Costochondritis

Written by: Dr Don Ponnamperuma – created: 12 February 2025; last modified: 12 February 2025

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Costochondritis

Publications group together pain at the articulations between ribs and sternum and pain of the costal cartilages as “costochondritis”; Tietze syndrome is a similar condition but is characterised by non-suppurative swelling over the costal cartilages and will not be discussed in this work.

Epidemiology

Costochondritis is thought to account for up to 30% of cases presenting to an acute medical service with chest pain.

Clinical Features

Diagnosis is made on history and examination; patients may complain of chest wall pain of a sharp or aching character, with varying intensity. The pain is most commonly localised over the 2^nd-5^th sternocostal joint, though any one of the seven ribs that articulate with the sternum may be affected. The pain may be exacerbated by movement, deep inspiration and exertion.

Examination may demonstrate pain on palpation the over affected joints; the ipsilateral upper arm and shoulder range of motion should also be examined as this will typically elicit movement-related pain. Most cases resolve within a matter of months, but approximately 30% may have pain at one year and up to 4% may experience recurrence over the subsequent two years.

Diagnosis

There is no gold standard investigation to diagnose costochondritis, with any investigations done used to rule out more serious conditions (e.g. ECG for MI). As such, there are no studies examining the validity of any physical examination techniques for diagnosing costochondritis, despite the description of special tests such as the crowing-rooster and crossed-arm adduction manoeuvres in aiding the diagnosis. Neither are there any studies examining the reliability of using these techniques for diagnosis.

Differential Diagnosis

Chest Wall Pain Differential Diagnoses

• Costochondritis
• Lower rib pain syndromes (slipping rib syndrome)
• Pain from thoracic spine
  • costovertebral joints
  • interspinous ligaments and paravertebral muscles
  • possibly not costotransverse joints or facet joints
• Sternalis Syndrome
• Stress fractures
• Tietze’s Syndrome
• Xiphoidalgia
• Spontaneous sternoclavicular subluxation
• Rheumatic diseases
  • Fibromyalgia
  • Rheumatoid arthritis
  • Axial Spondyloarthritis (including ankylosing spondylitis)
  • Psoriatic Arthritis
  • Systemic lupus erythematosus
  • Relapsing polychondritis
• Sternoclavicular hyperostosis
• Septic arthritis of the chest wall
• Non-rheumatic systemic causes
• Osteoporotic fracture
• Neoplasms
• Pathological fracture
• Bone pain
• Sickle cell disease (rare)

Management

The mainstay of managing costochondritis is analgesia and activity modification, such as avoiding activities that exacerbate the pain. However, there is a paucity of evidence on the management options for all causes of musculoskeletal chest wall pain. One study describes the use of corticosteroid injections to the tender areas of the chest wall, but this study did not describe whether imaging was used to confirm that the injection was into the sternocostal joint. There are no large studies examining the efficacy of corticosteroid injections in treating sternocostal joint-generated pain in the absence of an inflammatory condition

There are no anatomical studies describing the volume of the sternocostal joint, knowledge of which would aid in making decisions about the volume of injectate to utilise. Another anatomical consideration is the safety of introducing needles close to the lungs and pleurae and risking a pneumothorax.

Costochondritis discussed in literature were deemed to be of idiopathic aetiology. There is limited literature describing post-traumatic sternocostal joint-generated pain; one case report describes post-traumatic pain at the first sternocostal joint. MRI demonstrated increased signal intensity on STIR sequence, correlating with the site of pain. This was treated with fluoroscopy-guided corticosteroid and local anaesthetic injection, which provided complete pain relief. However, this publication did not detail the type (of either corticosteroid or local anaesthetic) or volume of injectate used. Treatment yielded four months of analgesia, after which the patient underwent resection arthroplasty of the first sternocostal joint, and the patient remained pain-free at two years.

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,