Costochondritis

Author(s): Mark A. Young, MD MBA FACP, Ayanna Kersey-McMullen, DO, MSPH

Originally published:09/20/2014

Last updated:09/20/2014

1. DISEASE/DISORDER:

Definition

Costochondritis is pain of the costosternal joints, or the costochondral junctions of the anterior ribs, most commonly the 2nd-5th. Also known as costosternal syndrome, parasternal chondrodynia, or anterior chest wall syndrome. Similar to Tietze syndrome, but distinct, as it is not characterized by edema, inflammation or laboratory changes.1

Etiology

Costochondritis does not always have a specific etiology. It may follow surgical procedures involving the chest wall, after repetitive and/or sudden movements involving the rib cage and upper extremities. Intercostal nerve impingement may be a rare etiology of pain.1 For example, in competitive rowers, costochondritis can present insidiously and is exacerbated with an oar striking the chest at the end of a stroke.2

Epidemiology including risk factors and primary prevention

Costochondritis is typically seen in women over the age of forty, but can present at any age and gender. It is exacerbated by deep inspiration (sneezing, coughing and valsalva) and twisting motions of the chest. Avoidance of these activities along with careful observation of proper mechanics during strenuous activities can help alleviate pain. Proper technique during repetitive motions, as with athletic activities, may reduce the risk of developing costochondritis. In competitive rowers, costochondritis is typically noted in sweep phase, due to an increased moment of rotation from the catch position. Therefore, patients may experience pain during adduction of the shoulder. Focus would be improvement of posture as spasms from surrounding musculature can refer pain to the anterior chest.1-4

Patho-anatomy/physiology

Costochondritis presents as reproducible pain of the costochondral articulations of the anterior chest wall, usually affecting the third, fourth, and fifth costochondral joints of the ribs. The ribs move with motions of the upper extremities, respiration, and with movement of the trunk.5Therefore, any of these movements can create an environment where costochondritis can occur, particularly in the case of repetitive movements.

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

  1. Acute – primary presentation is 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 costochondritis is most often 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 would cause stress fractures. In addition, unlike rib stress fractures that will typically present with pain in the posterior axillary line, patients with costochondritis will present with pain anteriorly at the interface of the rib costocartilage.2However, 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

Recent history of strenuous activity, coughing, or surgical procedures involving the anterior chest wall. The pain is variable in intensity and may be in multiple areas of the chest wall, though typically unilateral. Pain that is reproducible by palpation is suggestive of 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 also more common in patients 35 and younger. Similar conditions include: sternoclavicular joint arthritis, sternomanubrium joint pain, xiphoid syndrome, fibromyalgia, slipping rib syndrome, local neoplasms, traumatic myalgia, or herpes zoster.5

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

Physical examination

Careful palpation of the anterior chest wall using a single digit to reproduce pain. Lungs should be auscultated for possible respiratory sources of pain and skin should be examined 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.1,6,7

Functional assessment

There is no evidence to support the use of assistive devices in patients experiencing symptoms of costochondritis;1,5,7,10 however, devices such as long-handled reaching devices and long-handled sponges may be useful in management of the activities of daily living in the short term if the patient is experiencing significant pain that limits movement.

Laboratory studies

Laboratory tests are generally not needed as costochondritis is a clinical diagnosis. However, signs of infection or prolonged inflammation warrant further investigation. Chest radiographs, electrocardiograms, chest CT, and musculoskeletal ultrasound help to rule out more serious etiologies. Positive laboratory inflammation markers, such as elevated c-reactive protein, ESR, and WBC count. Prolonged symptoms require a work-up to rule out rheumatologic, cardiac, pulmonary, or gastro-esophageal disease. 1,5,6,7

Imaging

Imaging is not required to diagnose costochondritis. If the diagnosis is unclear, imaging can be utilized to eliminate differential diagnoses. Imaging options include:

  1. Plain Radiographs – to rule out cardiac or pulmonary etiology1
  2. CT scan – to rule out cardiac, pulmonary or soft tissue etiology1
  3. Musculoskeletal ultrasound – to differentiate between muscular, tendonous, 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. Plain X-ray film and a 3-phase bone scan 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

Patients are expected to recover fully from acute episodes of costochondritis, even without intervention. Treatment includes reassurance, analgesics, topical analgesics, local injection, manual manipulation, rest, and correction of body mechanics that could exacerbate pain. Symptoms typically resolve within one to two months but may last for up to one year.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

One should rule out more serious etiologies of anterior chest pain in patients with high risk.

  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 strain-counter strain, indirect myofascial release, facilitated positional release, as well as articulatory and thrusting techniques for inhalation or exhalation dysfunctions of the ribs.11,12

Local anesthetic injection w/wo cortisone to affected joints may also be beneficial. It can be perfomed supine, to the site of tenderness, and in standard aseptic fashion. 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

Iontophoresis may be used for costochondritis and is typically done in the setting of physical therapy.4 In reoccurring cases, stretching, ROM, and postural correction exercises may also be helpful. Patients are encouraged to rest in the acute phase of the condition to avoid exacerbation of symptoms.

Coordination of care

  1. Education in activity modification, proper body mechanics, ergonomics, and postural training.4
  2. Use of moist heat or ultrasound modalities. Kinesio-taping has recently been shown to improve upper extremity control and function.2,4
  3. Correction of muscle imbalances, especially of the anterior chest wall and thoracic rib cage.4,11
  4. Home exercise program in conjunction with therapy.
  5. Refractory cases of costochondritis may receive corticosteroid or lidocaine injections.10,13

Patient & family education

  1. Patients should be informed that costochondritis is a benign condition with expectations of full recovery. 1,3
  2. Further care may be considered if over age of 35, personal or family history of heart disease, diabetes, hypercholesterolemia, or hypertension.1
  3. Use of mild analgesics and modalities such as ice or heat are helpful.3

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

  1. 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
  2. Manual therapies, such as myofascial release, balanced ligamentous tension (BLT), rib mobilization techniques, and muscle energy techniques are non-invasion ways of addressing pain.11,12
  3. Correcting biomechanical dysfunctions may be both preventive and curative.4

4. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

Gaps in Evidence-based knowledge 1,5,8,10,13

  1. Cause of costochondritis unknown
  2. Unknown why some patients have longer course of condition

Issues for consideration when deciding whether to inject the anterior chest for the treatment of costochondritis:

  1. Severity of pain and its impact on function
  2. Technical skill of provider
  3. Patient’s requirement for work/athletics
  4. Failure to respond to more conservative modalities

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:.

Author Disclosure

Mark A. Young, MD MBA FACP
Nothing to Disclose

Ayanna Kersey-McMullen, DO, MSPH
Nothing to Disclose

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