Costochondritis

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Costochondritis
Other namesChest wall pain syndrome, costosternal syndrome
Gray390.png
The costal cartilages
Specialty Family medicine, internal medicine, general practitioners, rheumatology, orthopedics
Symptoms Chest pain
Risk factors Strenuous coughing, exercise, lifting, infection of the costosternal joint
Diagnostic method Clinical physical examination and the ruling out of other conditions
Differential diagnosis Acute coronary syndrome, pneumothorax, pulmonary embolism, aortic dissection, angina, myocardial infarction, Tietze syndrome, slipping rib syndrome, rib fracture, fibromyalgia, pneumonia
Treatment Analgesics, nonsteroidal anti-inflammatory drugs, ice, heat, rest, manual therapy, TENS unit, injections, opioids

Costochondritis, also known as chest wall pain syndrome or costosternal syndrome, is a benign inflammation of the upper costochondral (rib to cartilage) and sternocostal (cartilage to sternum) joints. 90% of patients are affected in multiple ribs on a single side, typically at the 2nd to 5th ribs. [1] Chest pain, the primary symptom of costochondritis, is considered a symptom of a medical emergency, making costochondritis a common presentation in the emergency department. One study found costochondritis was responsible for 30% of patients with chest pain in an emergency department setting. [2]

Contents

The exact cause of costochondritis is not known; however, it is believed to be due to repetitive minor trauma, called microtrauma. In rarer cases, costochondritis may develop as a result of an infectious factor. Diagnosis is predominantly clinical and based on physical examination, medical history, and ruling other conditions out. Costochondritis is often confused with Tietze syndrome, due to the similarity in location and symptoms, but with Tietze syndrome being differentiated by swelling of the costal cartilage.

Costochondritis is considered a self-limited condition that will resolve on its own. Treatment options usually involve rest, pain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), ice, heat, and manual therapy. Cases with persistent discomfort may be managed with an intercostal nerve blocking injection utilizing a combination of corticosteroids and local anesthetic. The condition predominantly affects women over the age of 40, though some studies have found costochondritis to still be common among adolescents presenting with chest pain. [1] [3] : 388 

Presentation

Anatomy of the costal cartilage Costal Cartilage.png
Anatomy of the costal cartilage

Costochondritis typically presents unilaterally (one side), which is typically the left side. [4] It affects primarily the 2nd to 5th ribs at the sternocostal and costochondral joints. [1] The most commonly reported symptom of costochondritis is chest pain that is often exacerbated by movement and deep breathing. Pain is typically widespread and reproducible with palpation of the anterior (front) chest at the affected joints. [5] [6] : 171  Pain from costochondritis can vary between individuals, and is typically described as a sharp, aching, dull, or pressure-like pain. [7] It may also be accompanied by a radiating pain to the shoulder, arm, front neck, or scapula (shoulder blade). [8] : 550 

The condition usually onsets gradually following repetitive coughing, strenuous physical activity, or trauma to the chest. [1] [6] : 171  Symptoms of costochondritis may be recurrent and last weeks to months; however, refractory cases of the condition can persist to over a year. [9] [10]

Costochondritis does not present with heat, erythema, or swelling of the affected area, the presence of which would indicate Tietze syndrome. [5] : 171  [9] Additionally, symptoms such as tachycardia, hypotension, radiating pain, shortness of breath, fever, nausea, or a productive cough are unrelated to costochondritis. These signs warrant further investigation for other, more serious causes of chest pain. [7]

Cause

The exact etiology of costochondritis is unknown. [6] Repetitive minor trauma is proposed to be a likely cause, with risk factors such as strenuous coughing, exercise, and lifting identified. [11]

Infection of the costosternal joint may cause costochondritis in rare cases. Most cases of infectious costochondritis are caused by Actinomyces ,7 Staphylococcus aureus , Candida albicans , and Salmonella . In rare cases, Escherichia coli can be a cause of infectious costochondritis. [12]

Pathogenesis

The pathogenesis underlying the development of costochondritis remains unclear. Proposed mechanisms of pain include neurogenic inflammation, muscular imbalances, neuropathy of the intercostal nerves, myofascial pain, or mechanical dysfunction. [8] [13]

Diagnosis

Costochondritis is predominately a clinical diagnosis only after life-threatening conditions have been ruled out, with physical examination and medical history being considered. Before a costochondritis diagnosis is made, other serious causes of chest pain are investigated. Further evaluation for cardiopulmonary or neoplastic causes is typically based on history, age, and risk factors, with diagnostic imaging and tests, completed to assess for life-threatening emergencies. If there is a suspicion of infection or a rheumatoid condition, laboratory work may be conducted. [10] [6]

A physical exam will assess for tenderness or pain upon palpation, with an absence of heat, erythema, or swelling. The physical exam may assess if the pain is worsened with movements of the upper body or breathing, and may be reproduced upon using the crowing rooster maneuver, the hooking maneuver, or the horizontal flexion maneuver. Medical history is considered in diagnosing costochondritis, such as inquiry regarding any recent trauma, coughing, exercise, or activity involving the upper body that may have caused the symptoms. [6] [14]

Differential diagnosis

Cardiopulmonary

Life-threatening medical emergencies that may be associated with chest wall pain include acute coronary syndrome, aortic dissection, pneumothorax, or pulmonary embolism. Other cardiopulmonary causes of chest pain similar to that produced by costochondritis may include but are not limited to myocardial infarction, angina, and pericarditis. [6] [15] With costochondritis, the pain is typically worse with respiration, with movement, or within certain positions. Typically with other causes of chest pain, individuals will likely have radiating pain, shortness of breath, fever, a productive cough, nausea, dizziness, tachycardia, or hypotension. [7]

These conditions will be ruled out using tests such as X-rays, which will help assess for pneumonia, pneumothorax, lung mass, and other concerns. Other tests such as an electrocardiogram (ECG) can be performed to exclude infection, ischemia, and other conditions. A laboratory workup can rule out acute coronary syndrome, pulmonary embolism, and pneumonia. Costochondritis will yield normal results for these tests. [7]

Muscles of the thoracic wall 1114 Thorax.jpg
Muscles of the thoracic wall

Musculoskeletal

There are several musculoskeletal conditions similar to costochondritis that are often confused. [6] One such condition includes Tietze syndrome, which is often confused with costochondritis due to the similarity in location and symptomatology. Typically, costochondritis is a more common condition that is not associated with any swelling, affects multiple joints (usually of the 2nd to 5th ribs), and is usually seen in individuals older than 40 years of age. Tietze syndrome is a rarer condition that usually has visible swelling, commonly affecting a single joint (usually of the 2nd or 3rd rib), and typically seen in individuals younger than 40 years of age. [16]

A similar condition known as slipping rib syndrome is also associated with chest pain and inflammation of the costal cartilage. [17] Unlike costochondritis, the pain associated with slipping rib syndrome is often felt in the lower ribs, abdomen, and back, commonly affecting the interchondral junctions of the false 8th to 10th ribs. [18] [19] Costochondritis is typically experienced within the sternocostal junctions of the true 2nd to 5th ribs.

Other musculoskeletal conditions that may cause chest pain similar to costochondritis includes but are not limited to, painful xiphoid syndrome, muscle strain, myofascial pain syndrome, thoracic disk herniation, and rib fracture. [6] [20]

Other

Treatment

Costochondritis is usually self-limited, [15] meaning that it will typically resolve on its own without treatment. Conservative methods are often the first method to treat the condition. If the condition is a result of trauma or over-use of the upper extremity, individuals will be told to rest and avoid activities. Pain relief medications (analgesics) such as acetaminophen, or the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or meloxicam may be suggested to relieve discomfort. [7] [15] If the pain is localized, occasionally creams and patches containing compounds such as capsaicin, NSAIDs, or lidocaine may be used. [15] Heat or ice compresses may also be used for treatment. [6]

Outpatient follow-up may also be a form of treatment for costochondritis. Manual therapy methods such as myofascial release, muscle energy techniques, balanced ligamentous tension (BLT), rib mobilization techniques, and stretching exercises may be used. Additionally, educating the individual with costochondritis about their body mechanics, posture, and activity modification can be beneficial. [7] [6]

In severe cases where symptoms do not resolve and last up to a year or longer, corticosteroids or local anesthetic injections may be considered. [10]

Epidemiology

Costochondritis is a common condition that is responsible for approximately 13–36% of acute chest pain-related concerns from adults depending on the setting, with 14–39% for adolescents. [8] It is most often seen in individuals who are older than 40 years of age and occurs more often in women than in men. [3]

Related Research Articles

<span class="mw-page-title-main">Cough</span> Sudden expulsion of air from the lungs as a reflex to clear irritants

A cough is a sudden expulsion of air through the large breathing passages which can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three phases: an inhalation, a forced exhalation against a closed glottis, and a violent release of air from the lungs following opening of the glottis, usually accompanied by a distinctive sound.

<span class="mw-page-title-main">Shortness of breath</span> Feeling of difficulty breathing

Shortness of breath (SOB), known as dyspnea or dyspnoea, is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity", and recommends evaluating dyspnea by assessing the intensity of its distinct sensations, the degree of distress and discomfort involved, and its burden or impact on the patient's activities of daily living. Distinct sensations include effort/work to breathe, chest tightness or pain, and "air hunger". The tripod position is often assumed to be a sign.

<span class="mw-page-title-main">Compartment syndrome</span> Condition in which increased pressure results in insufficient blood supply

Compartment syndrome is a condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space. There are two main types: acute and chronic. Compartments of the leg or arm are most commonly involved.

<span class="mw-page-title-main">Thorax</span> Frontal part of an animals body, between its head and abdomen

The thorax or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the creature's body, each of which is in turn composed of multiple segments.

<span class="mw-page-title-main">Tietze syndrome</span> Inflammation, tenderness, and pain of the chest wall with swelling present

Tietze syndrome is a benign inflammation of one or more of the costal cartilages. It was first described in 1921 by German surgeon Alexander Tietze and was subsequently named after him. The condition is characterized by tenderness and painful swelling of the anterior (front) chest wall at the costochondral, sternocostal, or sternoclavicular junctions. Tietze syndrome affects the true ribs and has a predilection for the 2nd and 3rd ribs, commonly affecting only a single joint.

<span class="mw-page-title-main">Chest pain</span> Discomfort or pain in the chest as a medical symptom

Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with nausea, sweating, or shortness of breath. It can be divided into heart-related and non-heart-related pain. Pain due to insufficient blood flow to the heart is also called angina pectoris. Those with diabetes or the elderly may have less clear symptoms.

<span class="mw-page-title-main">Pancoast tumor</span> Medical condition

A Pancoast tumor is a tumor of the apex of the lung. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. Most Pancoast tumors are non-small-cell lung cancers.

<span class="mw-page-title-main">Nasal septum deviation</span> Disorder of the nose

Nasal septum deviation is a physical disorder of the nose, involving a displacement of the nasal septum. Some displacement is common, affecting 80% of people, mostly without their knowledge.

<span class="mw-page-title-main">Ear pain</span> Pain in the ear

Ear pain, also known as earache or otalgia, is pain in the ear. Primary ear pain is pain that originates from the ear. Secondary ear pain is a type of referred pain, meaning that the source of the pain differs from the location where the pain is felt.

<span class="mw-page-title-main">Chondromalacia patellae</span> Medical condition

Chondromalacia patellae is an inflammation of the underside of the patella and softening of the cartilage.

<span class="mw-page-title-main">Relapsing polychondritis</span> Medical condition

Relapsing polychondritis is a systemic disease characterized by repeated episodes of inflammation and in some cases deterioration of cartilage. The disease can be life-threatening if the respiratory tract, heart valves, or blood vessels are affected. The exact mechanism is poorly understood.

<span class="mw-page-title-main">Costal cartilage</span> Resilient, smooth, glass-like tissue at the front ends of ribs in vertebrates

The costal cartilages are bars of hyaline cartilage that serve to prolong the ribs forward and contribute to the elasticity of the walls of the thorax. Costal cartilage is only found at the anterior ends of the ribs, providing medial extension.

Myofascial pain syndrome (MPS), also known as chronic myofascial pain (CMP), is a syndrome characterized by chronic pain in multiple myofascial trigger points ("knots") and fascial constrictions. It can appear in any body part. Symptoms of a myofascial trigger point include: focal point tenderness, reproduction of pain upon trigger point palpation, hardening of the muscle upon trigger point palpation, pseudo-weakness of the involved muscle, referred pain, and limited range of motion following approximately 5 seconds of sustained trigger point pressure.

<span class="mw-page-title-main">Subcutaneous emphysema</span> Abnormal presence of air or gas under the skin

Subcutaneous emphysema occurs when gas or air accumulates and seeps under the skin, where normally no gas should be present. Subcutaneous refers to the subcutaneous tissue, and emphysema refers to trapped air pockets. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs around the upper torso, such as on the chest, neck, face, axillae and arms, where it is able to travel with little resistance along the loose connective tissue within the superficial fascia. Subcutaneous emphysema has a characteristic crackling-feel to the touch, a sensation that has been described as similar to touching warm Rice Krispies. This sensation of air under the skin is known as subcutaneous crepitation, a form of crepitus.

In medicine, Carnett's sign is a finding on clinical examination in which (acute) abdominal pain remains unchanged or increases when the muscles of the abdominal wall are tensed. For this part of the abdominal examination, the patient can be asked to lift the head and shoulders from the examination table to tense the abdominal muscles. An alternative is to ask the patient to raise both legs with straight knees.

<span class="mw-page-title-main">Chest pain in children</span> Medical condition

Chest pain in children is the pain felt in the chest by infants, children and adolescents. In most cases the pain is not associated with the heart. It is primarily identified by the observance or report of pain by the infant, child or adolescent by reports of distress by parents or caregivers. Chest pain is not uncommon in children. Many children are seen in ambulatory clinics, emergency departments and hospitals and cardiology clinics. Most often there is a benign cause for the pain for most children. Some have conditions that are serious and possibly life-threatening. Chest pain in pediatric patients requires careful physical examination and a detailed history that would indicate the possibility of a serious cause. Studies of pediatric chest pain are sparse. It has been difficult to create evidence-based guidelines for evaluation.

<span class="mw-page-title-main">Slipping rib syndrome</span> Pain in the false ribs due to the partial dislocation of the costal cartilage

Slipping rib syndrome (SRS) is a condition in which the interchondral ligaments are weakened or disrupted and have increased laxity, causing the costal cartilage tips to subluxate. This results in pain or discomfort due to pinched or irritated intercostal nerves, straining of the intercostal muscles, and inflammation. The condition affects the 8th, 9th, and 10th ribs, referred to as the false ribs, with the 10th rib most commonly affected.

<span class="mw-page-title-main">Twelfth rib syndrome</span> Medical condition caused by mobile floating ribs

Twelfth rib syndrome, also known as rib tip syndrome, is a painful condition that occurs as a result of highly mobile floating ribs. It commonly presents as pain that may be felt in the lower back or lower abdominal region as a result of the 11th or 12th mobile rib irritating the surrounding tissues and nervous systems. Diagnosis is often made by a physical examination after other conditions are ruled out. The condition is often labelled as slipping rib syndrome due to the unclear definitions of the conditions, with twelfth rib syndrome sometimes being referred to as a subtype of slipping rib syndrome.

<span class="mw-page-title-main">Iliocostal friction syndrome</span> Medical condition

Iliocostal friction syndrome, also known as costoiliac impingement syndrome, is a condition in which the costal margin comes in contact with the iliac crest. The condition presents as low back pain which may radiate to other surrounding areas as a result of irritated nerve, tendon, and muscle structures. It may occur unilaterally due to conditions such as scoliosis, or bilaterally due to conditions such as osteoporosis and hyperkyphosis.

<span class="mw-page-title-main">Amplified musculoskeletal pain syndrome</span> Condition characterized by amplified and chronic pain

Amplified musculoskeletal pain syndrome (AMPS) is an illness characterized by notable pain intensity without an identifiable physical cause.

References

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