Pediatric Costochondritis 

Updated: Aug 20, 2018
Author: Joseph P Garry, MD, FACSM, FAAFP; Chief Editor: Lawrence K Jung, MD 

Overview

Background

Chest pain is a common reason parents seek medical attention for their children. Annually, physicians evaluate >600,000 cases of chest pain in patients aged 10-21 years, a number that may reflect overwhelming concern about chest pain as a manifestation of cardiac disease as noted in older patients.[1, 2]

Costochondritis is a common cause of chest pain in children and adolescents. The condition is characterized as an inflammatory process of one or more of the costochondral cartilages that causes localized tenderness and pain of the anterior chest wall.[3] Most cases of costochondritis are idiopathic. The remaining cases may result from costochondral irritation due to direct trauma to the area, aggressive exercise resulting in a strain of the costochondral cartilage, or a prior upper respiratory tract infection with cough which can cause repeated stretching and strain at the costochondral junction resulting in local irritation and pain.

Costochondritis is a relatively benign and usually self-limited condition though symptom resolution can persist for up to three months.[4] Patients are often evaluated initially in the emergency department (ED) or in their primary care physician's office.

The term Tietze syndrome implies swelling; costochondritis refers to pain alone.

Pathophysiology

The exact pathophysiology of cartilage and capsular involvement is unknown because costochondritis does not warrant surgical intervention or tissue biopsy. Theoretically, the cartilage involved in costochondritis is either inflamed or fractured. Either condition presumably leads to inflammation with subsequent stimulation of pain receptors.

Epidemiology

Frequency

United States

Several studies of chest pain in pediatric patients report costochondritis prevalences of 14-32%[4, 1, 5, 6] ; a single study reported rates as high as 79%[7] however this higher prevalence may be due to a less stringent diagnostic criteria for costochondritis. The overall incidence is approximately 4% in children and adolescents.

Mortality/Morbidity

No reports have associated mortality with costochondritis, and no mortality is expected.

Race

A study indicates Hispanics may have an increased prevalence of costochondritis, but most studies do not mention race as a factor.[8]

Sex

Studies of chest pain in children demonstrate that males and females are affected equally. There are no recent studies evaluating the effect of gender in costochondritis.

Age

No data support an association between age and costochondritis; the condition is well described in children of all ages, including infants.[9]

 

Presentation

History

The key to the diagnosis of costochondritis, amid the differential diagnoses which include cardiac and pulmonary disorders, is a thorough history and physical examination.

Presenting characteristics of chest pain associated with costochondritis include the following:[10, 1, 11]

  • Onset - Typically insidious, occurring over several days or weeks; may be acute

  • Nature - Sharp and stabbing

  • Location - Anterior chest; pain usually unilateral, but may be bilateral; typically affecting the costochondral junctions 2-5

  • Radiation - Chest, back, or upper abdomen

  • Exacerbating factors - Coughing, sneezing, deep inspirations, movement of the upper torso and upper extremities (shoulders particularly)

  • Relieving factors - Rest, application of ice, or use of heat

  • Preceding conditions - Upper respiratory tract infection or exercise (common in the preceding 3 months); musculoskeletal strain; trauma to the chest wall

Physical

Vital signs should be assessed. Careful and complete pulmonary, cardiac, and abdominal examination reduces the probability of an underlying disease process involving any of these organ systems.

  • Inspection: focuses on symmetry of the chest wall. Asymmetry may indicate trauma as a cause of chest pain.

  • Swelling is uncommon. However, patients with Tietze syndrome may have swelling over a single upper costochondral junction.

  • Ecchymosis would be expected only in trauma.

  • Respiratory effort is normal.

  • Palpation that reveals tenderness over the costochondral junction is diagnostic. The tenderness should be localized and is most common at the sternocostal cartilage of the second through the fifth ribs, however may affect the lower ribs (6-7) as well (see the image below). The key to palpation in costochondritis is that the tenderness at the costochondral junction which the patient experiences should reproduce the chest wall pain that the patient has been experiencing.

    Sternocostal and interchondral articulations. Ante Sternocostal and interchondral articulations. Anterior view.
  • Examination may be performed with firm, single-digit palpation of the area.

  • Crepitus is uncommon and may indicate a fracture associated with trauma.

  • Auscultation of the lungs, heart, and abdomen are normal.

Causes

Most cases of costochondritis are idiopathic. The remaining cases may be the result of costochondral irritation caused by the following:

  • Direct trauma

  • Aggressive exercise resulting in a strain (eg, repeated twisting of the upper torso, stretching-pulling activities of the upper extremities)[12]

  • Preceding upper respiratory tract infection with cough (which can cause repeated stretching and strain at the costochondral junction)

 

DDx

Diagnostic Considerations

Several studies have demonstrated repeatedly that the most common causes of pediatric chest pain presenting to an emergency department or for an outpatient office visit include musculoskeletal causes as the most common etiology, followed by respiratory and then gastrointestinal causes.[1, 13, 6, 14] Among pediatric and adolescent patients who have no history of cardiac abnormality or cardiac disease, it is uncommon to elicit an actual cardiac cause to their chest pain. Drossner et al. studied pediatric patients presenting with chest pain to two tertiary care pediatric emergency departments over a 3 1/2 year time frame.[13] They found, among a study population of 4288 patients, a prevalence of 0.6% of patients who demonstrated a cardiac etiology as the cause of their chest pain.[13] Among a population of 380 children referred to a pediatric outpatient clinic for chest pain, only one patient (0.3%) was found to have a cardiac cause.[6] Saleeb et al. evaluated 3700 pediatric and adolescent patients seen at Children's Hospital Boston for an evaluation of chest pain over a period of ten years.[14] Their study found a prevalence of 37/3700 (1%) for cardiac causes for chest pain. Furthermore, they found that no patient who was diagnosed with non-cardiac chest pain (99%) subsequently died from a cardiac cause over the 17,886 patient years of follow up.[14]

Another important finding associated with pediatric and adolescent chest pain is that of underlying psychological conditions. In this population, it has been demonstrated that those with non-cardiac chest pain have a higher prevalence of both anxiety and depression.[15, 16] In comparison to a population of pediatric and adolescent patients with innocent heart murmurs, Lipsitz et al. found a prevalence of anxiety disorders of 70% in those with non-cardiac chest pain, as compared to a prevalence of 41% in those with innocent heart murmurs.[15] Furthermore, it was noted that the onset of the psychological condition predated the onset of non-cardiac chest pain. Lee et al., in a similar population of patients, also found significantly higher levels of anxiety, depression, and anxiety sensitivity among those with non-cardiac chest pain.[16] Anxiety sensitivity is defined as a "fear of fear", and represents a psychological vulnerability to the development of anxiety through heightened interoceptive awareness.[16] Loiselle et al. also found that among children with non-cardiac chest pain, these children demonstrated higher levels of internalizing and somatic complaints, as well as their parents who also demonstrated higher anxiety levels.[17] Their study also showed significantly higher health care utilization in the year prior to a cardiology evaluation for their non-cardiac chest pain.[17]

Overall, it is important to note that in pediatric and adolescent patients presenting with chest pain, absent an obvious etiology, the most common causes are musculoskeletal, pulmonary/respiratory, and gastrointestinal etiologies. A cardiac etiology for the chest pain has a very low prevalence of 1% or less. And psychological factors, comprising principally anxiety and depression, can be found in a higher prevalence among this cohort of patients.

Differential Diagnoses

 

Workup

Laboratory Studies

See the list below:

  • Costochondritis has no confirmatory or diagnostic laboratory tests.

Imaging Studies

See the list below:

  • Imaging studies are unnecessary to confirm a diagnosis of costochondritis.

  • Chest radiography may exclude other possible causes of chest pain but offer no diagnostic value to the clinical diagnosis of costochondritis. Occasional localized peripheral calcifications may be noted on chest radiography. In the absence of confounding physical findings, the diagnostic yield of a chest radiograph is minimal.

  • In the unusual circumstance that imaging is required, CT scanning is probably the best choice because it can demonstrate swelling or low attenuation signal of the costal cartilage.[18] Ultrasonography may also demonstrate swelling but is highly user dependent and thus generally less useful. Bone scanning may demonstrate uptake at the area of concern; however, increased uptake at costochondral junctions that do not produce symptoms may also be present, making this modality less useful.[19]

  • MRI can be utilized as an alternate imaging study in rare circumstances. While the costochondral cartilage can be well defined with this modality, there are no known studies utilizing MRI in this role. Furthermore, younger children may need to be sedated in order to obtain images thus increasing overall risk of this study in the younger age group.

Procedures

See the list below:

  • Costochondral joint injection is indicated for patients with severe pain for whom oral analgesics are either ineffective or contraindicated. Costochondral joint injection may have a role in treating refractory cases of costochondritis. Using a 22-gauge needle, inject 2% lidocaine or a combination of corticosteroid and lidocaine. A total volume ranging from 1-3 mL may be injected depending on patient size.

  • Contraindications include an uncooperative patient, known hypersensitivity to the injectant, unclear diagnosis, or unstable cardiopulmonary disease. Use caution in patients with a severe coagulopathy. Complications include bleeding, infection, and pneumothorax.

  • Manipulation using a high velocity, low amplitude technique has been described to produce relief in costochondritis, but no larger studies have been done to confirm this.[20]

 

Treatment

Medical Care

See the list below:

  • Reassure patients diagnosed with costochondritis that the cause of their chest pain is neither cardiac nor malignant in origin.

  • Treatment involves conservative local care with judicious use of nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics, as necessary. Cough suppressants may be beneficial if cough is an aggravating factor. Stretching exercises have also been suggested and demonstrated to be of some benefit for the resolution of costochondritis.[21]

  • Liberal use of ice is recommended for 20-minute intervals.

  • Advise relative rest for the patient's upper extremities and avoidance of possible precipitating or exacerbating activities.

Consultations

Occasional refractory cases may require consultation with the following specialists:

  • Primary care sports medicine physician[22]

  • Rheumatologist

At any time that there is a concern for an alternate or more serious diagnosis, consultation with the appropriate medical specialist would be prudent. Selbst described the conditions for which to refer pediatric and adolescent patients with chest pain according to the following findings or diagnoses:[23]

  • Acute distress

  • Significant trauma

  • History of heart disease or related serious medical problem

  • Chest pain with exercise, syncope, palpitations, dizziness

  • Serious emotional disturbance

  • Esophageal foreign body, caustic ingestion

  • Pneumothorax, pleural effusion

Activity

See the list below:

  • Activity restrictions include relative rest. Instruct the patient to avoid activities that exacerbate symptoms. Collision or contact sports may be limited until the patient can perform activity-specific movements without pain.

  • Applying ice after activity usually helps alleviate a significant amount of pain or discomfort.

  • Resumption of aggravating activities prior to resolution may cause relapse.

 

Medication

Medication Summary

NSAIDs provide analgesia for mild-to-moderate chest pain and may modulate the presumed inflammatory process. Purely analgesic drugs (eg, acetaminophen, tramadol hydrochloride) may suffice.

Nonsteroidal anti-inflammatory drugs

Class Summary

These provide analgesia and may play a role in controlling inflammation.

Ibuprofen (Motrin, Advil, Ibuprin)

Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Aleve)

Available as OTC preparation and in prescription form; OTC preparation has faster onset of action, though limited duration of action. Prescription form is available in both pill and elixir forms and has a convenient bid-dosing schedule.

Analgesics

Class Summary

These may be used to relieve mild-to-moderate pain.

Acetaminophen (Tylenol)

May be used to relieve mild-to-moderate pain. Inhibits prostaglandin synthetase in the CNS by inhibiting cyclooxygenase.

Tramadol hydrochloride (Ultram)

Inhibits ascending pain pathways, altering perception of and response to pain. Also inhibits reuptake of norepinephrine and serotonin.

 

Follow-up

Further Outpatient Care

See the list below:

  • Follow up as needed after initial diagnosis of costochondritis. Reevaluate patient if the nature, character, or severity of pain changes.

Prognosis

See the list below:

  • The overall prognosis of a patient with costochondritis is excellent and full recovery can be expected.

  • Driscoll described the average length of symptoms for costochondritis as 96 days in duration, so while prognosis is excellent, recovery can be somewhat prolonged.[4]

  • Resolution rarely lasts longer than 4-6 months. Relapse may occur if the patient returns to activity while still symptomatic.

Patient Education

See the list below:

  • For patient education resources, see eMedicineHealth's patient education articles on Costochondritis.