Costochrondritis

 

Definition/Description


Costochondritis is a self limiting condition defined as painful chronic inflammation of the costochondral junctions of ribs or chondrosternal joints of the anterior chest wall.[2] It is a clinical diagnosis and does not require specific diagnostic testing in the absence of concomitant cardiopulmonary symptoms or risk factors. Costochondritis is often confused with Tietzen syndrome. The difference is that there is a presence of swelling over the affected joints, a swelling occurs underneath the sternum and/or a reddening of the skin over the painful area, [3] [4] [5] [6]

Palpation of the affected chondrosternal joints of the chest wall elicits tenderness [2] and pain is reproduced by palpation of the affected cartilage segments which may radiate out into the chest wall.

Tietze syndrome is an inflammatory process causing visible enlargement of the costochondral junction. This condition causes severe pain on coughing and deep breathing. Tietze's syndrome is not life threatening or contagious, but it is fastidious and painful.[3] Costochondritis and Tietze's syndrome are often mistaken for each other, but the two very different conditions. [2]

Clinically Relevant Anatomy

The thoracic wall consists of the sternum anteriorly, the spinal column (12 thoracic vertebrae) posteriorly, bounded by 12 paired ribs and costal cartilages.[8] Ribs consist of bone and cartilage, with cartilage serving as an elastic bridge between the bony portion of the rib and the sternum. There are three types of ribs: the first seven pairs of ribs are called ‘true ribs’ because they are directly attached to the sternum. The eight to tenth pairs of ribs are called ‘false ribs’ because they are not attached to the sternum, but they are attached to each other. Finally the eleventh and twelfth are called ‘floating ribs’ because they are only attached posteriorly to the vertebrae.[9] Each rib is attached posteriorly to the spinal column: rib 1 is attached to vertebrae 1, rib 2 is attached to vertebrae 2 and so on.

Mechanism of action for inhalation and exhalation

Anteriorly, the costal cartilage of the first rib connects with the manubrium via a rigid fusion of bone and cartilage. The next seven pairs of ribs articulate with the sternum via cartilage at synovial-lined joints. Ribs eight through 10 attach anteriorly to the cartilaginous portion of the rib above them and often have synovial lined interchondral articulations. The lowest two ribs do not articulate with any structure anteriorly.[10]
The ribs move with respiration and with truncal motion or movement of the upper extremities. The intercostal nerves supply the innervation of the thoracic wall. The inspiratory muscles (external intercostals, diaphragm) expand the chest volume by elevating the rib cage. and the expiratory muscles (intercostals, intercostals intimi and succostals) decrease lung volume by depressing the ribcage.[8]

<span />Epidemiology /Aetiology

Costochondritis can affect children as well as adults. Approximately 14% of adolescents present with costochondritis in out patients.[11] In a prospective series of children three to 15 years of age presenting to an emergency department or cardiac clinic with chest pain, chest wall pain was the most common diagnosis, with respiratory and psychogenic conditions the next most common diagnoses.[12]

Costochondritis is a common diagnosis in adults with acute chest pain. It is present in 13 to 36 % of cases, depending on the study and the patient setting.[13] [14] This data issimilar to a study of patients with non cardiac chest pain that found reproducible chest wall tenderness (although not specifically defined as costochondritis) in 16 percent of patients.[15] A European study found a higher prevalence of musculoskeletal diagnoses in patients with chest pain presenting in primary care settings compared with hospital settings (20 versus 6%, respectively).[16]

Costochondritis usually affects the 3rd, 4th and 5th costochondral joint and occurs more often in women, whereas Tietze’s syndrome most commonly affects a singular joint only, particularly the 2nd or 3rd costal cartilage and both sexes are affected equally. [17] Both conditions can be of an acute or insidious onset at any age.

Characteristics/Clinical Presentation

Cartilage connects the sternum with the ribs and the clavicle making movement of the thorax possible while breathing [18] Elevation of the ribs and expansion of the rib cage result from the coordinated action of the rib cage muscles. [19] Inflammation of the cartilage of one or more ribs causes reddening, a temperature increase and swelling of the cartilage, which is both visible and palpable [6] There is pain with varying intensity in the chest wall and this pain is aggravated by movements of the torso, deep breathing, coughing and exertion. [2] [6] [3] Pain on palpation is indicative of costochondritis, but it could also be of cardiac origin [3] [2] or a tumor [20] [3] [18]. Due to the inflammatory pain, normal movement of the joints is disrupted, there may be audible crepitus on movements of the shoulder and pain may occur. [18] [3] Symptoms may occur gradually and can disappear spontaneously after a few days, but equally it may take years to disappear. [18] [21] Even after the symptoms have resolved, they may return at the same location or at another rib level. [6]

On examination there may be hypomobility of the upper thoracic spine, costovertebral joints, and the lateral ribs. Interventions include postural exercises and manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility.[19]

Clinically, the syndrome is characterised by inflammation of the costal cartilage and is associated with a gradual or rapid onset of pain and swelling of the upper costal cartilage of the costochondral junction. Pain is intensified by coughing, sneezing and chest movements [22]. There are no systemic symptoms or adenopathy. [23]

Differential Diagnosis

Costochondritis is also known as;

  • Costosternal chondrodynia, a Tietze’s syndrome variant [24]
  • Parasternal chondrodynia [2]
  • Anterior chest wall syndrome

Costochondritis should be distinguished from other, more serious causes of chest pain. [2]

The symptoms and signs of Tietze’s syndrome may occur in all arthropathies involving the anterior chest wall, particularly in seronegative spondylarthropathy and rheumatoid arthritis. Luckily these are distinguished easily by their other clinical features. Other skeletal causes sometimes mistaken for Tietze’s syndrome are:

  • xiphoidalgia: painful swelling and discomfort of the xiphoid process of the sternum [25]
  • slipping rib syndrome: hypermobility of the anterior ends of the false rib costal cartilages [26]

Other diseases to consider in differential diagnosis:mul

  • tiple myeloma: a malignancy of mature plasma cells [26]
  • primitive neoplasms of the bone and soft tissues [27]
  • chondrosarcoma of the chondrocostal joints
  • breast and lung tumours with extension to the costal cartilage
  • metastases of breast, kidney, and prostate neoplasms [28]

Malignancy is a cause that should be excluded. The use of appropriate diagnostic investigations such as electrocardiography[18], CT, MRI is necessary. [20]

Tietze's syndrome, a non-suppurative, tender swelling of the anterior chest wall, is a disorder of uncertain etiology and pathology, not to be associated with constitutional disturbances and of a prolonged fluctuating course. Familiarity with the uniform clinical manifestations of this relatively frequent entity makes its recognition fairly simple. The therapeutic approach includes reassurance of the patient as to the benign nature of this condition, along with supportive measures chiefly to allay pain. However, Tietze’s syndrome is much less common than costochondritis, and it tends to cause chest swelling in addition to the other symptoms, whereas costochondritis does not.[22]

Tietze syndrome and costochondritis [2]
Feature Tietze syndrome Costochondritis
Prevalence Rare More common
Age Younger than 40 years Over 40 years
Number of sites Affected one (in 70 percent of the patients) More than one (in 90 percent of the patients)
Costochondral junctions most commonly affected Second and third Second to fifth
Local swelling Present Absent

Diagnostic Procedures

Patients with fever, chest wall swelling, persistent cough or other respiratory issues should primarily have appropriate chest investigations. CT imaging can delineate a pathology in costal cartilages and rule out underlying pathologies such as tumors. CT is only reserved for cases where is high suspicion of neoplastic processes or infections, but CT cannot image bilateral involvement in one patient.[29] Nuclear scanning with Technetium 99 scitigraphy is not useful for identifying costochrondritis. In patients with signs and symptoms of chest wall inflammation, scintigraphy can directly diagnose costochondritis. Bone scintigraphy delineates both the extent of individual costochondral lesions and their multiplicity.

Patients older than 35 years who have a history with coronary artery disease and patients with cardio pulmonary symptoms should have an electrocardiogram and possibly chest radiography. Further testing should be considered for ruling out a cardiac cause if clinically indicated by age or risk status.[2]
Routine laboratory testing is not necessary in patients with suspected costochrondritis unless the diagnosis is uncertain or when there are signs of inflammation.

Outcome Measures

Patient-specific functional scale ( PSFS): specific questionnaires for costochondritis have not yet been produced, but the PSFS is a valid, reproducable, and responsive outcome measure for patients with neck pain, back pain, and upper quarter complaints 19

The Global rating of change (GROC): to measure the patient’s subjective rate of improvement .[2]

Measurement of thoracic and cervical mobility: This is a relevant measure with costochondritis as the inflammation of the costochondral joints or the anterior chest wall can cause a reduction in mobility of the spinal area.[30]

These five most valid tests are:

  • Rotation of the thoracolumbar spine (TR): TR has high validity and sensitivity ranks and improvement of the measurement technology would probably result in a superior test for the follow-up.
  • Finger to floor distance (FFD): high reliability and sensitivity, but poor correlation with spinal changes
  • The Schober test
  • Thoracolumbar flexion
  • Occiput to wall distance [31]

Examination


Patients with Costochondritis will present with chest pain that is reproducable by palpation of the affected area, with ribs 2 to 5 mostly affected. Aggravating factors can be slouching or exercise. It often occurs after a recent illness with coughing or after intense exercise and it mostly of unilateral origin.[2] There may be an associated restriction of the corresponding costovertebral and costotransverse on examination. There is also loss of normal spinal movement associated with the chest pain.[32]

Palpation should be performed with 1 digit, on the anterior, posterior and lateral side of the chest, the clavicle, the cervical and thoracic spine. When on the affected area it reveals a reproducable pain which might suggest Costochondritis, but it cannot entirely concluded.[2]

Motion palpation is a manual process of moving a joint into its maximal end range of motion, after which it is challenged with a light springing movement. This end point of joint movement forms the basis for determining the normal or abnormal joint movement. When motion palpation is reduced, the joint is considered fixated or hypokinetic.[32]

Cardiac causes should be ruled out in patients who present with a high risk.

Medical Management

Treatment consists of conservative management and is usually symptomatic, [33] to resolve the condition and manage pain.[34] Management includes reassurance, local injections and topical or oral analgesics.[33] The aim of reassurance is to reduce anxiety and to change beliefs and behaviours.[35]

Local injections with steroid into the joint, tendon sheath or around the nerve, inhibits inflammation, reduces swelling and pain to improve movement. [36] Alternative treatments may also include: ice, acupuncture, manual therapy, exercise and other medications such as sulfasalazine which may have an additional long-term benefit in the management of costochondritis [37]

Physical Therapy Management

Minimising activities that provoke the symptoms (e.g. reducing the frequency or intensity of exercise or work activities) or using cough suppressants may help relieve symptoms [2]

A course of trigger point therapy can help to reduce pain. This includes cross fibre friction massage and ischemic compression to the intercostal musculature and high velocity, low amplitude mobilisation of the rib in a posterior to anterior direction while the patient is in a supine position to create cavitation. Ice application may also be useful.[38]

Graston Technique [39]

Donald Aspergen at al. suggest using the Graston technique and Kinesio taping. The Graston technique is used on the chondrosternal joint of the concerned rib to relax the chondrosternal musculatuur. Kinesio tape is applied in 2 strips; the first strip goes vertically on the chondrosternal joint and the second strip is applied horizontally. Pain was improved by 70% after two weeks of treatment.[32]

Appropriate, progressive exercise and stretches are also useful for improving symptoms. They can begin with simple mobility exercises progressing to body weight as tolerated [38]as well as stretches for the pectoralis major for example.[40] Treatment can also include mobilisation of the spine and ribs to avoid the thorax becoming stiff and to reduce symptoms. [16]

Education should be part of the treatment programme to reassure the patient by explaining the condition [12]

Key Evidence

ANNE M. PROULX. Costochondritis: Diagnosis and Treatment. Am Fam.Physician. 2009 Sep 15; 80(6):617-620.

Resources

Resources for pictures :
- Fig 1 & 2 : From THIEME Atlas of Anatomy, General Anatomy and Musculoskeletal System, © Thieme 2005, Illustration by Karl Wesker
- Fig 3 : Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. Apr-Jun 2009;31(2):169-71

Clinical Bottom Line

Costochondritis is defined as painful chronic inflammation of costochondral junctions of the ribs or chondrosternal joints of the anterior chest wall and it is often confused with Tietzen syndrome. Diagnosis is confirmed by a scan or bone scintigraphy and by a physical assessment of the affected costal cartilage.

Currently, there have been no clinical trials of treatment for costochondritis.[41] The treatment of costochondritis consists of conservative management and is usually symptomatic [38]

Treatment protocol consists of cross fibre frictions, HVLA, stretching of the pectoral muscles, kinesio taping, Graston techniques and pectoral muscle strength exercises.

References

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