When chest pain has been investigated and the heart and lungs have been cleared, a chest wall cause is the most likely explanation — costochondritis, Tietze syndrome, slipped rib syndrome, thoracic outlet syndrome, or focal nerve pain from the rib. Patients describe these as ‘a stabbing pain when I breathe,’ ‘a tender spot on my rib,’ ‘a clicking under my ribs,’ or ‘pain that won’t go away.’ The diagnosis is usually made at the bedside, not on a scan. Dr Lawrence Okiror, Consultant Thoracic and Robotic Surgeon (GMC 6150382), reviews chest wall pain personally at London Bridge Hospital and The Lister Hospital Chelsea within 2–3 days. Self-referrals welcome.
Last reviewed: May 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
After heart and lungs have been cleared, the most likely source is the chest wall — ribs, costal cartilage, intercostal nerves, or the joints where ribs meet the spine and breastbone. Common, benign, and treatable.
A focused chest wall examination — how the pain reproduces with palpation, with movement, with the hooking manoeuvre — discriminates the common causes within minutes. Imaging confirms; it does not lead.
Each cause has a specific treatment. Most resolve with conservative management. Some — slipped rib syndrome, thoracic outlet syndrome, persistent intercostal schwannoma — have an effective surgical option when conservative measures fail.
Most chest wall pain comes from soft tissue, joints, and nerves — structures that imaging shows poorly. The discrimination between the common causes is at the bedside, not on the scan. The hooking manoeuvre under the costal margin is the test for slipped rib syndrome — a positive hook reproduces the pain. Reproducible tenderness over multiple costochondral junctions, without visible swelling, is costochondritis. The same pattern at a single junction with visible or palpable swelling is Tietze syndrome. Specific provocation tests reproduce thoracic outlet syndrome. A pinpoint tender spot along the line of one rib points to focal intercostal nerve pain — sometimes a schwannoma.
The CT may be normal in any of these. Examination decides; imaging confirms. Dr Okiror examines the chest wall personally at the first appointment, applies the specific manoeuvres, and discusses the differential and the plan in plain language. Private appointments at London Bridge Hospital and The Lister Hospital Chelsea within 2–3 working days. Self-referrals welcome.
All three are common causes of chest wall pain. They are easy to confuse from history alone but easy to discriminate at the bedside.
The hooking manoeuvre — a finger placed under the costal margin and pulled gently outward — is the single most useful bedside test for slipped rib syndrome. A positive hook reproduces the pain.
Patients describe these as ‘a stabbing pain when I breathe,’ ‘a tender spot on my rib,’ ‘a clicking under my ribs,’ ‘an ache that won’t go away,’ or ‘pain into my arm and shoulder.’ Different patterns point to different causes.
Often Misdiagnosed
A condition where the cartilage that connects the lower ribs (8th, 9th, 10th) loses its normal stability, allowing the rib tip to slip and irritate the intercostal nerve underneath. Pain is typically lower chest or upper abdomen, often misattributed to reflux, gallbladder problems, or musculoskeletal back pain. Many patients have seen multiple specialists before the diagnosis is made.
Diagnosis is by the hooking manoeuvre. Conservative management with targeted physiotherapy is first-line; surgery (cartilage excision and rib stabilisation) is highly effective when conservative measures fail. More on slipped rib syndrome →
Common — Inflammation
Both involve inflammation at the costochondral junctions — where the ribs meet the breastbone. Costochondritis affects multiple junctions, often upper ribs, with no visible swelling. Tietze syndrome affects a single junction (most often the 2nd or 3rd rib) with visible or palpable swelling at that point.
Both are benign and usually settle with anti-inflammatories and time. Neither needs surgery. Reassurance from a confident bedside diagnosis is part of the treatment, because the pain can be intense and many patients have been worried about a heart problem.
Pain into the Arm
A group of conditions where the nerves and blood vessels passing between the collarbone and the first rib become compressed. The pain pattern is usually arm, shoulder, neck, or upper chest, often with tingling, weakness, or colour change in the hand. Specific provocation tests reproduce the symptoms at the bedside.
When confirmed and conservative management fails, surgical decompression (first rib resection) resolves the symptoms in the majority of patients. More on thoracic outlet syndrome →
Focal Nerve Pain
A schwannoma is a benign tumour growing from the protective sheath around a nerve. When it arises from an intercostal nerve, it causes focal pain or tingling along the line of a single rib, sometimes with a small lump that can be felt between the ribs. The pain is well-localised, often described as a pinpoint tender spot, and may be reproduced by pressing on the same place each time.
MRI is the imaging investigation of choice. Removal — usually by robotic keyhole surgery, with the patient home within 24–48 hours — is offered when the pain is persistent, when the lesion is growing, or when the diagnosis needs to be confirmed. More on schwannoma →
Post-Trauma or Stress
Rib fractures cause sharp, well-localised pain that worsens with deep breathing, coughing, or movement. Stress fractures — particularly in runners, rowers, golfers, and those with chronic cough — can cause similar pain without a clear trauma history and are sometimes invisible on a chest X-ray.
Most heal with rest. Where multiple displaced fractures or a flail segment is present, surgical fixation (SSRF) is sometimes appropriate. More on rib fracture fixation →
Pleural & Pulmonary
Pain from the lining of the lungs (the pleura) is sharp, worse on deep breathing, and often felt to one side of the chest. It can follow pneumonia, pleural effusion, pneumothorax, or pulmonary embolism — conditions that warrant imaging and often urgent assessment. Where pleural pain is suspected, a chest X-ray and CT are the appropriate first steps.
Most chest wall pain does not need imaging. The features below are the signal that a scan is the next step.
Outpatient assessment and any subsequent surgery for chest wall pain take place at London Bridge Hospital or The Lister Hospital Chelsea. Both hospitals have the operating theatre infrastructure for keyhole and robotic chest wall surgery. London Bridge Hospital is the primary base for more complex cases, including thoracic outlet syndrome surgery and intercostal schwannoma resection. The Lister Chelsea is the second operating base, suitable for many slipped rib syndrome operations and for follow-up appointments depending on convenience.
First-appointment consultations and follow-up appointments are also available at the HCA outpatient clinics in Canary Wharf and the City of London. Surgery and overnight care take place at London Bridge Hospital or The Lister Chelsea.
If your heart and lungs have already been cleared, the most likely source is the chest wall — and that is reassuring. Most chest wall pain is benign and treatable. What matters next is a focused chest wall examination to identify which specific cause is responsible.
Most chest wall pain is from soft tissue, joints, or nerves — structures that imaging shows poorly. A normal CT does not exclude a chest wall cause; it just confirms there is nothing visibly wrong with the lungs, the airways, or the bones. The diagnosis is made at the bedside.
A focused history of how the pain behaves, followed by a chest wall examination — palpation of the costochondral junctions, the hooking manoeuvre under the lower ribs, provocation tests for thoracic outlet syndrome, and assessment of any focal tender spots. Most patients leave with a confident diagnosis and a plan in 30 minutes.
Self-referrals welcome — no GP letter needed before booking. Private appointments at London Bridge Hospital and The Lister Hospital Chelsea within 2–3 days. Bring any existing imaging or cardiac workup results. New consultations from £250. Most major insurers accepted.
Questions most commonly asked by patients with chest pain that has been investigated and where the heart and lungs have been cleared.
Book an Assessment →Or call Jo Mitchelson:
020 7952 2882
Self-referrals welcome. Private appointments at London Bridge Hospital and The Lister Hospital Chelsea within 2–3 days. Dr Okiror examines the chest wall personally and discusses the differential and treatment options at the first appointment.
Jo Mitchelson, Designated Medical PA · 020 7952 2882 · pa@lungsurgeon.co.uk
St Thomas’ Hospital #1 UK · Guy’s Hospital #2 UK · London Bridge Hospital #10 UK · Newsweek World’s Best Hospitals 2026