Costochondritis

 

Definition/Description

Costochondritis is a self limited condition defined as painful chronic inflammation of the costochondral junctions of ribs or chondrosternal joints of the anterior chest wall.⁴⁵ 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, ^{52,53,54,55,45}

Palpation of the affected chondrosternal joints of the chest wall elicits tenderness.^{45 and p}ain is reproduced by palpation of the affected cartilage segments which may radiate out into the chest wall.⁴⁶

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.^52,51 Costochondritis ⁵⁴ and Tietze's syndrome are often mistaken for each other, but are two very different conditions. ⁵⁶

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.⁴² 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.⁴³ 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.⁴³

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.^2,1
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 muscles of the chest wall influence expansion of the chest wall. The inspiratory muscles expand the chest volume by elevating the rib cage. The expiratory muscles decrease lung volume by constricting the ribcage downwards.⁴²

Epidemiology /Etiology

Costochondritis can affect children as well as adults. Approximately 14% of adolescents present with costochondritis in out patients.⁵ 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.⁸
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.^4,7,24 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.⁴ 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).¹⁰
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.⁵⁷ Both conditions can be of an acute or insidious onset any age.

Characteristics/Clinical Presentation

Cartilage connects the sternum with the ribs and the clavicle making movement of the thorax possible while breathing ^49,51. Elevation of the ribs and expansion of the rib cage result from the coordinated action of the rib cage muscles. ⁴¹ Inflammation of the cartilage of one or more ribs causes a reddening, a temperature increase and swelling of the cartilage, which is both visible and palpable ^51,55. 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. ^55,56,52,49 Pain on palpation is indicative of costochondritis, but it could also be of cardiac origin ^56,52 or a tumor ^52,53,49. 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. ^{49,51,52 52} Symptoms may occur gradually and can disappear spontaneously after a few days, but equally it may take years to disappear. ^49,58 Even after the symptoms have resolved, they may return at the same location or at another rib level. ^49,55

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.⁴⁰

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 cough, sneezing and chest movements ¹². There are no systemic symptoms or adenopathy. ¹³

Differential Diagnosis

Costochondritis is also known as;
• Costosternal chondrodynia, a Tietze’s syndrome variant ³⁴
• Parasternal chondrodynia ³⁵
• Anterior chest wall syndrome ³⁵
• Tietze syndrome.^{14, 35}

Costochondritis should be distinguished from other, more serious causes of chest pain. ³⁵

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 sternum³⁸
• slipping rib syndrome: hypermobility of the anterior ends of the false rib costal cartilages ³⁹

Other diseases to consider in differential diagnosis:
• multiple myeloma: a malignancy of mature plasma cells ³⁹
• primitive neoplasms of the bone and soft tissues
• chondrosarcoma of the chondrocostal joints
• breast and lung tumours with extension to the costal cartilage
• metastases of breast, kidney, and prostate neoplasms⁵⁹.

Malignancy is a cause that should be excluded. The use of appropriate diagnostic investigations such as electrocardiography^60,51, CT ^61,53, MRI^53,60, is necessary.

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. ³⁶ 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.³⁶

Tietze syndrome and costochondritis 35
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.²⁸ 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.²⁸

Patients older than 35 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.¹⁵
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 .15

Measurement of thoracic and cervical mobility: This is a relevant measure with costochondritis as the inflammation of the costochondral joints of the ribs or the anterior chest wall can cause a of mobility in the spinal area.65
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 64

Examination

Patients with Costochondritis will present with chest pain that is reproducable by palpation of the affected area, mostly ribs 2 to 5 and in most patients several ribs are affected. Other aggravating factors are slouching or exercise. It often occurs after a recent illness with coughing or after intense exercise and it mostly of unilateral origin.¹⁵ 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.²⁷
-palpation: palpation should be performed with 1 digit, on the anterior, posterior and lateral side of the chest, the clavicula,the cervical and thoracic spine. When on the affected area reveals a reproducable pain this might suggest Costochondritis but it cannot entirely conclude it.¹⁵
- Motion palpation : 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 play. When the motion palpation is reduced, the joint is considered fixated or hypokinetic.²⁷

In a small number of patients the cardiac pain is due to cardiac causes.in 3-6% of the patients with pain to palpation a myocard infarction has occurred.patients older then 35 and with a history of cardiac problems have a higher risk.they should reveive a ecg and chest radiography.¹⁵

• 10 Medical Management

The treatment of costochondritis consists of conservative management and is usually sympotamatic.^29,30 Conservative management can be useful in attempting to resolve the condition and managing pain.³⁰ (LOE : 4)
The management includes reassurance, local injections and topical or oral analgesics.²⁹ (LOE : 4) The aim of reassurance is reducing anxiety and changing beliefs and behaviours. Reassurance consists of affective reassurance (showing empathy) and cognitieve reassurance (providing education and explanations).⁶⁶ (LOE : 2A)
Local injections with steroid in the joint, tendon sheath or around the nerve, inhibits the inflammation. This reduces the swelling and the pain and allows the patient to move better again. It is proved to be clinically safe and effective in the treatment of patients with Tietze’s syndrome.³¹ (LOE : 2B)
The conservative treatment also includes: ice, acupuncture, manual therapy, exercise prescription and prescription of other drugs including sulfasalazine.³⁰
Cold therapy and acupuncture were used to decrease the local inflammation and providing analgesia.³⁰ The drug sulfasalazine may have an additional long-term benefit in the management of costochondritis. This drug has an anti-inflammatory action.³² (LOE : 2C)
Currently, there have been no clinical trials of treatment for costochondritis.³³ (LOE : 2C)

• 11 Physical Therapy Management

The treatment of Tietze’s syndrome is not yet perfect, because there is a lack of literature³³. It is not known weather the disease is dealt definitely or not.[3] For now, trustworthy clinical studies on the treatment of Tietze's syndrome are lacking [8][4][6]. Treatment is usually directed at pain relief with acetaminophen, nonsteroidal anti-inflammatory drugs when safe and appropriate, or other analgesics. Applying heat with compresses or heating pads can help, particularly in the case of muscle overuse. Minimizing activities that provoke the symptoms (e.g., reducing the frequency or intensity of exercise or work activities) or using cough suppressants may also help relieve symptoms¹⁵ (LOE:5)

From the article of Karen Hudes where she reported a case study we can conclude that a course of trigger point therapy can reduce pain. This included cross fiber friction massage an ischemic compression to the intercostal musculature. In addition to this we can also use high velocity, low amplitude mobilisation of the rib in a posterior to anterior direction while the patient is in a supine position to create a cavitation. We can also use oscillation of the ribs in a posterior to anterior motions with a contact on the dorsal surface of the rib adjacent to the thoracic spinal articulation. Also the patient can instructed to use ice pack that will be wrapped in a light towel. This ice packed must be applied on the sternum for a duration of ten minutes. After 10 minutes will be followed by a 20 minutes rest, this process will be repeating 4 cycles.¹⁸ (LOE: 4)

From the article of Donald Aspergen at al. who studied a case of a young (21 year) female volleyball player we can found follow instruction to the rehabilitation. They used HVLA like they do in the article of Karen Hudes, Graston technique, and Kinesio taping methods. The Graston technique was applied on the chondrosternal joint of the concerned rib, this is a soft tissue technique to relax the chondrosternal musculatuur. Kinesio tape was applied in 2 strips. The first strip was applied vertically on the chondrosternal joint and the second strip was applied horizontally on the concerned rib.
-> By following these instructions the pain was improved by 70% after two weeks of treatment.²⁶ (LOE: 4)

What exercise?
After 6,7 visit we can ad rehabilitative exercises like:
• A un-weighted supine arm pushes to activate the pectoral musculature and seated in-weighted plusses
• Wall push ups and progressed to full push ups and plusses at visit 8
-> The patient was instructed to begin with 5-10 repetitions of each exercise. This exercise were tolerance progressing to 3 sets of 10 repetitions each.
If following this instructions the patient showed a 80% improvement in symptoms and a reduction of the VAS- score on pain.¹⁸ (LOE: 4)
From the article of G. Rovetta et al. we can concluded that stretching of the pectoral muscle have a positive effect on the reducing of pain. It must be down in a correct way to be effective. Patients must place their forearm with elbow bent around 90° on wall or backside of a doorway and the elbow must be at least at shoulder height.²³ (LOE: 3A)

The physiotherapist can:
- Reassure the patient by explaining the condition ^8,4
- Instruct a good body position and give exercise advice. Patients need a good balance between exercise and rest.^8,10,7,6
- Use heat pads on the costosternal joint and massage to help against the overloading of muscles and to lessen the pain. ^8,1,6
- Conservative treatment involving use of nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics, as necessary.²³
- Mobilize spine and ribs to avoid rigidity of the thorax and to reduce complaints. 10,3
- Teach the patient breathing exercises³
- Cough suppressants may be beneficial if cough is an aggravating factor.²³
- Learn the patient to cope with pain. ^8,6
- Exercise for shoulder and back can be provocative, therefore only when the complaints have disappeared, they can be applied³

 It is urgent to work on literature studies for the physical treatment of costochondritis, because there is at this moment no literature study for this treatment.³³

• 12 Key Evidence

ANNE M. PROULX. Costochondritis: Diagnosis and Treatment. Am Fam.Physician. 2009 Sep 15; 80(6):617-620.¹⁵

• 13 Resources

Resources we used 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

Books :
(43) Schunke M. et al. ; Anatomische atlas : Prometheus, algemene anatomie en bewegingsapparaat ; Bohn Stafleu van Loghum houten ; 2010 ; tweede druk ; p130-133
(44) Schunke M. et al. ; Anatomische atlas : Prometheus, algemene anatomie en bewegingsapparaat ; Bohn Stafleu van Loghum houten ; 2010 ; tweede druk ; p142-157

• 14 Clinical Bottom Line Missing information

Costochondritis is defined as painful chronic inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall.Costochondritis is often confused with Tietzen syndrome. The difference is that in Tiete’s syndrome there is a presence of swelling over the affected joints.⁴⁵ Costochondritis and the Tietze's syndrome are often mistaken one for the other but in fact they are two different diseases.⁸

The diagnosis of costochrondritis can be made by bone scan or bone scintigraphy. It can also be examined by palpation of the affected costal cartilage. Patients older than 35 years have a higher risc of cardiac problems. These patients should recieve a radiography of the chest.^28,47

Currently, there have been no clinical trials of treatment for costochondritis.³³ The treatment of costochondritis consists of conservative management and is usually sympotamatic.^29,30

The therapy consist of cross fiber frictions, HVLA, stretching of the pectoral muscles, kinesiotaping, graston techniques and pectoral muscle strength exercises.

• 15 Recent Related Research (from Pubmed)

http://www.ncbi.nlm.nih.gov/pubmed/22787240
http://www.ncbi.nlm.nih.gov/pubmed/19827277
http://www.ncbi.nlm.nih.gov/pubmed/17360222
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140236

• 16 References

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