Costochondritis

Costochondritis, also known as chest wall pain, costosternal syndrome, or costosternal chondrodynia[1] is an acute[2] and often temporary inflammation of the costal cartilage, the structure that connects each rib to the sternum at the costosternal joint. The condition is a common cause of chest pain.[1][3][4] Though costochondritis often resolves on its own, it can be a recurring condition that has little or no signs of onset.[5]

Costochondritis
The costal cartilages
SpecialtyPain rehabilitation, Rheumatology
SymptomsPain and, inflammation in the costal cartilage
ComplicationsArthritis, Chest injuries
Diagnostic methodBased on symptoms
Differential diagnosisheart attack, chest pain,
MedicationNSAIDs

Costochondritis symptoms can be similar to the chest pain associated with a heart attack.[6][7] Chest pain is considered a medical emergency until life-threatening heart disease (such as an acute coronary syndrome) can be ruled out.[4][7] Severe cases of costal cartilage inflammation that also involve painful swelling are sometimes referred to as Tietze's syndrome, a term sometimes used interchangeably with costochondritis. However, some physicians view costochondritis and Tietze's syndrome as separate disease states due to the absence of costal cartilage swelling in costochondritis.[2][8]

Treatment options for costochondritis are limited and usually involve a combination of rest, pain-relieving medications, and anti-inflammatory medications.[8] Cases with persistent discomfort may be managed with cortisone injections[6][8] or surgery may be indicated if the condition is severe. Individuals with costochondritis are typically instructed to avoid strenuous physical activity to prevent the onset of an attack.[9]

Signs and symptoms

Pain or tenderness to palpation usually occurs on the sides of the sternum, affects multiple ribs, and is often worsened with coughing, deep breathing, or physical activity.[2][10] On physical examination, a physician inspects and feels the patient for swollen or tender areas, and can often produce the pain of costochondritis by moving the patient's rib cage or arms.[2][4][8][11]

A factor that may aid in the differentiation of costochondritis from Tietze syndrome is the location of the pain on the sternum. Costochondritis typically affects the third, fourth, and fifth costosternal joints in contrast to Tietze's syndrome, which usually affects the second or third costosternal joint.[8] Pain from costochondritis typically resolves within one year.[12]

Causes

In most cases of costochondritis, no cause is identified.[1][2][6] However, it may be the result of physical trauma (due to direct injury, strenuous lifting, or severe bouts of coughing), associated with scoliosis, ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, or a tumor (benign or cancerous).[13]

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.[14] There is anecdotal evidence of costochondritic chest pain being associated with Vitamin D deficiency in some cases,[15] and multiple anecdotal reports that it could be associated with chest binding, as practiced by some members of the transgender community.[16] Some case studies and a case series suggest that the pain and inflammation at the sternocostal joints are a consequence of hypomobility at the costovertebral and/or costotransverse joints.[17][18][19]

Pathogenesis

The pathogenesis underlying the development of costochondritis remains unclear. Proposed mechanisms of injury include neurogenic inflammation, muscular imbalance, increased muscular pull on the rib,[12] mechanical dysfunction at the costotransverse joint of the rib,[12] or a derangement of the mechanical structure of the costochondral junction.[7] A commonly held view in New Zealand and Australian manual physiotherapy regards hypomobility at the costovertebral and costotransverse joints as the driver of compensatory excessive movement at the more structurally delicate sternocostal joints, leading to strain and localised inflammatory response.[20]  This mechanism is biologically plausible and would account for the extreme specificity of the symptoms at the sternocostal joints, which a systemic mechanism does not.

Diagnosis

Differential diagnosis
Sternum with sternocostal joints and cartilage

Other causes of chest pain similar to that produced by costochondritis may include, but are not limited to the following:[7][21]

Treatment

Costochondritis may be treated with physical therapy (including ultrasonic, TENS, with or without nerve stimulation) or with medication. Treatment may involve the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or other pain relief medications (analgesics) such as acetaminophen.[3][4] Severe cases of costochondritis may call for the use of opioid medications such as hydrocodone or oxycodone, tricyclic antidepressant medications such as amitriptyline for pain from chronic costochondritis, or anti-epileptic drugs such as gabapentin may be used.[23] Oral or injected corticosteroids may be used for cases of costochondritis unresponsive to treatment by NSAIDs; however, this treatment has not been the subject of study by rigorous randomized controlled trials and its practice is currently based on clinical experience.[24] Rest from stressful physical activity is often advised during the recovery period.[4]

Epidemiology

Costochondritis is a common condition and is responsible for 30% of emergency room chest-pain-related visits. One-fifth of visits to the primary care physician are for musculoskeletal chest pain; of this 20% of primary care office visits, 13% are due to costochondritis.[7] Costochondritis cases are most often seen in people older than age 40 and occur more often in women than in men.[8]

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See also
  • Costochondral cartilage

References
  1. Mayo Clinic Staff (2012). "Costochondritis Definition". Mayo Clinic. Retrieved 26 December 2012.
  2. Jindal, A; Singhi, S (2011). "Acute chest pain". Indian Journal of Pediatrics. 78 (10): 1262–1267. doi:10.1007/s12098-011-0413-1. PMID 21541647.
  3. U.S. National Library of Medicine (2010). "Costochondritis". National Institutes of Health. Retrieved 26 December 2012.
  4. Proulx, AM; Zryd, TW (2009). "Costochondritis: diagnosis and treatment". American Family Physician. 80 (6): 617–620. PMID 19817327.
  5. Stochkendahl, MJ; Christensen, HW (2010). "Chest pain in focal musculoskeletal disorders". The Medical Clinics of North America. 94 (2): 259–273. doi:10.1016/j.mcna.2010.01.007. PMID 20380955.
  6. Ricker Polsdorfer, M.D. (2012). "Costochondritis". Keck Medical Center of USC. Retrieved 30 December 2012.
  7. Ayloo A, Cvengros T, Marella S (December 2013). "Evaluation and treatment of musculoskeletal chest pain". Prim Care (Review). 40 (4): 863–87. doi:10.1016/j.pop.2013.08.007. PMID 24209723.
  8. Fauci, Anthony S.; Eugene Braunwald; Dennis L. Kasper; Stephen L. Hauser; Dan L. Longo; J. Larry Jameson; Joseph Loscalzo (2008). Chapter 330. Arthritis Associated with Systemic Disease, and Other Arthritides Harrison's principles of internal medicine (17th ed.). New York: McGraw-Hill. ISBN 978-0-07-147693-5.
  9. Beers, Mark (2006). "Chapter 5". The Merck Manual of Diagnosis and Therapy (18th ed.). Merck Research Laboratories. ISBN 978-0-911910-18-6.
  10. Mayo Clinic Staff (2012). "Costochondritis:Symptoms". Mayo Clinic. Retrieved 26 December 2012.
  11. Mayo Clinic Staff (2012). "Costochondritis:Tests and diagnosis". Mayo Clinic. Retrieved 26 December 2012.
  12. Sik EC, Batt ME, Heslop LM (March–April 2009). "Atypical chest pain in athletes". Curr Sports Med Rep. 8 (2): 52–8. doi:10.1249/JSR.0b013e31819c7d01. PMID 19280769.
  13. Mayo Clinic Staff (2012). "Causes". Mayo Clinic. Retrieved 26 December 2012.
  14. Sakran, W; Bisharat, N (2011). "Primary Chest Wall Abscess Caused by Escherichia coli Costochondritis". Am J Med Sci. 342 (3): 241–6. doi:10.1097/MAJ.0b013e31821bc1b0. PMID 21681074.
  15. Shipton EA, Shipton EE (2015). "Vitamin D and Pain: Vitamin D and Its Role in the Aetiology and Maintenance of Chronic Pain States and Associated Comorbidities". Pain Research and Treatment (Review). 2015: 1–12. doi:10.1155/2015/904967. PMC 4427945. PMID 26090221. Citing Oh RC, Johnson JD (2012). "Chest pain and costochondritis associated with vitamin d deficiency: a report of two cases". Case Reports in Medicine. 2012: 1–3. doi:10.1155/2012/375730. PMC 3384935. PMID 22761623.
  16. McClean Clinic (2014). "Consequences of Chest Binding". McClean Clinic. Retrieved 24 October 2016.
  17. Rabey, Martin Ian (2008-02-01). "Costochondritis: Are the symptoms and signs due to neurogenic inflammation. Two cases that responded to manual therapy directed towards posterior spinal structures". Manual Therapy. 13 (1): 82–86. doi:10.1016/j.math.2006.12.007. ISSN 1356-689X. PMID 17360222.
  18. Grindstaff TL, Beazell JR, Saliba EN, Ingersoll CD (2010). "Treatment of a female collegiate rower with costochondritis: a case report". Journal of Manual and Manipulative Therapy. 18 (2): 64–68. doi:10.1179/106698110X12640740712653. PMC 3101071. PMID 21655387.CS1 maint: multiple names: authors list (link)
  19. Zaruba Richard A., Wilson Eric (June 2017). "Impairment based examination and treatment of costochondritis: a case series". International Journal of Sports Physical Therapy. 12 (3): 458–467. PMC 5455195. PMID 28593100.
  20. Zaruba, Richard A.; Wilson, Eric (June 2017). "IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES". International Journal of Sports Physical Therapy. 12 (3): 458–467. ISSN 2159-2896. PMC 5455195. PMID 28593100.
  21. "Costochondritis Diagnosis Differential". BMJ Publishing Group. 2012. Retrieved 26 December 2012.
  22. Seferović PM, Ristić AD, Maksimović R, Simeunović DS, Milinković I, Seferović Mitrović JP, Kanjuh V, Pankuweit S, Maisch B (May 2013). "Pericardial syndromes: an update after the ESC guidelines 2004". Heart Fail Rev. (Review). 18 (3): 255–66. doi:10.1007/s10741-012-9335-x. PMID 22855353.
  23. "Treatments and drugs". Mayo Clinic. 2012. Retrieved 26 December 2012.
  24. Gandhi V, Costello J (August 2012). "Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: The use of corticosteroids in the management of costochondritis". Emerg Med J (Review). 29 (8): 686. doi:10.1136/emermed-2012-201590.4. PMID 22787240.
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