Costochondritis

Costochondritis
Other names	chest wall pain syndrome, costosternal syndrome
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) junctions. 90% of patients are affected in multiple ribs on a single side, typically at the 2nd to 5th ribs.^[1] The condition is thought to be caused by repetitive minor trauma, known as microtrauma, and in rare cases can be caused by an infectious factor. Chest pain is considered a symptom of a medical emergency, and 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 and misdiagnosed several other conditions, especially Tietze syndrome, due to the similarity in location and symptoms. However, costochondritis and Tietze syndrome are differentiated by the absence of costal cartilage swelling in costochondritis.

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 is responsible for approximately 16-36% of acute chest pain concerns by adults, and predominantly affects women over the age of 40.^[3][4]

The most commonly reported symptom of costochondritis is chest pain that is often worse with movements and deep breathing. Pain is typically widespread and can be reproducible with palpation of the costosternal and costochondral joints on the chest.^[5] Costochondritis pain varies between individuals and may be described as dull or sharp.^[6] The condition is usually gradual onset and may happen after repetitive upper body movements, a history of trauma to the chest, or following a cough. Symptoms usually will resolve within a few weeks to some months however, costochondritis can also persist for up to a year or more in some cases.^[7]

Costochondritis does not present with swelling of the affected area, which would indicate Tietze syndrome.^[5] Additionally, symptoms such as tachycardia, hypotension, radiating pain, shortness of breath, fever, nausea, or a productive cough will lead to concerns for other more serious causes of chest pain, as it is not associated with costochondritis.^[6]

The exact etiology of costochondritis is unknown.^[8] Repetitive minor trauma is proposed to be a likely cause, with risk factors such as strenuous coughing, exercise, and lifting identified.^[9]

Infection of the costosternal joint may cause costochondritis in rare cases. Most cases of infectious costochondritis are caused by Actinomyces, Staphylococcus aureus, Candida albicans, and Salmonella. In rare cases, Escherichia coli can be a cause of infectious costochondritis.^[10]

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. ^{[4] [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.^[7][8]

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.^[8][12]

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.^[8][13] 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.^[6]

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.^[6]

There are several musculoskeletal conditions similar to costochondritis that are often confused.^[8] 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.^[14]

A similar condition known as slipping rib syndrome is also associated with chest pain and inflammation of the costal cartilage.^[15] 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.^[16][17] 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.^[8][18]

• Rheumatologic conditions such as fibromyalgia, SAPHO syndrome, ankylosing spondylitis, rheumatoid arthritis, and psoriatic arthritis can cause symptoms similar to costochondritis.^[8][13]
• Oncology-related conditions, namely neoplasms and myelomatous pleural effusion have been associated with chest pain.^[8][19]
• Chest pain is occasionally experienced with respiratory-related conditions such as pleuritis, precordial catch syndrome, and pneumonia.^[6][13]
• Psychogenic conditions such as anxiety disorders, panic disorders, and hyperventilation syndrome may cause chest pain.^[18][20]
• Some gastroenterology conditions may be associated with costochondritis-like chest pain such as gastroesophageal reflux disease, and esophagitis.^[20]
• Viral infections such as herpes zoster and Bornholm disease are seen as differential diagnoses for costochondritis due to chest pain being a reported symptom.^{[citation needed]}
• Vitamin D deficiency can be a differential diagnosis for costochondritis as it may cause chest pain.^[8]
• Chest pain has also been reported following the use of cocaine, which can increase the risk of various cardiovascular conditions.^[21]

Costochondritis is referred to as being self-limited,^[13] which is a condition in which will typically resolve on its own without treatment.^[22] 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.^[6][13] If the pain is localized, occasionally creams and patches containing compounds such as capsaicin, NSAIDs, or lidocaine may be used.^[13] Heat or ice compresses may also be used for treatment.^[8]

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.^[6][8]

In severe cases where symptoms do not resolve and last up to a year or longer, corticosteroids or local anesthetic injections may be considered.^[7]

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.^[4] 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]