BASICSSmriti Ohri, MD
BASICS
DESCRIPTION
• Anterior chest wall pain associated with pain and tenderness of the costochondral and costosternal regions
• System(s) affected: musculoskeletal
• Synonym(s): costosternal syndrome; parasternal chondrodynia; anterior chest wall syndrome (1)
EPIDEMIOLOGY
• Predominant age: 20 to 40 years
• Predominant gender: female
Incidence
• 30% of chest pain visits in emergency room (2)
• 20% of chest pain visits in primary care office were due to musculoskeletal causes with 13% because of costochondritis (3).
ETIOLOGY AND PATHOPHYSIOLOGY
Not fully understood
RISK FACTORS
• Unusual physical activity or overuse that stresses the upper extremity
• Recent trauma (including motor vehicle accident, domestic violence) or new activity
• Recent upper respiratory infection (URI) with coughing
DIAGNOSIS
• Pain is usually sharp, achy, or pressure-like
• Pain involves multiple and mostly unilateral 2nd to 5th costal cartilages.
• Exacerbated by upper body movements and exertional activities
• Reproduced by palpation of the affected cartilage segments
• Chest tightness is often associated with the pain.
HISTORY
• A complete and thorough history is mandatory for the diagnosis, with special emphasis on cardiac risk factor evaluation.
• Social history: careful screening and evaluation for domestic violence and substance abuse
PHYSICAL EXAM
• A physical exam to exclude more serious conditions that may present with chest pain is necessary for the diagnosis.
• Tenderness elicited over the costochondral junctions is necessary to establish the diagnosis but does not completely exclude other causes of chest pain.
• If swelling or redness of costal cartilage is present, this may be termed as Tietze syndrome.
• Movement of upper extremity of the same side may reproduce the pain (1).
• Palpation of epigastric region to evaluate for gastroesophageal reflux disease (GERD) and deep palpation in right upper quadrant of abdomen to evaluate gallbladder
Pediatric Considerations
• Consider psychogenic chest pain in children who perceive family discord.
• Consider slipping rib syndrome in children with chronic chest and abdominal pain (4).
Geriatric Considerations
• Presents with multiple problems capable of causing chest pain, making a thorough history and physical exam imperative
• Consider herpes zoster in elderly patients with nonspecific musculoskeletal chest pain.
DIFFERENTIAL DIAGNOSIS
• Cardiac
– Coronary artery disease (CAD)
– Cardiac contusion from trauma
– Aortic aneurysm
– Pericarditis
– Myocarditis
• Gastrointestinal
– Gastroesophageal reflux
– Peptic esophagitis
– Esophageal spasm
– Cholecystitis
• Musculoskeletal (4)
– Fibromyalgia
– Slipping rib syndrome
– Costovertebral arthritis
– Painful xiphoid syndrome
– Rib trauma
– Ankylosing spondylitis
– Precordial catch syndrome
• Psychogenic
– Anxiety disorder
– Panic attacks
– Hyperventilation
• Respiratory
– Asthma
– Pulmonary embolism
– Pneumonia
– Chronic cough
– Pneumothorax
• Other
– Domestic violence and abuse
– Herpes zoster
– Spinal tumor
– Metastatic cancer
– Substance abuse (cocaine)
DIAGNOSTIC TESTS & INTERPRETATION
• The diagnosis of costochondritis is primarily based on a thorough history and physical exam.
• Laboratory exams should be used to exclude other differential diagnosis.
• ESR is inconsistently elevated.
Initial Tests (lab, imaging)
No imaging is indicated for the diagnosis of costochondritis; chest x-ray and rib films are often normal.
Diagnostic Procedures/Other
• None indicated for the diagnosis of costochondritis.
• Consider ECG in patients age >35 years, those with history or risk of CAD (5)[C].
• Consider chest x-ray in patients with cardiopulmonary symptoms (5)[C].
• Consider spiral CT for pulmonary embolism and D-dimer if history or risk factors are present.
Test Interpretation
Costochondral joint inflammation
Reassurance of benign nature of condition and potential for long, slow recovery from pain
GENERAL MEASURES
• Rest and heat (or ice massage, whichever makes the patient feel better) (6,7)[C]
• Stretching exercises
• Minimizing activities that provoke the symptoms (e.g., reducing the frequency or intensity of exercise or work activities) (6,7)[C]
MEDICATION
• Pain relief with NSAIDs (ibuprofen, naproxen, or diclofenac); acetaminophen or other analgesics may be considered in noninflammatory disorders (6,7)[C].
• Use of skeletal muscle relaxants may be beneficial if associated with muscle spasm.
ISSUES FOR REFERRAL
Consider referral to physical therapy or osteopathy. Refractory cases of costochondritis can be treated with local injections of combined lidocaine (Xylocaine)/corticosteroid into costochondral areas if severe; however, this is rarely necessary (8)[C].
COMPLEMENTARY & ALTERNATIVE MEDICINE
Limited data on use of manipulation or ice massage but may be safely tried if patient is interested.
ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS
Only indicated if differential diagnosis is unclear and cardiac or other more serious etiology of chest pain is being considered
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Follow up within 1 week if diagnosis is unclear or symptoms do not abate with conservative treatment.
PATIENT EDUCATION
• Educate the patient in regard to the self-limited (although potentially recurrent) nature of the illness.
• Instruct patient on proper physical activity regimens to avoid overuse syndromes.
• Stress importance of avoiding sudden, significant changes in activity.
PROGNOSIS
• Self-limited illness lasts for weeks to months but usually abates by 1 year, although sometimes chronic especially in adolescents.
• Often recurs
COMPLICATIONS
Incomplete attention to differential diagnosis or overly aggressive interventions to ensure a more life-threatening diagnosis is not missed.
REFERENCES
1. Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80(6):617–620.
2. Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466–2469.
3. Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract. 1994;38(4):345–352.
4. Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013;40(4):863–887. doi:10.1016/j.pop.2013.08.007.
5. Miller CD, Lindsell CJ, Khandelwal S, et al. Is the initial diagnostic impression of “noncardiac chest pain” adequate to exclude cardiac disease? Ann Emerg Med. 2004;44(6):565–574.
6. How J, Volz G, Doe S, et al. The causes of musculoskeletal chest pain in patients admitted to hospital with suspected myocardial infarction. Eur J Intern Med. 2005;16(6):432–436.
7. Spalding L, Reay E, Kelly C. Cause and outcome of atypical chest pain in patients admitted to hospital. J R Soc Med. 2003;96(3):122–125.
8. Aspegren D, Hyde T, Miller M. Conservative treatment of a female collegiate volleyball player with costochondritis. J Manipulative Physiol Ther. 2007;30(4):321–325.
ADDITIONAL READING
• Cayley WE Jr. Diagnosing the cause of chest pain. Am Fam Physician. 2005;72(10):2012–2021.
• Freeston J, Karim Z, Lindsay K, et al. Can early diagnosis and management of costochondritis reduce acute chest pain admissions? J Rheumatol. 2004;31(11):2269–2271.
• Verdon F, Herzig L, Burnand B, et al. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly. 2008;138(23–24):340–347.
CODES
ICD10
M94.0 Chondrocostal junction syndrome [Tietze]
CLINICAL PEARLS
• A very common disorder, accounting for perhaps 30% of all cases of chest pain
• Diagnosis is based primarily on history and physical with lab and other testing done to exclude various differentials based on thorough history and risk factors.
• Educate the patient in regard to the self-limited (although potentially recurrent) nature of the illness. Instruct patient on proper physical activity regimens to avoid overuse syndromes.
TREATMENT