Costochondritis

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Costochondritis

Costochondritis is a benign cause of chest pain that is characterised by inflammation of the cartilage of the chest wall at the junction of the rib and the costal cartilage. When inflammation occurs at the junction of the sternum and the costal cartilage, this is referred to as Sternochondritis. In both cases, the inflammation can lead to chest pain and discomfort, often mistaken for more serious conditions such as heart or lung disease.

Costochondritis most commonly occurs in adults between 40 and 50 years of age, with a slight predominance in females. Costochondritis typically presents unilaterally and primarily affects the costochondral joints of the 2nd to 5th ribs.

The cause of costochondritis is not always clear. Possible causes or triggers include:

• Strenuous physical activity
• Impact chest injury
• Profuse or repetitive coughing
• Poor posture

Patients with costochondritis typically present with multiple areas of tenderness without any evidence of swelling over the costochondral junctions. This differs from a less common condition called Tietze’s disease, which typically involves only one painful area with demonstrable swelling.

With conservative therapy, most patients with costochondritis will have a complete resolution of symptoms within a few weeks. Maintaining good posture and avoiding activities that strain the chest muscles may help reduce the risk of developing costochondritis.

While musculoskeletal causes represent the predominant source of chest pain, it is important to initially consider potential cardiovascular, pulmonary, and gastrointestinal origins in the differential diagnosis of chest pain. Consequently, a comprehensive evaluation involving a thorough clinical history and physical examination becomes crucial in order to rule out serious causes of chest pain. Chest pain in the presence of radiating pain, difficulty in breathing, lightheadedness, elevated body temperature, productive cough, and nausea, as well as chest pain that is worsened during physical activity, are all indicative of potential non-musculoskeletal origins. It is advisable to explore alternative reasons for chest pain before confirming a diagnosis of costochondritis.

• Pain that is felt adjacent to the sternum over the costochondral junctions (typically unilateral)
• Pain may be variously described as sharp or dull
• Pain may be exacerbated by thoracic spine or chest movement and by certain postures
• Pain that is worsened with deep breathing
• Pain may be exacerbated by neck extension

• No visible or palpable swelling of the involved joint(s)
• Point tenderness on palpation over one or more costochondral junctions
• Pain exacerbated by thoracic spine or chest movement
• Positive ‘Crowing Rooster’ and Crossed-Chest Adduction Manoeuvres
• May have a positive Rib Compression test

Costochondritis is not typically detected by plain radiography. However, it is advisable to include chest radiography as part of the diagnostic process as this helps to exclude conditions such as rib fracture, pneumonia, and spontaneous pneumothorax.

The following are examples of red flags for patients presenting with chest pain:

• Radiating chest pain (particularly into the neck or the arms)
• Shortness of breath
• Exertional chest pain
• History of a significant injury
• Severe pain
• Unrelenting pain
• Nocturnal pain
• Unexplained weight loss
• Fever
• Persistent or productive cough
• Chest deformity
• Significant swelling
• Presence of tingling, numbness, burning, or other neurological impairment
• Severe tenderness on palpation or severe pain with any examination procedure

If any red flags are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.

Differential Diagnosis of Anterior Chest Pain

The differential diagnosis of anterior chest pain should include:

• Heart and cardiovascular conditions
• Costochondritis
• Sternochondritis
• Thoracic spine dysfunction
• Tietze syndrome (described below)
• Slipping rib syndrome (described below)
• Myofascial pain syndrome (described below)
• Fibromyalgia
• Rib fracture
• Cervical angina
• Neoplasm
• Infection
• Herpes zoster

Tietze Syndrome

Tietze syndrome is a rarer condition than costochondritis. It commonly affects a single joint and usually has a visible area of swelling.

Slipping Rib Syndrome

Unlike costochondritis, slipping rib syndrome produces pain in the lower ribs, abdomen, and back.

Myofascial Pain Syndrome Causing Anterior Chest Pain

In patients presenting with chest pain, a complete clinical examination should include an evaluation of the following muscles to check for the presence of myofascial trigger points as the concomitant or primary cause of the patient’s pain:

• Sternalis
• Pectoralis major
• Pectoralis minor

Trigger points may be located anywhere within a muscle and its fascia. Therefore, the entire muscle should be examined thoroughly. However, based on our clinical experience, the common locations for trigger points in the above muscles are presented in the images below.