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]
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 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]
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]
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
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.
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]
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]
^Hoffman RJ, Wang VJ, Scarfing R, Godambe S, Nagler J, eds. (2019). Fleisher and Ludwig's 5-Minute Pediatric Emergency Medicine Consult (2nd ed.). Philadelphia: Wolters Kluwer. ISBN978-1-4963-9455-2. OCLC1202480568.
^Sakran W, Bisharat N (September 2011). "Primary chest wall abscess caused by Escherichia coli costochondritis". The American Journal of the Medical Sciences. 342 (3): 241–6. doi:10.1097/MAJ.0b013e31821bc1b0. PMID21681074. S2CID28782743.
^Ayloo A, Cvengros T, Marella S (December 2013). "Evaluation and treatment of musculoskeletal chest pain". Primary Care (Review). 40 (4): 863–87, viii. doi:10.1016/j.pop.2013.08.007. PMID24209723.
^Fares MY, Dimassi Z, Baydoun H, Musharrafieh U (February 2019). "Slipping Rib Syndrome: Solving the Mystery of the Shooting Pain". The American Journal of the Medical Sciences. 357 (2): 168–73. doi:10.1016/j.amjms.2018.10.007. PMID30509726. S2CID54554663.
^ abGoh DL, Ramamurthy MB (2017). "Chapter 15: Chest Pain". In Field DJ, Isaacs D, Stroobant J (eds.). Pediatric Differential Diagnosis - Top 50 Problems (1st Southeast Asia ed.). Elsevier Health Sciences. pp. 157–64. ISBN978-981-4666-24-4.
^Riveiro V, Ferreiro L, Toubes ME, Lama A, Álvarez-Dobaño JM, Valdés L (March 2018). "Characteristics of patients with myelomatous pleural effusion. A systematic review". Revista Clinica Espanola (in Spanish and English). 218 (2): 89–97. doi:10.1016/j.rce.2017.11.001. PMID29197468.
^Agrawal PR, Scarabelli TM, Saravolatz L, Kini A, Jalota A, Chen-Scarabelli C, et al. (November 2015). "Current strategies in the evaluation and management of cocaine-induced chest pain". Cardiology in Review. 23 (6): 303–11. doi:10.1097/CRD.0000000000000050. PMID25580707. S2CID8362920.