Costochondritis

Costochondritis, also known as chest wall pain syndrome or costosternal syndrome, is a benign inflammation of the upper costochondral (rib to cartilage) and sternocostal (cartilage to sternum) joints. This condition predominantly affects women over the age of 40 but is also common among adolescents presenting with chest pain. Costochondritis is a common cause of chest pain in emergency departments, accounting for approximately 30% of such cases.

Presentation

Costochondritis typically presents unilaterally, usually on the left side, affecting the 2nd to 5th ribs at the sternocostal and costochondral joints. The primary symptom is chest pain, which is often exacerbated by movement and deep breathing. This pain can be sharp, aching, dull, or pressure-like and may radiate to the shoulder, arm, front neck, or scapula.

The condition usually develops gradually following repetitive coughing, strenuous physical activity, or trauma to the chest. Symptoms can last from weeks to months, with some refractory cases persisting for over a year. Unlike Tietze syndrome, costochondritis does not present with heat, erythema, or swelling of the affected area. Signs such as tachycardia, hypotension, shortness of breath, fever, nausea, or a productive cough are unrelated to costochondritis and warrant further investigation.

Cause

The exact cause of costochondritis is unknown. It is believed to result from repetitive minor trauma, with risk factors including strenuous coughing, exercise, and lifting. In rare cases, infection of the costosternal joint by organisms such as Actinomyces, Staphylococcus aureus, Candida albicans, Salmonella, or Escherichia coli can cause costochondritis.

Diagnosis

Costochondritis is predominantly diagnosed clinically based on physical examination, medical history, and ruling out other conditions. A physical exam will assess for tenderness or pain upon palpation, with an absence of heat, erythema, or swelling. Movements of the upper body or breathing that worsen the pain help to confirm the diagnosis. The crowing rooster manoeuvre, the hooking manoeuvre, or the horizontal flexion manoeuvre can reproduce the pain for further confirmation.

Differential Diagnosis

• Cardiopulmonary: Acute coronary syndrome, aortic dissection, pneumothorax, pulmonary embolism, myocardial infarction, angina, pericarditis.
• Musculoskeletal: Tietze syndrome, slipping rib syndrome, painful xiphoid syndrome, muscle strain, myofascial pain syndrome, thoracic disc herniation, rib fracture.
• Other: Fibromyalgia, SAPHO syndrome, ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, neoplasms, myelomatous pleural effusion, pleuritis, precordial catch syndrome, pneumonia, anxiety disorders, panic disorders, hyperventilation syndrome, gastroesophageal reflux disease, esophagitis, herpes zoster, Bornholm disease, vitamin D deficiency, cocaine use.

Treatment

Costochondritis is usually self-limited and will resolve on its own. Initial treatment often involves conservative methods such as rest, pain relief medications (e.g., acetaminophen, NSAIDs like ibuprofen or naproxen), and the use of heat or ice compresses. Creams and patches containing compounds like capsaicin, NSAIDs, or lidocaine may also be beneficial.

Manual therapy methods such as myofascial release, muscle energy techniques, balanced ligamentous tension (BLT), rib mobilisation techniques, and stretching exercises can aid in recovery. Educating patients about body mechanics, posture, and activity modification is also important.

In severe cases where symptoms persist for a year or longer, corticosteroids or local anaesthetic injections may be considered.

Epidemiology

Costochondritis is a common condition responsible for 13–36% of acute chest pain-related concerns among adults, depending on the setting, and 14–39% among adolescents. It primarily affects individuals over the age of 40 and is more common in women than men.

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Self-assessment MCQs (single best answer)

Which of the following joints are primarily affected in costochondritis?

Costochondritis predominantly affects which demographic?

What is the primary symptom of costochondritis?

Which of the following is NOT typically associated with costochondritis?

Which organisms can rarely cause infectious costochondritis?

Which of the following is a typical conservative treatment for costochondritis?

In severe cases of costochondritis that persist for over a year, what treatment might be considered?

Which of the following manoeuvres is used to reproduce pain for confirming the diagnosis of costochondritis?

Which condition is NOT a differential diagnosis for costochondritis?

What percentage of acute chest pain cases in emergency departments are attributed to costochondritis?