Costochondritis – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Anterior chest wall pain associated with pain and tenderness of the costochondral and costosternal regions
  • System(s) affected: Musculoskeletal
  • Synonym(s): Costosternal syndrome; Parasternal chondrodynia; Anterior chest wall syndrome; Tietze disease and syndrome; Chondrocostal junction syndrome

Pediatric Considerations

Pay special attention to psychogenic chest pain in children who perceive family discord.

Epidemiology

  • Predominant age: 20–40 years
  • Predominant gender: Female

Incidence

∼10% of chest pain complaints; 15–20% of teenagers with chest pain may have costochondritis.

Risk Factors

  • Unusual physical activity or overuse
  • Recent trauma (including motor vehicle accident, domestic violence, etc.) or new activity
  • Recent upper respiratory infection (URI)

Etiology

  • Not fully understood
  • Trauma
  • Overuse

Commonly Associated Conditions

URI

Chest pain, Physical examination, Non-steroidal anti-inflammatory drug, causes of chest pain, motor vehicle accident, syndrome tietze, upper respiratory infection, costochondral, pleuritic pain,

Diagnosis

  • Insidious onset
  • Pain, usually sharp, sometimes pleuritic
  • Pain involves multiple locations, the 2nd–5th costal cartilages are most often involved.
  • Pain worsens with movement and breathing.
  • Heat often relieves pain.
  • Chest tightness is often associated with the pain.
  • Pain sometimes radiates into arm.
  • Nonsuppurative edema and tenderness at rib articulations
  • Redness and warmth at sites of tenderness

History

A complete and thorough history is mandatory for the diagnosis, with special emphasis on cardiac risk factor evaluation.

Physical Exam

A physical exam to exclude more serious conditions that may present with chest pain is necessary for the diagnosis. Tenderness elicited over the costochondral junctions is necessary to establish the diagnosis, but does not completely exclude other causes of chest pain.

Geriatric Considerations

  • Often presents with multiple problems capable of causing chest pain, making a thorough history and physical exam imperative.

Diagnostic Tests & Interpretation

Lab

  • The diagnosis of costochondritis is primarily based on a thorough history and physical exam.
  • Laboratory exams should be used only if concern exists regarding other elements of the differential diagnosis.
  • Erythrocyte sedimentation rate is inconsistently elevated.

Imaging

No imaging is indicated for the diagnosis of costochondritis; chest x-ray normal.

Diagnostic Procedures/Surgery

None indicated for the diagnosis of costochondritis

Pathological Findings

Costochondral joint inflammation

Differential Diagnosis

  • Cardiac:
    • Coronary artery disease
    • Aortic aneurysm
    • Mitral valve prolapse
    • Pericarditis
    • Myocarditis
  • Gastrointestinal:
    • Gastroesophageal reflux
    • Peptic esophagitis
    • Esophageal spasm
    • Gastritis
  • Musculoskeletal:
    • Fibromyalgia
    • Slipping rib syndrome involves the lower ribs
    • Costovertebral arthritis
    • Painful xiphoid syndrome
    • Rib trauma with swelling
    • Thoracic disc compression
    • Ankylosing spondylitis
    • Epidemic myalgia
    • Precordial catch syndrome
  • Psychogenic:
    • Anxiety disorder
    • Panic attacks
    • Hyperventilation
  • Respiratory:
    • Asthma
    • Pulmonary embolism
    • Pneumonia
    • Chronic cough
    • Pneumothorax
  • Other:
    • Domestic violence and abuse
    • Herpes zoster
    • Spinal tumor
    • Metastatic cancer
    • Substance abuse (cocaine)

Treatment

Reassurance of benign nature of condition

Medication

First Line

Nonsteroidal anti-inflammatory drugs (aspirin, ibuprofen, naproxen, or diclofenac). Narcotics rarely indicated (1,2)[C].

Second Line

Acetaminophen (1,2)[C]

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Additional Treatment

General Measures

  • Patient reassurance, rest, and heat (or ice massage)
  • Stretching exercises

Complementary and Alternative Medicine

Limited data on use of manipulation or ice massage, but may be safely tried if patient interested

In-Patient Considerations

Admission Criteria

Only indicated if differential diagnosis is unclear and cardiac or other more serious etiology of chest pain is being considered (3)[C]

Discharge Criteria

When diagnosis is established

Ongoing Care

Follow-Up Recommendations

Follow-up within 1 week if diagnosis is unclear

Diet

Normal

Patient Education

Educate the patient in regard to the self-limited (although potentially recurrent) nature of the illness. Instruct patient on proper physical activity regimens to avoid overuse syndromes. Also stress importance of avoiding sudden, significant changes in activity.

Prognosis

  • Self-limited illness, although sometimes chronic
  • Often recurs

Complications

Incomplete attention to differential diagnosis or inappropriate interventions in a desire to ensure that a more life-threatening diagnosis is not missed

References

1. Freeston J, Karim Z, Lindsay K, et al. Can early diagnosis and management of costochondritis reduce acute chest pain admissions? J Rheumatol. 2004;31:2269–71.

2. Jensen S. Musculoskeletal causes of chest pain. Aust Fam Physician. 2001;30:834–9.

3. Mukamel M, Kornreich L, Horev G, et al. Tietze’s syndrome in children and infants. J Pediatr. 1997;131:774–5.

Additional Reading

Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med.1994;154:2466–9.

Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002;32:235–50.

Rovetta G, Sessarego P, Monteforte P et al. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. 169–71.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Chest Pain

Codes

ICD9

733.6 Tietze’s disease

Snomed

64109004 Costal chondritis (disorder)

Clinical Pearls

  • A very common disorder, accounting for perhaps 10% of all cases of chest pain, and a greater percentage in teenagers and young adults
  • Educate the patient in regard to the self-limited (although potentially recurrent) nature of the illness. Instruct patient on proper physical activity regimens to avoid overuse syndromes. Also stress importance of avoiding sudden, significant changes in activity.
  • Consider an anxiety disorder as a contributor to all cases of persistent chest pain, whether musculoskeletal or cardiac.

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