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Costochondritis

Basics

  • Anterior chest wall pain and tenderness, mostly involving 2nd to 5th costal cartilages.
  • Also called costosternal syndrome, parasternal chondrodynia, anterior chest wall syndrome.
  • System affected: musculoskeletal.
  • Tietze syndrome: inflammatory condition with swelling/redness of costal cartilage, often unilateral on ribs 2 or 3.

Epidemiology

  • Predominantly affects females aged 40-50.
  • Accounts for ~30% of ER visits for chest pain, 13% primary care chest pain visits.

Etiology and Pathophysiology

  • Likely inflammation due to muscle pulling at costochondral/costosternal junctions.
  • Causes include unusual physical activity, overuse, trauma, and recent upper respiratory infection with cough.

Risk Factors

  • Upper extremity overuse or unusual physical activity.
  • Trauma including accidents or domestic violence.
  • Recent upper respiratory infections with cough.

Diagnosis

History

  • Sharp, aching, or pressure-like chest pain, usually unilateral involving multiple costal cartilages (2nd to 5th).
  • Pain worsened by upper body movement and exertion.
  • Chest tightness may accompany pain.
  • Complete history including cardiac risk stratification mandatory.
  • Screen for domestic violence and substance abuse.

Physical Exam

  • Cardiopulmonary exam to exclude cardiac/pulmonary causes.
  • Tenderness over costochondral junctions confirms diagnosis.
  • Pain reproducible by palpation.
  • Upper extremity movement on affected side may provoke pain.
  • In swelling/redness, consider Tietze syndrome.

Pediatric and Geriatric Considerations

  • Pediatric: consider psychogenic chest pain or slipping rib syndrome.
  • Geriatric: consider herpes zoster.

Differential Diagnosis

  • Cardiac: CAD, ACS, cardiac contusion, aortic aneurysm, pericarditis, myocarditis.
  • GI: GERD, esophagitis, esophageal spasm, cholecystitis.
  • Musculoskeletal: fibromyalgia, slipping rib syndrome, costovertebral arthritis, painful xiphoid syndrome, rib trauma.
  • Psychogenic: panic attacks.
  • Respiratory: PE, pneumonia, chronic cough, pneumothorax.
  • Other: domestic violence, herpes zoster, spinal tumor, metastatic cancer, cocaine abuse.

Diagnostic Tests

  • Primarily clinical diagnosis.
  • Imaging not routinely indicated for costochondritis.
  • Consider ECG (>35 years or cardiac risk), chest X-ray (cardiopulmonary symptoms).
  • CT if suspicion for aortic dissection, neoplastic or infectious causes.
  • D-dimer and spiral CT if PE suspected.

Treatment

General Measures

  • Reassure benign nature and slow recovery.
  • Rest, local heat or ice, massage.
  • Stretching exercises.
  • Avoid symptom-provoking activities.

Medication

  • NSAIDs (oral/topical), acetaminophen.
  • Lidocaine patches, capsaicin cream.
  • Skeletal muscle relaxants if muscle spasm present.
  • Local lidocaine/corticosteroid injections for refractory cases (rare).

Referral

  • Physical therapy for prolonged symptoms.
  • Gastroenterology or cardiology if alternate diagnosis suspected.

Complementary and Alternative Medicine

  • Limited evidence; may try chiropractic manipulation, exercise, dry needling, acupuncture, massage.

Admission and Nursing

  • Admission only if cardiac or other serious chest pain etiology suspected.

Ongoing Care

  • Follow up within 1 week if unclear diagnosis or no symptom improvement.

Patient Education

  • Educate on self-limited and potentially recurrent nature.
  • Avoid sudden or excessive physical activity changes.

Prognosis

  • Usually self-limited; symptoms last weeks to months.
  • Often recurrent or refractory in some cases.

Complications

  • Refractory or recurrent chest pain.

ICD10: - M94.0 Chondrocostal junction syndrome [Tietze]

Clinical Pearls: - Costochondritis accounts for up to 30% of chest pain presentations. - Diagnosis is clinical; exclude other causes with risk-based testing. - Activity modification helps prevent recurrences.