Costochondritis

Author(s): Michael Bruce Furman, MD, Vivek Narendra Babaria, DO and Shannon Schultz, MD, MPH

Originally published:09/20/2014

Last updated:07/03/2018

1. DISEASE/DISORDER:

Definition

Costochondritis is a type of musculoskeletal anterior chest wall syndrome. It is described as an atypical, noncardiac chest pain of the costosternal joints or the costochondral junctions. It is also known as costosternal syndrome or parasternal chondrodynia, but distinct from Tietze syndrome.1

Etiology

In most cases, there is no specific etiology. However, costochondritis may be the result of physical trauma (direct injury, strenuous lifting, severe bouts of coughing), associated with scoliosis, ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, or a tumor (benign or cancerous).13 It may follow surgical procedures involving the chest wall or esophagus, or after repetitive and/or sudden movements involving the rib cage and upper extremities. Intercostal nerve impingement is an uncommon etiology.1 Rare case series of candida costochondritis have become more prevalent with the rise of intravenous drug use.14

Epidemiology including risk factors and primary prevention

Some studies approximate a 10% prevalence for  musculoskeletal chest pain. In a 1994 emergency department study, 30% of patients with chest pain had costochondritis. Women comprised 69% of patients with costochondritis versus 31% in the control group.19

Avoidance of aggravating activities along with careful observation of proper mechanics during strenuous activities can help prevent occurrence. For example, in competitive rowers, costochondritis is typically noted in the sweep phase, and patients may experience pain during shoulder adduction.

Improvement of posture can reduce spasms from surrounding musculature that refer pain to the anterior chest.1-4

Patho-anatomy/physiology

Reproducible pain of the costochondral articulations of the anterior chest wall, usually affecting the  second to fifth costochondral joints of the ribs unilaterally. The superior ribs move with in a flexion-extension pattern mimicking the upper limbs, respiration, and with axial motion, resulting in increase inflammation. 5

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  1. Acute – primary presentation of acute pain over anterior chest wall. Typically sharp, stabbing, achy, or pressure-like. The intensity of pain is variable and exacerbated by movements of the upper extremities or trunk, deep respirations, or exercise. Adduction of the shoulder while rotating the head to the same side is a common precipitant of pain.1
  2. Sub acute – presentation is similar to acute phases but with decreased intensity of pain.1
  3. Terminal – pain is further diminished to completely resolved. With treatment, pain may resolve within one to two months but may persist for up to one year.1

Specific secondary or associated conditions and complications

Costochondritis is not associated with secondary conditions, and given that it typically self-limiting and self-resolving, there are no predictable or expected complications.

Both costochondritis and stress fractures are seen in cases of repetitive movement or activity, but there is no evidence to suggest that costochondritis causes stress fractures.

Rib stress fractures will typically present with pain in the posterior axillary line.2

It is possible that irritation to the soft tissues proximal to a stress fracture of the ribs may precipitate costochondritis in a susceptible individual.

2. ESSENTIALS OF ASSESSMENT

History

Questions regarding cardiac or upper abdominal causes of pain should be investigated, particularly if patient is over the age of 35 and/or has a personal or family history consistent with cardiac dysfunction, gastrointestinal or rheumatologic disease, or neoplasm.5

A recent history of strenuous activity, blunt trauma, coughing, or surgical procedures involving the anterior chest wall are more likely to indicate a musculoskeletal origin. The pain is variable in intensity and may be in multiple areas. Concordant pain reproducible by palpation suggests costochondritis but does not exclude other etiologies. 1

A similarly presenting condition is Tietze syndrome, which is characterized by localized swellings in the regions of pain along with inflammation over the second and third ribs (70% of cases). Tietze syndrome is more common in younger patients (< 35).

Similar conditions include: sternoclavicular joint arthritis, sternomanubrium joint pain, xiphoid syndrome, fibromyalgia, slipping rib syndrome, local neoplasms, traumatic myalgia, or herpes zoster.5

Physical examination

Careful palpation of the anterior chest wall using a single digit to reproduce concordant pain. Auscultate lungs for possible respiratory etiology and examine the skin to rule out rashes or other lesions, e.g., vesicular or dermatomal patterned.

Active and passive range of motion of the anterior chest wall musculature should be assessed. This should include, but is not limited to, the pectoralis major, the levator scapulae, the serratus anterior, and platysma. Similarly, anterior and posterior rib motion can also be evaluated with inspiration and expiration.1,6,7

Maneuvers, such as the “crowing rooster” and horizontal arm flexion maneuvers, have also been found to be useful. A study involving 1212 patients, done in an outpatient primary care setting, showed that the presence of at least two of four specific features (localized muscle tension, stinging pain, pain reproducible by palpation, and absence of cough) was associated with a diagnosis of chest wall syndrome, with 63 percent sensitivity and 79 percent specificity. 16

Functional assessment

Measurement of thoracic and cervical mobility: This is a relevant measure with costochondritis as the inflammation of the costochondral joints or the anterior chest wall can cause a reduction in mobility of the spinal area.23

Patient-specific functional scale ( PSFS): specific questionnaires for costochondritis have not yet been produced, but the PSFS is a valid, reproducible, and responsive functional assessment measure for patients with neck pain, back pain, and upper quarter complaints

The Global rating of change (GROC): to measure the patient’s subjective rate of improvement.24

Laboratory studies

There is no specific laboratory test to diagnose costochondritis. Positive laboratory inflammation markers  such as elevated CRP, ESR, and WBC count may indicate signs of infection, prolonged inflammation, and edema, which warrant further investigation. Prolonged symptoms require a work-up to rule out rheumatologic, cardiac, pulmonary, or gastro-esophageal disease which all can result in viscero-somatic pain.  1,5,6,7

Imaging

Imaging is not required to diagnose costochondritis; however, imaging can be utilized to eliminate differential diagnoses. Options include:

  1. Plain Radiographs – rule out cardiac, pulmonary etiology1
  2. CT scan – rule out cardiac, pulmonary, or soft tissue etiology1
  3. Musculoskeletal ultrasound – to differentiate between muscular, tendinous, or inflammatory etiology. Under ultrasound, an area of chest wall with costochondritis would be hypoechoic, whereas in Tietze syndrome, the area being inspected would have a dishomogeneous increase of the echogenicity in pathological cartilage and an increased thickness.8
  4. Triple-phase bone scans usually are not useful in identifying the area of pain but bone scan may become positive over time.4

Supplemental assessment tools

There are no specific assessment tools required for the diagnosis of costochondritis. It is primarily a clinical diagnosis.1,5,7,10

Early predictions of outcomes

Symptoms usually resolve within one to two months but may last for up to one year. There is insufficient data to show recurrence rates of similar presentations. 1,3,6,7  

Environmental

Environmental allergies that predispose to repeated sneezing or coughing may increase the risk of developing costochondritis. Professional or recreational activities that require repeated movements of the upper limbs and upper thoracic cage may also increase risk.1,4,14

Social role and social support system

Though not life-threatening in nature, chest pain from costochondritis can be a distressing experience for patients. Reassurance that the pain is musculoskeletal, and most often self-resolving, may help to relieve anxiety. Changes in the quality, severity or referral pattern of pain, or symptoms of nausea, dyspnea, diaphoresis, syncope, or fever warrant further/immediate investigation.1,3,6

Professional Issues

Ruling out more serious etiologies of anterior chest pain in patients with high risk is imminent.

  1. Wells Criteria to assess risk for pulmonary embolism (Level A evidence)9
  2. Diehr Criteria to assess risk for pneumonia (Level A evidence)9
  3. Rouan Criteria to assess risk for myocardial infarction (Level C evidence)9

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

Treatment of costochondritis usually consists of ice, oral analgesics, NSAIDS and/or topical analgesics.

Osteopathic manipulation aimed at correcting rib dysfunction or myofascial dysfunctions can be used in this patient population. Techniques include counterstrain, indirect myofascial release, facilitated positional release, muscle energy, articulatory and thrusting techniques for inhalation or exhalation dysfunctions of the ribs.11,12

Consider local anesthetic injection with and without steroid to affected joints. It can be performed supine. It is not necessary to advance the needle fully into the costochondral joint (to the cartilage only), as infiltration of the tissues over the joint is usually adequate for pain relief. Accuracy of needle placement is enhanced with use of ultrasound, which also significantly reduces the chances of an inadvertent and unpleasant complication of pneumothorax.10 The use of oral steroids has yet to be defined.15

Iontophoresis may be used for costochondritis and is typically done in the setting of physical therapy.4 In recurring cases, stretching, active ROM, and postural correction exercises have been shown to decrease pain and result in a quicker return to previous activities.19 Patients are encouraged to rest in the acute phase of the condition to avoid exacerbation of symptoms.

The use of acupuncture in adult patients with costochondritis has been effective with pain relief seen by 1-3 treatments.20 Preliminary research is promising regarding the role of acupuncture in adolescents suffering from costochondritis.16

Coordination of care

Multidisciplinary approach involving patient education of activity modification along with coordination of care between primary care, physiatry, physical, occupational, recreational, and vocational therapy is beneficial for the patient.  The goal is to increase patient motivation, proper body mechanics, ergonomics, and postural training to manage the musculoskeletal pain.4, 19.

Patient & family education

Patients should be informed that costochondritis is a benign condition of unknown etiology but with expectations of full recovery. 1,3 Further care may be considered if over age of 35, personal or family history of heart disease, diabetes, hypercholesterolemia, or hypertension.1 Use of mild analgesics and modalities such as ice or heat are helpful.3 Activity modification, complementary alternative treatment modalities are available for the acute and refractory phases. 3,19,23.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Like other forms of musculoskeletal pain, an injection of a 2-cc mixture of 40 mg of methylprednisolone acetate or equivalent and a local anesthetic can work quite well helping to resolve pain.11

Manual therapies, such as myofascial release, balanced ligamentous tension (BLT), rib mobilization techniques, and muscle energy techniques are non-invasive modalities of addressing pain.11,12,19 Correcting biomechanical dysfunctions may be both preventive and curative.4

Acupuncture can be an effective primary treatment or adjunct to NSAIDs.20

4. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

Though the prevalence of atypical, non-cardiac chest pain has been documented, the exact mechanism of costochondritis is not clear and often ends up as a diagnosis of exclusion. There is lack of high quality randomized, double blinded studies to draw definitive conclusions. Further research is needed to establish evidence based guidelines regarding the diagnosis and treatment of costochondritis and appropriate indications for interventions.  1,5,8,10,13,19,23

REFERENCES

  1. Proulx A, Zryd T. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80(6):617-620.
  2. Hosea T, Hamilton, J. Rowing Injuries. Sports Health. 2012;4(3): 236-245.
  3. Proulx A, Zryd, T. Costochondritis: what you need to know [Supplemental Patient information handout]. Am Fam Physician. 2009;80(6):617-s1. http://www.aafp.org/afp/2009/0915/p617-s1.html (date accessed, 9/2/14)
  4. Rumball J, Lebrun C, DiCiacca S, et al. Rowing injuries. Sports Medicine. 2005;35(6):537-555.
  5. Kasper D, Braunwald E, Hauser S, et al, eds. Harrison’s Principles of Internal Medicine. 16th ed. Vol. II. New York, NY: McGraw-Hill; 2005;2063.
  6. Flowers LK, Wippermann BD. Costochondritis. eMedicine. eds. William Chiang, et al. 2007. Medscape. 6 Mar. 2009.
  7. Anderson, CB. Office Orthopedics for Primary Care: Treatment. St. Louis, MO: Elsevier; 2006;105.
  8. Martino F, D’Amore M, Angelelli G, et al. Echographic study of Tietze’s syndrome. Clinical Rheumatology. 1991;10(1):2-4.
  9. Cayley WE. Diagnosing the cause of chest pain. Am Fam Physician. 2005;72(10):2012-2021.
  10. Jones D, Hernandez A. DeLisa’s Physical Medicine & Rehabilitation, Principles and Practice. 5th ed. Baltimore, MD: Lippencott Williams & Wilkins; 2010:1855.
  11. DiGiovanna E, Schiowitz S, Dowling D. An Osteopathic Approach to Diagnosis and Treatment. Baltimore, MD: Lippincott Williams & Wilkins; 2005:393-399.
  12. Savarese R, Copobianco J, Cox J. OMT Review: A Comprehensive Review of Osteopathic Medicine. 3rd ed. Satas Librairie Editions, Brussels, Belgium, 2003;129-133.
  13. Imamura M, Cassius DA. Costosternal Syndromes. In: Frontera WR, Silver JK, Rizzo Jr TD, eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2008:.
  14. Crawford, S. J., Swan, C. D., Boutlis, C. S., & Reid, A. B. (2016). Candida costochondritis associated with recent intravenous drug use. Idcases, 4, 59-61. doi:10.1016/j.idcr.2016.04.002
  15. Gandhi, V., & Costello, J. (2012). THE USE OF CORTICOSTEROIDS IN THE MANAGEMENT OF COSTOCHONDRITIS. Emergency Medicine Journal, 29(8), 686-686. doi:10.1136/emermed-2012-201590.4
  16. Lin, K., & Tung, C. (2017). Integrating Acupuncture for the Management of Costochondritis in Adolescents. Medical Acupuncture, 29(5), 327-330. doi:10.1089/acu.2017.1233
  17. Nowicki, J. L., Dean, N. R., & Watson, D. I. (2016). A Case Report of Candida albicans Costochondritis after a Complicated Esophagectomy. Plastic and Reconstructive Surgery-Global Open, 4(1). doi:10.1097/gox.0000000000000599
  18. Sakran, W., & Bisharat, N. (2011). Primary Chest Wall Abscess Caused by Escherichia coli Costochondritis. American Journal of the Medical Sciences, 342(3), 241-246. doi:10.1097/MAJ.0b013e31821bc1b0
  19. Zaruba, R. A., & Wilson, E. (2017). IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES. International Journal of Sports Physical Therapy, 12(3), 458-467.
  20. Li B. 106 cases of non-suppurative costal chondritis treated by acupuncture at xuanzhong point. J Tradit Chin Med. 1998; 18(3):195–196.
  21. Disla E, Rhim HR, Reddy A, Karten I, Taranta A. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994 Nov 14. 154(21):2466-9.
  22. Bösner S, Becker A, Hani MA, et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Fam Pract 2010; 27:363.
  23. Freeston J; Can Early Diagnosis and Management of Costochondritis Reduce Acute Chest Pain Admissions?; The Journal of Rheumatology November 2004, 31 (11) 2269-2271
  24. Proulx, A. Teresa. W.; Costochondritis: Diagnosis and Treatment; Am Fam Physician. 2009 Sep 15;80(6):617-620

Original Version of the Topic

Mark A. Young, MD MBA FACP, Ayanna Kersey-McMullen, DO, MSPH. Costochondritis. 09/20/2014.

Author Disclosure

Michael Bruce Furman, MD
Nothing to Disclose

Vivek Narendra Babaria, DO
Nothing to Disclose

Shannon Schultz, MD, MPH
Nothing to Disclose

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