Costochondritis

Costochondritis
The costal cartilages
Classification and external resources
Specialty	Emergency medicine
ICD-10	M94.0
ICD-9-CM	733.6
MedlinePlus	000164

Costochondritis, also known as chest wall pain, costosternal syndrome, or costosternal chondrodynia^[1] is an acute^[2] and often temporary inflammation of the costal cartilage, the structure that connects each rib to the sternum at the costosternal joint. The condition is a common cause of chest pain.^[1][3][4] Though costochondritis often resolves on its own, it can be a recurring condition that has little or no signs of onset.^[5]

Costochondritis symptoms can be similar to the chest pain associated with a heart attack.^[6][7] Unexplained chest pain is considered a medical emergency until life-threatening cardiac issues can be ruled out.^[4][7] Severe cases of costal cartilage inflammation that also involve painful swelling are sometimes referred to as Tietze's syndrome, a term sometimes used interchangeably with costochondritis. However, some physicians view costochondritis and Tietze's syndrome as separate disease states due to the absence of costal cartilage swelling in costochondritis.^[2][8]

Treatment options are quite limited and usually involve a combination of rest, analgesics, or anti-inflammatory medications.^[8] Cases with persistent discomfort may be managed with cortisone injections^[6][8] or surgery may be indicated if the condition is severe. Individuals with costochondritis are typically instructed to avoid strenuous physical activity to prevent the onset of an attack.^[9]

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.^[2][10] 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.^{[2][4][8][11]} 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.^[12]

Causes

In most cases of costochondritis, no cause is identified.^[1][2][6] 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).^[13] 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.^[14] There is anecdotal evidence of costochondritic chest pain being associated with Vitamin D deficiency in some cases,^[15] and multiple anecdotal reports that it could be associated with chest binding, as practiced by some members of the transgender community.^[16] It also can be caused by Relapsing Polychrondritis

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,^[12] mechanical dysfunction at the costotransverse joint of the rib,^[12] or a derangement of the mechanical structure of the costochondral junction.^[7]

Differential diagnosis

Sternum with sternocostal joints and cartilage

Other causes of chest pain similar to that produced by costochondritis may include, but are not limited to the following:^[7][17]

• Cardiac:
  • Heart attack^[6]
  • Pericarditis/myocarditis^[18]
  • Aortic aneurysm
• Gastrointestinal:^[6]
  • 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 with physical therapy (including ultrasonic, TENS, with or without nerve stimulation) or with medication. Treatment may involve the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or other pain relief medications (analgesics) such as acetaminophen.^[3][4] Severe cases of costochondritis may call for the use of opioid medications such as hydrocodone or oxycodone, tricyclic antidepressant medications such as amitriptyline for pain from chronic costochondritis, or anti-epileptic drugs such as gabapentin may be used.^[19] Oral or injected corticosteroids may be used for cases of costochondritis unresponsive to treatment by NSAIDs; however, this treatment has not been the subject of study by rigorous randomized controlled trials and its practice is currently based on clinical experience.^[20] Rest from stressful physical activity is often advised during the recovery period.^[4]

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% is due to costochondritis.^[7] Costochondritis cases are most often seen in people older than age 40 and occurs more often in women.^[8]

See also

• Costochondral cartilage

References

External links

• MayoClinic.com
• Benign Tender Chest Wall Pain of Costosternal Joints Inflammation at patient.info
• Costochondritis and Tietze Syndrome