Tietze syndrome

Tietze syndrome typically presents unilaterally at a single joint of the anterior chest wall, with 70% of patients having tenderness and swelling on only one side, usually at the 2nd or 3rd rib.[2][3] Research has described the condition to be both sudden[4] and gradual, varying by the individual.[5][6] Pain and swelling from Tietze syndrome are typically chronic and intermittent and can last from a few days to several weeks.[6]

The most common symptom of Tietze syndrome is pain, primarily in the chest, but can also radiate to the shoulder and arm.[2][6] The pain has been described as aching, gripping, neuralgic, sharp, dull, and even described as "gas pains".[3] The symptoms of Tietze syndrome have been reported to be exacerbated by sneezing, coughing, deep inhalation, and overall physical exertion.[5][7] Tenderness and swelling of the affected joint are important symptoms of Tietze syndrome and differentiate the condition from costochondritis.[8][9] It has also been suggested that discomfort can be further aggravated due to restricted shoulder and chest movement.[10]

The true etiology of Tietze syndrome has not been established, though several theories have been proposed. One popular theory is based on observations that many patients begin developing symptoms following a respiratory infection and dry cough, with one study finding 51 out of 65 patients contracted Tietze syndrome after either a cough or respiratory infection.[3][11][12] Thus, it has been hypothesized that the repetitive mild trauma of a severe cough from a respiratory infection may produce small tears in the ligament called microtrauma,[6][13] causing Tietze syndrome.[12][14] However, this theory is disputed as it does not account for symptoms such as the onset of attacks while at rest as well as the fact that swelling sometimes develops before a cough.[11][13][15] The respiratory infection has also been observed accompanying rheumatoid arthritis[6][12] which, coupled with leukocytosis,[2][16] neutrophilia,[12] c-reactive protein (CRP),[16] and elevated erythrocyte sedimentation rate (ESR),[9][12] suggest an infectious and rheumatoid factor, though the evidence is conflicting.[15] Many theories such as malnutrition,[17][18] chest trauma,[10] and tuberculosis,[17] were thought to be among the potential causes but have since been disproven or left unsupported.[4][12][14]

Diagnosis for Tietze syndrome is primarily a clinical one, though some studies suggest the use of radiologic imaging.[1][19] Musculoskeletal conditions are estimated to account for 20-50% of non-cardiac related chest pain in the emergency department.[1] Ruling out other conditions, especially potentially life-threatening ones such as myocardial infarction (heart attack) and angina pectoris, is extremely important as they can present similarly to Tietze syndrome.[8] These can usually be ruled out with diagnostic tools such as an electrocardiogram and a physical examination showing reproducible chest wall tenderness, .[1][6] After eliminating other possible conditions, physical examination is considered the most accurate tool in diagnosing Tietze syndrome. Physical examination consists of gentle pressure to the chest wall with a single finger to identify the location of the discomfort.[2] Swelling and tenderness upon palpation at one or more of the costochondral, sternocostal, or sternoclavicular joints, is a distinctive trait of Tietze syndrome and is considered a positive diagnosis when found.[2][3]

There are some pathological features that can be observed with Tietze syndrome, including degeneration of the costal cartilage, increase in vascularity, and hypertrophic changes (enlarged cells).[20] However, these features can only be identified from a biopsy.[8] Some studies have begun exploring and defining the use of radiographic imaging for diagnosing Tietze syndrome. This includes computed tomography (CT),[21] magnetic resonance imaging (MRI),[22] bone scintigraphy,[23] and ultrasound,[24] though these are only case studies and the methods described have yet to be thoroughly investigated.[22] Methods such as plain radiographs, better known as an x-ray, are helpful in the exclusion of other conditions, but not in the diagnosis of Tietze syndrome.[6][8] Some researchers believe that ultrasound is superior to other available imaging methods, as it can visualize the increased volume, swelling, and structural changes of the costal cartilage.[2][8]

Tietze syndrome is considered to be a self-limiting condition that usually resolves within a few months with rest.[3] Management for Tietze syndrome usually consists of analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, aspirin, acetaminophen (paracetamol), and naproxen.[29] Other methods of management include manual therapy and local heat application.[1][14] These are intended to relieve pain and are not expected to treat or cure Tietze syndrome as the condition is expected to resolve on its own.

Tietze syndrome was named after and first described in 1921 by German surgeon Alexander Tietze.[17] Tietze first cited 4 cases in Germany of painful swelling where he originally believed the condition was as a result of tuberculosis or wartime malnutrition.[18]