Costochondritis 

Updated: Sep 12, 2019
Author: Lynn K Flowers, MD, MHA, ABAARM, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP 

Overview

Practice Essentials

Costochondritis is inflammation of the costal cartilage at the articulation of the ribs and sternum.[1] It is an important consideration in the differential diagnosis of chest pain, as in contrast to myocardial ischemia or infarction, it is a benign disorder.[2] 2 Although the term costochondritis often is used interchangeably with fibrositis and Tietze syndrome, these are distinct diagnoses. Reassurance and pain control are the principal objectives of emergency care; NSAIDs may be useful.  For discussion of costochondritis in children, see Pediatric Costochondritis.

Background

 CX

Pathophysiology

Costochondritis is an inflammatory process of the costochondral or costosternal joints that causes localized pain and tenderness. Any of the 7 costochondral junctions may be affected, and more than 1 site is affected in 90% of cases. The second to fifth costochondral junctions most commonly are involved.

Epidemiology

Frequency

United States

The exact prevalence of a musculoskeletal etiology for chest pain is not known, although overall prevalence of a musculoskeletal etiology for chest pain was approximately 10% in one study. In a 1994 emergency department study, 30% of patients with chest pain had costochondritis.[3]

Mortality/Morbidity

The condition's course generally is self-limited, but symptoms often recur or persist.

Sex

In Disla's costochondritis study, women comprised 69% of patients with costochondritis versus 31% in the control group.[3]

 

Presentation

History

The onset of costochondritis is often insidious. Chest wall pain with a history of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture) is common. Pain may be described as follows:

  • Exacerbated by trunk movement, deep inspiration, and/or exertion
  • Lessens with decreased movement, quiet breathing, or change of position
  • Sharp, nagging, aching, or pressurelike
  • Usually quite localized but may extend or radiate extensively
  • May be severe
  • May wax and wane

Physical

Pain with palpation of affected costochondral joints is a constant finding in costochondritis. The second through the fifth costochondral junctions typically are involved. More than one junction is involved in more than 90% of patients. Surprisingly, patients may not be aware of the chest wall tenderness until examination. The diagnosis should be reconsidered in the absence of local tenderness to palpation.

Physical examination can help differentiate costochondritis from Tietze syndrome and from slipping rib syndrome. Although Tietze syndrome also produces costochondral tenderness, it is acute rather than chronic and it is additionally characterized by nonsuppurative edema (usually of the second and third costochondral junctions), heat, and erythema, all of which are absent in costochondritis.[4, 5]

Slipping rib syndrome involves the anterior portions of ribs 8-10—the vertebrochondral false ribs, which unlike the first 7 ribs (the true ribs) are connected not to the sternum directly but to each other by fibrocartilaginous bands (it does not involve ribs 11 and 12, the floating false ribs, whose ventral ends are free). Slipping rib syndrome is caused by laxity of the intercostal attachments of the vertebrochondral false ribs, which allows the costal cartilage tips to subluxate and impinge on the intercostal nerves.[6, 7]

Patients with slipping rib syndrome may or may not report a history of trauma. They may describe insidious onset of dull, chronic pain or sudden onset of sharp, stabbing pain, which may be preceded by a slipping, clicking, or popping sensation. The pain may be precipitated by breathing or by certain movements. It may be thoracic or abdominal.   

The classic diagnostic test for slipping rib syndrome is the hooking maneuver: with the patient supine, the examiner hooks the fingers under the inferior margin of the ribs (ribs 8-10) and pulls straight up. The maneuver is positive if it reproduces the pain or rib movement. Relief of the pain with an intercostal nerve block strongly supports the diagnosis. Treatments include osteopathic manipulation, surgical resection, and diclofenac gel.[6, 7]

A comprehensive physical examination should include assessment of the lateral ribs and the cervical and thoracic spine, as hypomobility in those areas may be a factor in the development of costochondritis. In such cases, upper thoracic mobilization and manipulation for the treatment of rib dysfunction may be incorporated into the treatment plan.[5]

Causes

The etiology of costochondritis is not well defined. Repetitive minor trauma has been proposed as the most likely cause. Bacterial or fungal infections of these joints occur uncommonly, usually in patients who are intravenous drug users or who have had thoracic surgery.[8, 9] Costochondritis, among others, is a common cause of atypical chest pain (chest pain not caused by myocardial ischemia) in athletes.[10, 5, 11] Case reports have described costochondritis in vitamin D–deficient patients that resolved with vitamin D supplementation.[12]

 

DDx

Diagnostic Considerations

Other problems to be considered in the differential diagnosis of costochondritis include the following:

  • Pericarditis
  • Pleurodynia
  • Polychondritis
  • Fibromyalgia

 

Differential Diagnoses

 

Workup

Approach Considerations

No specific laboratory or imaging studies exist for identifying costochondritis. The workup is directed toward excluding cardiac disorders and other causes of chest pain. The clinical scenario and the most likely differential diagnoses should guide the choice of tests, but an electrocardiogram and a chest radiograph are commonly ordered.[13] On bone scans, increased uptake at the costochondral junctions is not specific for costochondritis; however, bone scans can rule out stress fracture.[5, 14]

 

Treatment

Prehospital Care

Prehospital care should follow standard local protocols for patients with chest pain.

Emergency Department Care

Reassuring the patient of the benign nature of the condition and adequate pain control are the important objectives. Nonsteroidal anti-inflammatory drugs (NSAIDs) typically suffice. Narcotic analgesics generally are not required.

 

Medication

Medication Summary

The goal of therapy is to reduce inflammation. To accomplish this goal, nonsteroidal anti-inflammatory drugs (NSAIDs) are useful.

Nonsteroidal anti-inflammatory drugs

Class Summary

These agents are typically used for the relief of mild to moderate pain and inflammation. Although the effects of NSAIDs in the treatment of pain and inflammation tend to be patient specific, ibuprofen usually is the drug of choice (DOC) for initial therapy. Other options include flurbiprofen, mefenamic acid, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderate pain if no contraindications exist.

Inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase, which results in inhibition of prostaglandin synthesis.

Flurbiprofen (Ansaid)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, causing inhibition of prostaglandin biosynthesis that, in turn, may result in analgesic and anti-inflammatory activities.

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderate pain and inflammation. Initially, administer small dosages to patients with a small body size, the elderly, and those with renal or liver disease. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patients' responses.

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of the enzyme cyclooxygenase, which results in a decrease of prostaglandin synthesis.

 

Follow-up

Further Outpatient Care

Outpatient treatment for costochondritis may include the following

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control
  • Local heat
  • Local infiltration of local anesthetic, steroid, or intercostal nerve block (reserved for refractory cases)
  • Biofeedback
  • Gentle stretching of the pectoralis muscles 2-3 times a day may be beneficial
  • Primary care follow-up for patients with persistent symptoms [15]

Deterrence/Prevention

Measures to prevent costochondritis include the following:

  • Avoid repetitive misuse of muscles.
  • Modify improper posture or ergonomics of the home or work place.

Prognosis

The prognosis for patients with costochondritis is excellent. However, after 1 year, about half of patients still may have discomfort. Approximately one third report tenderness with palpation.

Patient Education

See the list below:

  • Reassure patients of the benign nature of the problem, and instruct them regarding avoidance of provoking activities.

  • Provide patients with a good understanding of the proper use and potential adverse effects of NSAIDs.

  • For patient education information, see the First Aid and Injuries Center, as well as Costochondritis and Chronic Pain.

 

Questions & Answers