- 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
Pay special attention to psychogenic chest pain in children who perceive family discord.
- Predominant age: 20–40 years
- Predominant gender: Female
∼10% of chest pain complaints; 15–20% of teenagers with chest pain may have costochondritis.
- Unusual physical activity or overuse
- Recent trauma (including motor vehicle accident, domestic violence, etc.) or new activity
- Recent upper respiratory infection (URI)
- Not fully understood
Commonly Associated Conditions
- 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
A complete and thorough history is mandatory for the diagnosis, with special emphasis on cardiac risk factor evaluation.
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.
- Often presents with multiple problems capable of causing chest pain, making a thorough history and physical exam imperative.
Diagnostic Tests & Interpretation
- 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.
No imaging is indicated for the diagnosis of costochondritis; chest x-ray normal.
None indicated for the diagnosis of costochondritis
Costochondral joint inflammation
- Coronary artery disease
- Aortic aneurysm
- Mitral valve prolapse
- Gastroesophageal reflux
- Peptic esophagitis
- Esophageal spasm
- 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
- Anxiety disorder
- Panic attacks
- Pulmonary embolism
- Chronic cough
- Domestic violence and abuse
- Herpes zoster
- Spinal tumor
- Metastatic cancer
- Substance abuse (cocaine)
Reassurance of benign nature of condition
Nonsteroidal anti-inflammatory drugs (aspirin, ibuprofen, naproxen, or diclofenac). Narcotics rarely indicated (1,2)[C].
- 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
Only indicated if differential diagnosis is unclear and cardiac or other more serious etiology of chest pain is being considered (3)[C]
When diagnosis is established
Follow-up within 1 week if diagnosis is unclear
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.
- Self-limited illness, although sometimes chronic
- Often recurs
Incomplete attention to differential diagnosis or inappropriate interventions in a desire to ensure that a more life-threatening diagnosis is not missed
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.
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
733.6 Tietze’s disease
64109004 Costal chondritis (disorder)
- 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.