Costochondritis

Costochondritis
Other names: Costosternal syndrome,[1] anterior chest wall syndrome,[1] costosternal chondrodynia,[2] parasternal chondrodynia[1]
The costal cartilages
Specialty	Emergency medicine
Symptoms	Pain and tenderness at the costal cartilage[3]
Duration	Weeks to months[1]
Risk factors	Repetitive physical activities, preceding cough[3][1]
Diagnostic method	Based on symptoms after ruling out other causes[4][5]
Differential diagnosis	Heart attack, angina, heartburn, pneumonia, pulmonary embolism, shingles, Tietze's syndrome[4][1]
Treatment	NSAIDs, ice and heat, physiotherapy[5][1]
Prognosis	Good[5]
Frequency	~25% of chest pain[1]

Costochondritis is chest wall pain at the costal cartilage, the structure that connects each rib to the sternum.^[5] The pain is generally localized and can be recreated by pushing on the area.^[4] Multiple areas of cartilage may be involved.^[1] Pain may be worsened with certain movements and taking a deep breath.^[5] The quality of the pain may be sharp or dull.^[5] Costochondritis typically resolves with time, though may recur.^[5]

Risk factors include repetitive physical activities or a preceding cough.^[3][1] Diagnosis involves ruling out other conditions that may present similarly including: heart attack, angina, heartburn, pneumonia, and pulmonary embolism.^[5][4] Vital signs are generally normal.^[5] The underlying mechanism is believed to involved inflammation.^[1] If swelling is involved the condition is known as Tietze's syndrome, a term which maybe used interchangeably but is considered a separate disease.^[1][6]

Chest pain is considered a medical emergency until life-threatening diseases are ruled out.^[5] Treatment of costochondritis may include rest, ice and heat, paracetamol (acetaminophen), and nonsteroidal anti-inflammatory medication (NSAIDs).^[1] Persistent cases may be managed with physiotherapy^[5] or local steroid injections.^[1] Costochondritis represents about 13 to 36%% of cases of chest pain.^[4][1] Both children and adults may be affected.^[1]

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.^[6][7] 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.^[6][1][8][9]

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.^[10]

Causes

In most cases of costochondritis, no cause is identified.^[2][6][11] 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).^[12]

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.^[13] There are reports of an associated with chest binding, as practiced by some members of the transgender community.^[14]

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,^[10] mechanical dysfunction at the costotransverse joint of the rib,^[10] or a derangement of the mechanical structure of the costochondral junction.^[15]

Diagnosis

Diagnosis is based on symptoms after ruling out other potential causes.^[4][5] Pain that can be produced by pushing on the chest wall does not rule out a heart attack.^[1]

Differential diagnosis

Sternum with sternocostal joints and cartilage

Other causes of chest pain similar to that produced by costochondritis may include:^[15][16]

• Cardiac:
  • Heart attack^[11]
  • Pericarditis/myocarditis^[17]
  • Aortic aneurysm
• Gastrointestinal:^[11]
  • Gastroesophageal reflux disease
  • Gastritis
  • Esophagitis
• Musculoskeletal:
  • Fibromyalgia
  • Rib fracture
  • Ankylosing spondylitis
  • Bone metastasis from cancers such as prostate cancer, breast cancer, plasmacytoma, and sarcomas^[8]
  • Reactive arthritis^[8]
• Psychogenic:
  • Anxiety disorder
  • Panic disorder
  • Hyperventilation
• Respiratory:
  • Pneumonia
  • Pneumothorax
  • Pleuritis
  • Pulmonary embolism
• Other:
  • Herpes zoster
  • Drug abuse
  • Multiple myeloma

Treatment

Costochondritis may be treated rest, ice, heat, and pain medications.^[1] Medication may include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or paracetamol (acetaminophen).^[1] Persistent cases may be managed with physiotherapy^[5] or local steroid injections.^[1] In severe cases opioids, tricyclic antidepressantss such as amitriptyline, or gabapentin may be used.^[18] While steroids by mouth or by injection may be used for cases unresponsive to NSAIDs; this treatment has not been well studied.^[19] Rest from stressful physical activity is often advised during the recovery period.^[1]

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.^[15] Costochondritis cases are most often seen in people older than age 40 and occur more often in women than in men.^[8]

References

External links

• Benign Tender Chest Wall Pain of Costosternal Joints Inflammation at patient.info Archived 2015-10-21 at the Wayback Machine