphoid syndrome usually settles with painkillers and occasionally an injection, an American review says, and surgery is rarely needed.
The NHS suggests smaller, more frequent meals, nothing to eat within 3 or 4 hours of bed, losing weight if you need to, avoiding the food and drink that trigger it and clothes that are tight around the waist, and raising the head of the bed by 10 to 20 cm with blocks or books rather than extra pillows, which can increase pressure on your belly. A pharmacist can advise on medicines, and a GP can prescribe stronger ones. NICE agrees that raising the head of the bed and having the main meal well before bed may help some people. In pregnancy, the NHS adds propping your head and shoulders up and sleeping on your left side.
The NHS's breathing exercise for stress, breathing gently in through the nose and out through the mouth, counting up to 5 each way if it helps, for at least 5 minutes, is a comfortable way to keep the chest moving and settle worry. After a bruising blow, the NHS says breathe normally, take slow, deep breaths regularly and cough when you need to, holding a pillow against your chest, to help keep the lungs clear. Neither has been tested for breastbone pain.
Start only once a clinician has checked your chest pain. During breathing, stretching and strength work, a mild ache up to about 3 out of 10 is fine if it is in the same spot you can press on, settles within an hour and leaves you no worse the next morning. If it is worse, do less next time, not nothing. These limits are editorial, borrowed from our costochondritis and chest muscle pain guides, and deliberately lower than the 5 out of 10 used for other joints, so that a different kind of chest pain stands out. In trials of long-lasting muscle and joint pain, exercise that allowed some pain did no worse than pain-free exercise.
Stop any exercise that brings on sharp pain at the breastbone, and leave out the movements that do for now; an American review advises cutting back the activities that provoke costochondritis. After a blow to the chest, breathe normally and cough when you need to, holding a pillow against your chest (the NHS). After heart surgery through the breastbone, the surgical and cardiac rehabilitation team's limits come first; the NHS says no heavy lifting for 3 months.
Never a pain-rule question: chest discomfort that comes on with effort, such as brisk walking or stairs, and eases within a few minutes of rest, or that feels tight, squeezing or heavy, or comes with breathlessness, sweating or feeling sick. That is how angina and heart attacks behave: stop, and follow the warning signs.
Start at the first stage. Each move opens a full guide with a 3D demo.
About weeks 0 to 2, or during a flare, and only once your chest pain has been checked. Ibuprofen if it suits you, and heat, are the usual first steps; ease off whatever brings it on, such as heavy lifting, pressing or a lot of reaching, but keep walking and moving. After a blow, the NHS's breathing and coughing advice comes first (the written steps below); after heart surgery, follow your cardiac team's plan instead.
3D demoSlow breathing (6 breaths a minute)Beginner · No equipmentAt least 5 minutes, once or twice a day; small, quiet breaths if a deep breath catches the sore spot · The move page's dose, from the NHS breathing exercise; once or twice a day is the page's editorial suggestion
Easier: Breath reach · Harder: Crocodile breathing (prone diaphragmatic breathing)
3D demoTreadmill walkingBeginner · Cardio machine10 to 30 minutes most days, at a pace you can talk at · As in our costochondritis guide (editorial); walking outdoors counts the same. Stop for any chest discomfort that comes on with the effort
Harder: Treadmill jogging
3D demoShoulder rollsBeginner · No equipment10 to 15 slow circles each way, once or twice through · The move page's dose, an editorial starting point
3D demoThoracic rotationBeginner · No equipment6 rotations each side, moving with the breath, within comfort · The move page's dose
Easier: Side-lying open book · Harder: World's greatest stretch
3D demoCat-cowBeginner · No equipment8 waves, slower than feels natural · The move page's dose
Move on when: Pressing on the sore spot hurts less, a deep breath and turning are easier, and walking brings on no chest discomfort.
About weeks 2 to 6: the mobility moves daily, the strength moves 3 days a week. Lie on the less sore side for the open book, and keep everything within the pain rule.
3D demoSide-lying open bookBeginner · No equipment8 to 10 slow openings each side, pausing 2 s at the end · The move page's dose, an editorial starting point; lie on the less sore side first
Harder: Thoracic rotation
3D demoIsometric chest squeeze (palm press)Beginner · No equipment6 to 10 holds of 5 to 10 s, from gentle to firm over the stage, elbows close to your body · The move page's dose, an editorial starting point, as our chest muscle pain guide uses it
Harder: Machine chest fly (pec deck)
3D demoWall push-upBeginner · A wall2 to 3 sets of 10 to 15, a short range at first · As in our costochondritis and chest muscle pain guides (editorial)
Harder: Push-up
3D demoBand rowBeginner · A band + An anchor point3 sets of 10 to 15, stopping 2 to 3 reps short of failure · The move page's dose, an editorial starting point
3D demoDoorway chest openerBeginner · A wallLate in the stage: 2 to 3 gentle holds of 20 to 30 s, elbows low · As in our costochondritis and chest muscle pain guides (editorial). Not in the first weeks after a blow
Easier: Elbows back · Harder: Fish pose (Matsyasana)
3D demoFoam roller thoracic extensionBeginner · A foam roller5 to 8 slow breaths at each of 3 or 4 spots along the upper back · The move page's dose, an editorial starting point. Check with your clinician first if you have osteoporosis, as the move page says, and leave it out after a recent chest injury
Harder: Fish pose (Matsyasana)
Move on when: These feel comfortable, reaching and carrying the shopping don't flare it, and the wall push-ups stay within the pain rule.
From about week 6, or once it has settled, 2 or 3 days a week, one change at a time, adding range before load (the written steps below). Go back a step if pressing flares the breastbone. After heart surgery, the cardiac team's timetable replaces this stage.
3D demoIncline push-upBeginner · A bench or box3 sets of 8 to 12, lowering the surface over the weeks · As in our costochondritis and pec strain guides (editorial)
Easier: Wall push-up · Harder: Push-up
3D demoDumbbell floor pressIntermediate · A dumbbell2 to 3 sets of 8 to 12, stopping with 2 or 3 reps in reserve · The move page's dose, an editorial starting point. The floor stops your elbows at about shoulder level
Easier: Chest press machine · Harder: Bench press with chains
3D demoBand pull-apartIntermediate · A band2 to 3 sets of 15 · As in our costochondritis guide (editorial)
Easier: Prone Y-T-W raises · Harder: Tuck back lever
3D demoDead bugBeginner · No equipment8 slow reps each side · As in our costochondritis guide (editorial)
Easier: Dead bug heel taps · Harder: Forearm plank
3D demoPush-upIntermediate · No equipment3 sets, building back to your usual numbers · As in our pec strain and chest muscle pain guides (editorial)
Easier: Wall push-up · Harder: Close-grip push-up (close triceps position)
Move on when: Our suggestion: your usual pressing, lifting and sport stay within the pain rule and your chest is no worse the next morning. If it flares, drop back a stage for a few days rather than stopping. Any new chest discomfort with effort is a warning sign, not a flare.
Our 3D figure can't show these changes. No trial has tested a sleeping position for breastbone pain, so each step names its source or is our suggestion.
The breathing steps come from the NHS; the posture steps are our suggestion, because no study we read tested posture as a cause of breastbone pain.
No NHS page covers a bruised breastbone, so these steps borrow the NHS's advice for bruised or broken ribs. A broken breastbone usually follows a high-energy injury such as a car crash and often comes with other injuries, so after a serious accident, 999 or A&E comes first.
These come from the NHS, with NICE's agreement on the bed and meal timing.
No trial has tested this. These steps are our suggestion, as our chest muscle pain and pec strain guides set them out.
Source 17
Your surgical and cardiac rehabilitation team's plan comes first. The NHS says recovery usually takes 2 to 3 months, most people are back to most of their normal activities after about 6 weeks, and there should be no heavy lifting for 3 months. Lasting pain around the breastbone is common and becomes less common over the years, in two separate studies, but a wound that is getting more painful or red, bleeding or leaking pus, a high temperature or palpitations need the care team. Our exercise page for heart surgery covers the precautions.
| Habit or position | Why it matters | Instead |
|---|---|---|
| Pushing on through chest discomfort that comes on with effort | Chest discomfort brought on by exercise and eased by rest is how angina behaves. | Stop, and get it checked: see the warning signs. |
| Heavy pressing, push-ups, chest flys and dips while the breastbone is sore | They load the joints beside the breastbone, and cutting back the activities that provoke it is the usual advice. | Wall push-ups, then incline push-ups, built up gradually.Try: Wall push-up |
| Pressing on the sore spot to see if it's still there | Repeated pressing keeps it irritated (our suggestion). | Judge progress by breathing, turning and daily tasks. |
| Rolling a ball or foam roller across the front of the chest | It presses on irritated joints, with no evidence of benefit, as our costochondritis guide says. | Roll the upper back only, and check with your clinician first if you have osteoporosis.Try: Foam roller thoracic extension |
| Lying face down or on the sore side | The NHS says costochondritis can be worse lying down; the face-down advice is our suggestion. | Your back or the other side, propped up if needed. |
| A big meal late in the evening, then lying flat, with burning behind the breastbone | Heartburn is worse after eating and lying down, and the NHS says don't eat within 3 or 4 hours of bed. | Smaller, earlier meals, and raise the head of the bed. |
| Extra pillows to prop yourself up for reflux | The NHS says extra pillows can increase pressure on your belly and make reflux worse. | Blocks or books under the head end of the bed, raising it 10 to 20 cm. |
| Clothes that are tight around your waist | The NHS advises against them with heartburn. | Looser clothes. |
| Coughing hard without support | Coughing a lot is linked with costochondritis, and after a blow the NHS advises holding a pillow against your chest to cough. | Hug a pillow to your chest when you cough, and get the cough treated. |
| Staying still and breathing shallowly after a blow | The NHS says don't lie down or stay still for a long time, and take slow, deep breaths regularly, to help prevent a chest infection. | Slow breathing and short walks.Try: Slow breathing (6 breaths a minute) |
| Strapping your chest | The NHS says ribs can't easily be splinted and are left to heal naturally; no source covers strapping the breastbone. | No strapping; keep breathing and moving. |
| Starting a new, strenuous upper-body programme as soon as it settles | Recent strenuous exercise and upper-body activity often come before costochondritis, a review says. | The stage plan: wall, then incline, then full push-ups.Try: Incline push-up |
A 6-minute breathing routine: slow breathing, crocodile breathing, alternate nostril breathing, box breathing and 4-7-8 breathing.
6 minBeginner5 movesNo equipmentA 15-minute routine that moves your neck, upper back and lower back through bending, arching, side bending and twisting, then holds the spine steady.
15 minBeginner12 movesNo equipmentA 12-minute routine for a stiff upper back and rounded shoulders: chin tucks, wall angels, Y-T-W raises and open books.
12 minBeginner8 movesA foam roller, A wallA steady 30 to 45 minute cardio session at talk-but-not-sing pace: walk, cycle, row or cross-train, counting toward weekly activity guidelines.
40 minBeginner3 movesCardio machine, A wallA 3-minute standing break to repeat every 30 to 60 minutes at your desk: sit-to-stands, calf raises, marching, an upper-back turn and chin tucks.
3 minBeginner5 movesA bench or box, A wallWork up to full push-ups: wall, incline and knee push-ups, then the floor push-up and harder variations.
15 minBeginner8 movesA wall, A bench or boxIn general practice, the chest wall causes between a quarter and a half of chest pain, the heart and circulation about 1 in 7, and the lungs, anxiety and the gut most of the rest. Chest wall causes include costochondritis and strained chest muscles, but you can't tell them from the heart yourself, so chest pain always needs checking.
Call 999 for chest pain that is sudden, tight, heavy or squeezing, spreads to your arm, neck, jaw or back, or comes with breathlessness, sweating or feeling sick. Call 999 too for chest pain with sudden breathlessness or coughing up blood. For chest pain that comes and goes, see a GP or call NHS 111.
Pain you can press on, beside the breastbone, is typical of costochondritis. But it doesn't rule out the heart: in one emergency department, 6% of people diagnosed with costochondritis were having a heart attack, so get new chest pain checked first.
A burning pain after eating, lying down or bending over is usually heartburn, eased by smaller meals, nothing to eat 3 or 4 hours before bed and raising the head of the bed. Difficulty swallowing, food sticking, weight loss or heartburn most days need a GP. Burning chest pain that is sudden and doesn't go away can be the heart: call 999.
Costochondritis and bruised ribs hurt on a deep breath or a cough. Sharp pain on breathing in can also be pleurisy or pericarditis, which needs an urgent GP appointment or NHS 111. Sudden breathlessness, coughing up blood or a very fast heartbeat need 999.
Yes: panic attacks can cause chest pain, a racing heart, sweating and breathlessness, usually for 5 to 20 minutes, and anxiety and other psychological causes account for about 1 in 10 to 1 in 5 cases of chest pain in general practice. The same symptoms can come from the heart and lungs, so new chest pain needs checking before it's put down to anxiety.
Recent strenuous upper-body exercise often comes before costochondritis, and chest muscles can be strained. Ease off pressing and build back gradually, from wall push-ups up. Chest discomfort that comes on during effort and eases with rest is different: it can be angina and needs checking.
You can't tell yourself. In a Dutch trauma registry, about half of broken breastbones came from car crashes, and many came with other injuries, so go to A&E after a serious accident. Bruised or broken ribs usually heal within 2 to 6 weeks; no source we read gives a time for a bruised breastbone.
Lasting pain is common: about 1 in 5 people still had some pain 3 years after heart surgery in one survey, and about 1 in 10 had pain around the incision at 7 years in another. Contact your care team for a wound that is red, more painful or leaking, a high temperature or palpitations, and see your GP about pain that limits you.
Long COVID can cause chest pain or tightness, and pericarditis can follow a viral infection. Call 999 or go to A&E for chest pain or tightness, severe breathlessness or a pounding heart within a few days of a COVID-19 vaccine, because of a rare risk of heart inflammation.
Costochondritis was commoner in women in one emergency department (69%), but heart disease causes chest pain in women too, and the NHS says angina becomes more likely from 55 in women. In pregnancy, heartburn is common: small meals, propping your head and shoulders up and sleeping on your left side help. Pain below the ribs, or heartburn that doesn't ease with medicines, in pregnancy or the weeks after a birth needs urgent help: it can be pre-eclampsia.
Costochondritis can be worse lying down, heartburn is worse lying down, and pericarditis is worse lying down and better leaning forward. Breastbone pain that is constant or worse at night, with weight loss, a fever or night sweats, needs a GP.
Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.
