Abstract
Costosternal syndrome is a common, but poorly understood musculoskeletal pain condition. The chronic chest pain is non-cardiac in origin. Costosternal syndrome is commonly considered a benign and self-limited condition that resolves on its own, but in some cases, the pain may become disabling and chronic. Costochondritis is a synonym that is often used and generally involves inflammation and reproducible tenderness of the costochondral junctions of ribs or the costosternal joints of the anterior chest wall. Tietze syndrome is considered the “acute” form of costochondritis, with localized, prominent swelling of a single costal cartilage. It is associated with warmth and erythema of the involved costosternal or costochrondral joint and usually involves the second or third rib. Initially, activity modification such as reducing frequency or intensity of the work or exercise that induces the pain, or treating perpetuating factors such as chronic cough/bronchospasm, is recommended. In terms of pharmacotherapy, nonsteroidal anti-inflammatory medications, acetaminophen, sulfasalazine, and other analgesics can be used. Modalities such as heat or ice may help, usually applied intermittently while symptoms are present. Rehabilitation interventions may also focus on stretching exercises and deep breathing. Trained clinicians can address myofascial pain, biomechanical derangements, and imbalanced musculature of the back and chest wall. Patients should be instructed on corrective ergonomics, postural retraining, and stretching and strengthening exercises.
Keywords
Chest pain, chondritis, costal chondritis, costosternal syndrome, non-cardiac chest pain, Tietze’s, Tietze syndrome
| Synonyms | |
| |
| ICD-10 codes | |
| M94.0 | Chondrocostal junction syndrome (Tietze), costochondritis |
Definition
Costosternal syndrome, or anterior chest wall syndrome, is a very common but poorly understood musculoskeletal pain syndrome referring to non-cardiac induced chest pain. Costosternal syndrome is the most frequent cause of chest pain in the primary care setting. It may also be called costochondritis , which involves inflammation and reproducible tenderness of the costochondral junctions of ribs or the costosternal joints of the anterior chest wall.
There is also a related, much rarer condition described, known as Tietze syndrome . Tietze syndrome, first described in 1921 by the German surgeon Alexander Tietze (1864–1927), is considered the “acute” form of costochondritis, with localized, prominent swelling of a single costal cartilage. It is associated with warmth and erythema of the involved costosternal or costochrondral joint and usually involves the second or third rib. It involves a single rib 70% of the time and is more common in patients younger than 40 years old. Most importantly, Tietze syndrome is often associated with infection, malignancy, or other inflammatory rheumatological conditions.
The diagnosis of costosternal syndrome or costochondritis is often made by excluding more serious conditions. Chest pain is one of the most common complaints presenting to the hospital, with prevalence rates over 50%. Costochondritis is found in 13% to 36% of adults presenting with acute chest pain, depending on the setting, and 14% to 39% of adolescents. In one prospective study of adults presenting to the emergency department with chest pain, 30% were diagnosed with costochondritis. Many of these patients undergo extensive workup before they are reassured that their pain is not cardiac-related. The more serious causes of chest pain should be excluded through appropriate clinical assessment before making the diagnosis of costosternal syndrome (i.e., cardiopulmonary disease, malignancy, infection, and autoimmune disorders must be ruled out and treated appropriately).
Examples of associated autoimmune disorders causing anterior chest wall pain may include: osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, psoriatic arthritis, and the SAPHO ( s ynovitis, a cne, p ustulosis, h yperostosis, and o steitis) syndrome.
There are also a number of chest wall infections reported in the literature. Infections can be associated with IV drug use or traumatic injury, the latter often seen in the setting of penetrating wounds, post-thoracotomy, or other cardiopulmonary surgeries. Infections of the costosternal joints have been associated with tuberculosis, fungus (i.e., mycetoma, pulmonary aspergilloma, and Candida albicans ), syphilis, viruses, and even Escherichia coli . The most common pathogens include: Staphylococcus aureus, Pseudomonas aeruginosa , and Candida albicans .
Malignancy of the costosternal joints must also be ruled out, which may arise from a primary malignant neoplasm, such as a chondrosarcoma or thymoma, or from metastatic carcinoma, most commonly from the breast, kidney, thyroid, bronchus, lung, or prostate. Chondromas and multiple exostoses are the most common benign tumors. Other causes for non-cardiac chest pain may include anxiety, gastroesophageal reflux disease, aneurysm, pulmonary embolus, or referred visceral pain.
The exact pathogenesis of costosternal syndrome remains unclear, but theories include: neuropathy, particularly of the intercostal nerves, muscular imbalances, and myofascial pain. There is no gold standard diagnostic criterion for this syndrome. The diagnosis is largely made by history and clinical exam. Costochondritis can often be associated with illness, coughing, or trauma. It is suspected that repetitive overuse injuries of the costosternal joint may be involved in the degenerative changes sometimes seen on chest wall imaging of patients with this condition.
Symptoms
Chest pain that is sharp, aching, or pressure-like is the common presenting symptom. It may or may not be accompanied by pain radiation to the shoulder, arm, anterior neck, or scapular region. The onset is associated with postural changes and maneuvers that place stress on chest wall structures, rather than with physical exertion alone, as is seen in purely cardiac conditions. Costochondritis involves chest wall tenderness at multiple levels in the overwhelming majority of cases, most commonly the second through fifth costochondral joints and the third and fourth ribs. Tietze syndrome, in contrast, usually involves one joint ( Table 101.1 and Fig. 101.1 ). The left side of the chest is often involved in costosternal syndrome.
| Characteristics | Costochondritis | Tietze Syndrome |
|---|---|---|
| Signs of inflammation | Absent | Present |
| Swelling | Absent | Presence or absence indicates severity of problem |
| Joints affected | Multiple and unilateral >90%Usually second to fifth costochondral junctions involved (Fig. 2) | Usually single and unilateral Usually second and third costochondral junctions involved |
| Prevalence | Relatively common (Box 3) | Uncommon |
| Age group affected | All age groups, including adolescents and elderly | Common in younger age group |
| Nature of pain | Aching, sharp, pressure like | Aching, sharp, stabbing initially, later persists as dull aching |
| Onset of pain | Repetitive physical activity provokes pain, rarely occurs at rest | New vigorous physical activity such as excessive cough or vomiting, chest impact |
| Aggravation of pain | Movements of upper body, deep breathing, exertional activities | Movements |
| Association with other conditions | Seronegative arthropathies, angina pain | No known association |
| Diagnosis | Crowing rooster maneuver and other physical examination findings | Physical examination, exclude rheumatoid arthritis, pyogenic arthritis |
| Imaging studies | Chest radiograph, computed tomography scan, or nuclear bone scan to rule out infections or neoplasms if clinically suspected | Bone scintigraphy and ultrasonography can be used for screening for other conditions |
| Treatment | Reassurance, pain control, NSAIDs, application of local heat and ice compresses, manual therapy with stretching exercises. Corticosteroid or sulfasalazine injections in refractory patients | Reassurance, pain control with NSAIDs, and application of local heat. Corticosteroid and lidocaine injections to the cartilage, or intercostal nerve block in refractory patients |
There is usually no temporal pattern associated with costochondritis pain. In one study, 52% of patients with chest wall syndrome had localized retrosternal pain, 69.2% had chest pain on the left side, and 55.4% still had chest pain after 6 months. A simple “four-point score” with 95% confidence was used to help the clinician with the diagnosis, including: (1) localized muscle tension, (2) stinging pain, (3) pain reproducible by palpation, and (4) absence of cough.
Physical Examination
Visual and palpatory examination is key to the diagnosis of costosternal syndrome. On inspection, the examiner should look for abnormal or asymmetric postures; for example, the patient may be splinting their chest wall joints by keeping the shoulders stiffly neutral. There may be pain behaviors associated with respiration or specific neck/arm movements. With the patient’s skin exposed, the examiner may look for localized rib or joint swelling, as seen in Tietze syndrome, musculoskeletal deformities, muscle swelling or ecchymoses, signs of previous trauma or surgery resulting in chest wall wounds, signs of infection, or rashes such as those seen with herpes zoster or psoriasis.
The palpatory exam is made by applying gentle pressure to the anterior, posterior, and lateral chest wall regions, including the costochondral junctions and chondrosternal joints. Palpation should elicit reproducible, localized tenderness, which may be best appreciated by inducing gentle pressure with a single digit. The examiner should palpate the sternum, sternoclavicular joints, xiphoid process, intercostal spaces, bilateral parasternal junctions, ribs, pectoralis major, and the upper trapezius muscles. All or some of these structures may reproduce the patient’s pain. The cervical spine, clavicle, shoulders, and thoracolumbar spine should also be assessed to complete the musculoskeletal exam and rule out other pain generators causing overlapping pain referral patterns. The examiner should keep in mind that there are also chronic myofascial pain disorders in this body region, which are, by definition, associated with reproducible trigger points.
The examiner should note whether there is pain with deep inspiration/exhalation, or with ipsilateral upper extremity movement. The rib cage moves with respiration and coughing, as well as with trunk and upper extremity movements. Ascertaining whether or not there was an antecedent upper respiratory illness with coughing, or a history of strenuous exercise or overexertion of the upper extremity associated with pain onset, is helpful. One physical exam maneuver, called the horizontal flexion test ( Fig. 101.1 ), consists of having the arm flexed across the anterior chest with the application of steady prolonged traction in a horizontal direction while, at the same time, the patient’s head is rotated as far as possible toward the ipsilateral shoulder. Another test, called the crowing rooster maneuver ( Fig. 101.2 ), consists of having the patient extend the neck as much as possible by looking toward the ceiling, while the examiner, standing behind the patient, exerts traction on the posteriorly extended arms.
