Costochondritis: Difference between revisions

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&nbsp;<br>1 Search Strategy<br>2 Definition/Description<br>3 Clinically Relevant Anatomy<br>4 Epidemiology /Etiology<br>5 Characteristics/Clinical Presentation<br>6 Differential Diagnosis<br>7 Diagnostic Procedures<br>8 Outcome Measures<br>9 Examination<br>10 Medical Management
<div class="editorbox"> '''Original Editor '''- [[User:User Name|Nick Demunter]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
<div><br>11 Physical Therapy Management<br>12 Key Research<br>13 Resources<br>14 Clinical Bottom Line<br>15 Recent Related Research (from Pubmed)<br>16 References </div>
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<br>  
== &nbsp;Definition/Description ==
<br>Costochondritis is a self-limiting condition defined as painful chronic inflammation of the costochondral junctions of [[ribs]] or chondrosternal joints of the anterior chest wall.<ref name=":0">PROULX A and TERESA W.; Costochondritis: Diagnosis and Treatment; ''Am Fam Physician.'' 2009 Sep 15;80(6):617-620</ref>
* 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 [[Tietzes|Tietze syndrome]].
* Palpation of the affected chondrosternal joints of the chest wall elicits tenderness <ref name=":0" />  and pain is reproduced by palpation of the affected cartilage segments which may radiate out into the chest wall.
== Clinically Relevant Anatomy ==
The thoracic wall consists of the
* Sternum anteriorly,
* 12 thoracic vertebrae posteriorly,
* 12 paired ribs and associated costal cartilages.<ref name=":3">Clemens WM. et al. ; Introduction to Chest Wall Reconstruction : Anatomy and Physiology of the Chest and Indications for Chest Wall Reconstruction ; Semin Plast Surg. ; 2011 ; 25(1) : 5-15</ref>
Ribs consist of [[bone]] and [[cartilage]], with cartilage serving as an elastic bridge between the bony portion of the rib and the sternum.


<br>  
According to their attachment to the sternum, the ribs are classified into 3 groups: true, false, and floating ribs.
# True ribs are the ribs that directly articulate with the sternum with their costal [[cartilage]]<nowiki/>s - ribs 1-7. They articulate with the sternum by the sternocostal joints. The first rib is an exception to that rule; it is a [[Joint Classification|synarthrosis]] and the first rib could uniquely articulate with the clavicle by the costoclavicular joint
# The false ribs (8,9,10) are the ribs that indirectly articulate with the sternum, as their costal cartilages connect with the seventh costal cartilage by the costochondral joint.
# The floating ribs (11,12) do not articulate with the sternum at all (distal two ribs)<ref>Safarini OA, Bordoni B. [https://www.ncbi.nlm.nih.gov/books/NBK538328/ Anatomy, Thorax, Ribs]. InStatPearls [Internet] 2019 Feb 19. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK538328/ (last accessed 14.4.2020)</ref>.
<br><span>The ribs move with respiration and with truncal motion or movement of the upper extremities.</span><ref name=":3" />


<br>  
== Aetiology ==
Costochondritis is inflammatory. It is caused by inflammation of the costal cartilages and their sternal articulations, also known as the costochondral junctions<ref name=":1">Schumann JA, Parente JJ. [https://www.ncbi.nlm.nih.gov/books/NBK532931/ Costochondritis].Available from:https://www.ncbi.nlm.nih.gov/books/NBK532931/ (last accessed 29.4.2020)</ref>.


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=== Epidemiology ===
The epidemiology of costochondritis is not well established.
* In a small study published in 1994, there was a higher frequency of costochondritis seen in females and Hispanics.
* In a group of 122 patients presenting to the emergency department with chest pain not due to malignancy, fever, or trauma, costochondritis was the diagnosis in 36 of the patients (30%)<ref name=":1" />
* Can affect children as well as adults. A study of chest pain in an outpatient adolescent clinic found that 31 percent of adolescents had musculoskeletal causes, with costochondritis accounting for 14 percent of adolescent patients with chest pain<ref name=":0" />.


<u>• 1 Search Strategy</u>  
== Characteristics/Clinical Presentation ==
[[File:Ashkan-forouzani-oxaIBWkrGXE-unsplash.jpg|right|frameless]]
Consider pursuing other causes of chest pain prior to establishing a costochondritis diagnosis as Costochondritis is a diagnoses of exclusion. Cardiac and respiratory causes will need to be ruled out. If the patient complains of radiating pain, shortness of breath, dizziness, exertional chest pain, fever, or productive cough these are symptoms that may indicate different and more serious causes of chest pain. If there has been trauma an occult rib fracture should also be considered. If cardiopulmonary causes and trauma have been excluded the below findings should be present to varying degrees<ref name=":1" />.


Pubmed<br>Web of knowledge <br>Search criteria&nbsp;: costochondritis/treatment/outcome/tietze/  
Possible findings include
* Patient will give a history of the pain worsening with movement and certain positions. The pain will also typically be worse when the patient takes a deep breath.
* Pain quality is variable, but it may be described as a sharp or dull pain.
* Patients report a gradual or rapid onset of pain and swelling of the upper costal cartilage of the costochondral junction.
* Pain is usually reproducible by mild-to-moderate palpation. Often, there is point tenderness where one or two ribs meet the sternum (a pitfall of the typical physical exam findings is that pain due to acute coronary syndrome can also be described as reproducible)<ref name=":1" />.
* Symptoms may occur gradually and can disappear spontaneously after a few days, but equally it may take years to disappear. <ref name=":4">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389</ref> <ref>Gregory P.L., BISWAS A.C., Batt M.E.,Musculoskeletal problems of the chest wall in athletes, Sports Med., 2002;32(4):235-50.</ref> Even after the symptoms have resolved, they may return at the same location or at another rib level. <ref name=":2">Hurst J.W., Morris D.C., Williams B.R. “Chest Pain” in patients with costochondritis or Tietze's syndrome, Wiley-Blackwell, 2001, p23-29</ref>
* There may be hypomobility of the upper thoracic spine, costovertebral joints, and the lateral ribs.<ref name=":5">Han J N et al.; Respiratory function of the rib cage muscles; European Respiratory Journal ISSN 0903 1993. </ref>


<br>  
== Evaluation ==
Costochondritis is usually self-limited and benign - should be distinguished from other, more serious causes of chest pain.
* [[Coronary Artery|Coronary artery disease]] is present in 3 to 6 percent of adult patients with chest pain and chest wall tenderness to palpation.
* History and physical examination of the chest that document reproducible pain by palpation over the costal cartilages are usually all that is needed to make the diagnosis in children, adolescents, and young adults.
* Patients older than 35 years, those with a history or risk of coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiograph and possibly a chest radiograph<ref name=":6" />
* Consider further testing to rule out cardiac causes if clinically indicated by age or cardiac risk status<ref name=":6">Proulx AM, Zryd TW. [https://www.ncbi.nlm.nih.gov/pubmed/19817327 Costochondritis: diagnosis and treatment.] American family physician. 2009 Sep 15;80(6):617-20.Available from:https://www.ncbi.nlm.nih.gov/pubmed/19817327 (last accessed 29.4.2020)</ref>


<u>• 2 Definition/Description</u><br>Costochondritis is a painfull chronical inflammation of the cartilago of one or more costae at<br>the transition between sternum and costae.[1][2][3] Only when a swelling occurs underneath sternum and/or a reddening of the skin at the painfull spot, it's called Tietze's syndrome[4][5][6][7]. This disease causes severe pain when coughing and deep breathing. The Tietze's syndrome is not life-threatening or contagious but it is a fastidious and painfull disease.[4][3] Costochondritis[6] and the Tietze's syndrome are often confused but in fact they are two different diseases. [8]<br> <br>Costochondritis usually affects the third, fourth and fifth costochondral joint and occurs more often in women. Whereas Tietze’s syndrome most commonly affects one joint, in particularly the second or third costal cartilage and both sexes are affected equally [9]. Both diseases can start either acute or progressively at any age.
== Differential Diagnosis ==
The differential diagnosis for costochondritis is rather long. Some of the diagnoses included are associated with major morbidity and mortality. eg
* [[Acute Coronary Syndrome]] (ACS)
* [[Pneumothorax]]
* [[Pneumonia]]
* [[Pulmonary Embolism]]
* [[Tietzes|Tietze’s]] syndrome, much less common than costochondritis, and it tends to cause chest swelling in addition to the other symptoms,
* Xiphoidalgia: painful swelling and discomfort of the xiphoid process of the sternum <ref>Brian E Udermann et al.; Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report; J Athl Train. 2005 Apr-Jun; 40(2): 120–122</ref>
* [[Slipping Rib Syndrome]]: hypermobility of the anterior ends of the false rib costal cartilages <ref name=":8">Brenda M. Birmann et al.; Prediagnosis biomarkers of insulin-like growth factor-1, insulin, and interleukin-6 dysregulation and multiple myeloma risk in the Multiple Myeloma Cohort Consortium. Blood. 2012 Dec 13; 120(25): 4929–4937.</ref><sup></sup><sup></sup>
== Outcome Measures ==
[http://www.physio-pedia.com/Patient_Specific_Functional_Scale 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


[[Image:Costochrondritis.jpg|border|right|300x200px]]<br><u>• 3 Clinically Relevant Anatomy</u>  
[http://www.tandfonline.com/doi/pdf/10.1179/jmt.2009.17.3.163?redirect=1&#.V2bdQo9OLmK The Global rating of change (GROC)]: to measure the patient’s subjective rate of improvement.improvement .<ref name=":0" />  


The diagnosis of costochondritis relies on patient history and physical examination findings; therefore, understanding of the chest anatomy is important. Ribs consist of bone and cartilage, with cartilage&nbsp;serving as an elastic bridge between the bony portion of the rib and the sternum. 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 in front 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.2,1The ribs move with respiration and with truncal motion or movement of the upper extremities. The innervation of the thoracic wall is supplied mostly by the intercostal nerves. Impingement of these nerves by movement of the overlying rib or cartilage can cause pain.2 The shoulder girdle muscles develop in the lower cervical region and carry this innervation with them as they move to attach to the chest wall. Thus, cervical or shoulder problems may refer pain to the chest wall.
Measurement of thoracic and cervical mobility:<ref>FREESTON J; Can Early Diagnosis and Management of Costochondritis Reduce Acute Chest Pain Admissions?; The Journal of Rheumatology November 2004, 31 (11) 2269-2271</ref>
* 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.
* [[Fingertips to Floor Distance - Special Test|Finger to floor distance]] (FFD): high reliability and sensitivity, but poor correlation with spinal changes
* [http://www.physio-pedia.com/Schober_test The Schober test]
* Thoracolumbar flexion
* [[Occiput to Wall Distance OWD|Occiput to wall]] distance <ref>Viitanena J, H. Kautiainena, J. Sunia, M. L. Kokkoa &#x26; K. Lehtinena; The Relative Value of Spinal and Thoracic Mobility Measurements in Ankylosing Spondylitis; Scandinavian Journal of Rheumatology; Volume 24, 1995 - Issue 2</ref>


<br>  
== Examination ==
[[File:Katherine-hanlon-QgcdtM9rA5s-unsplash.jpg|alt=|right|frameless]]
Patients with Costochondritis will present with:
* Chest pain reproducible by palpation of the affected area, with ribs 2 to 5 mostly affected.
* Aggravating factors can be slouching or exercise.
* Often occurs after a recent illness with coughing or after intense exercise and it mostly of unilateral origin.<ref name=":0" />  
* May be an associated restriction of the corresponding costovertebral and costotransverse on examination.
* Loss of normal spinal movement associated with the chest pain.<ref name=":9">Aspegren D; Conservative Treatment of a Female Collegiate Volleyball Player with Costochondritis ; Journal of Manipulative and Physiological Therapeutics ; May 2007 Volume 30, Issue 4, Pages 321–325 </ref>
* Palpation should be performed with 1 digit, on the anterior, posterior, and lateral side of the chest, the clavicle, the cervical and thoracic spine. When on the affected area it reveals a reproducible pain which might suggest Costochondritis, but it cannot entirely concluded.<ref name=":0" />
* 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 movement. When motion palpation is reduced, the joint is considered fixated or hypokinetic.<ref name=":9" />
* Cardiac causes should be ruled out in patients who present with a high risk.


<span>&nbsp;</span><br><u>• 4 Epidemiology /Etiology</u>  
== Medical Management ==
Treatment consists of conservative management and is usually symptomatic, <ref name=":12">Grindstaff L.T. et al. ; Treatment of a female collegiate rower with costochondritis : a case report ; J Man Manip Ther. ;2010 ;18(2) : 64-68 </ref>


Costochondritis can affect children as well as adults. A study of chest pain in an outpatient adolescent clinic found that 31 percent of adolescents had musculoskeletal causes, with costochondritis accounting for 14 percent of adolescent patients with chest pain.5 In this series, no definite cause of chest pain was found in 39 percent of cases.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<br>Costochondritis is a common diagnosis in adults with acute chest pain. It is present in 13 to 36 percent of these patients, depending on the study and the patient setting.4,7,24 In a prospective study of adult patients presenting to an emergency department with chest pain, 30 percent had costochondritis. A prospective study of episodes of care for chest pain in a primary care office network found musculoskeletal causes in 20 percent of episodes of care, with costochondritis responsible for 13 percent.9 These data are similar to a study of patients with noncardiac 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 percent, respectively).10
Management includes
* Reassurance
* Topical or oral analgesics.<ref name=":12" />
* Local injections with steroid into the joint, tendon sheath or around the nerve, inhibits inflammation, reduces swelling and pain to improve movement. <ref>Kamel M. et al. ; Ultrasonographic assessement of local steroid injection in Tietze’s syndrome ; Br J Rheumatol ; 1997 ;36(5) : 547-50 </ref>
* If patients have severe or refractory costochondritis, refer for outpatient follow-up. Physical therapy is a treatment option for refractory costochondritis<ref name=":1" />
* Alternative treatments may also include: ice, acupuncture, manual therapy, exercise, and other medications such as sulfasalazine which may have an additional long-term benefit in the management of costochondritis <ref>Freeston J. et al. ; Can early diagnosis and management of costochondritis reduce acute chest pain admissions ?; J Rheumatol ; 2004 ; 31(11)-2269-71 </ref>


<br><u>• 5 Characteristics/Clinical Presentation</u>  
== Physical Therapy Management ==
May Include:
[[File:Toa-heftiba-a9pFSC8dTlo-unsplash.jpg|right|frameless]]
* Education - reassure the patient by explaining the condition <ref name=":10">Massin MM, Bourguignont A, Coremans C, Comté L, Lepage P, Gérard P. Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic. Clin Pediatr  2004;43(3):231-238</ref>


The cartilage connects sternum with costae and clavicula, and makes the movement of the thorax possible while breathing. [1][3] The inflammation of the cartilage of one or more costae causes a red, warm swelling of the cartilage. This will be both visible and palpable.[3][7]There is pain with a varying intensity in the chest wall and this pain aggravated by movements of the torso, deep breathing, coughing and exertion. [7][8][4][1] Pain occurring during the palpation of the painful spot suggests costochondritis but the pain could also have a cardiac origin [8] [4] tumor [4] [3] [1]. From the pain of inflammation, the normal movement in joints is disrupted, the movements of the shoulder crepitates and pain may occur. [1][3][4] Complaints occur gradually and can disappear spontaneously after some days but it may take years to disappear. [1][10] Even after a spontaneously healing, the complaints can return on the same place or another spot around the costae. [1][7]
* Minimising activities that provoke the symptoms (e.g. reducing the frequency or intensity of exercise or work activities)
* A course of [[Trigger Points|trigger point]] therapy to reduce pain - eg.cross fibre friction [[massage]]
* Heat or cold therapies can be used as conservative management strategies to reduce pain levels <ref name=":13">Hudes K, Low-tech rehabilitation and management of a 64 year old male patient with acute idiopathic onset of costochondritis. J Can Chiropr Assoc. 2008 December; 52(4): 224–228</ref>
* Postural exercises - Re-train proper [[posture]] in functional positions (Neuro-muscular control). Functional training is all about using the right muscles at the right time, to sustain the correct posture, in daily activities. Simple activities like eg. correct standing posture, sit to stand and walking up stairs all need be addressed to ensure correct technique and muscle recruitment.
* [[Thoracic Manual Techniques and Exercises|Thoracic manual therapies]] directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility<ref name=":5" />
* Exercises in the range of motion should be induced as soon as possible. The patient may not have pain when he is doing the exercises eg.rotation exercises for thoracic spine. Do not invoke pain.
* Progressive stretches. They can begin with simple mobility exercises as tolerated <ref name=":13" />eg <ref>Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. Apr-Jun 2009;31(2):169-71 </ref> Stretching of the M. pectoralis major can be helpful (stretch the M. pectoralis major, stand in a corner for 10 sec with both of your hands against the wall (like when you do a push-up)repeat it a few times a day for 1 or 2 minutes).  
* Mobilisation of the spine and ribs to improve thorax mobility and to reduce symptoms. <ref name=":11">Buntinx F, Knockaert D, Bruyninckx R, et al. Chest pain in general practice or in the hospital emergency department: is it the same? Fam Pract. 2001;18(6):586-589.
</ref>
* On the painful area they can use transcutaneous electrical stimulation and electroacupuncture. The acupuncture needle (also known as a solid filiform needle) is placed within the involved spinal segment. Than low-frequency electrical currents are applied on the inserted needle.<ref>Imamura ST., et al., syndrome de tietze, Cossermeli W., Terapêutica em reumatologia, Sao Paulo, lemos editorial, p773-777, 2000.</ref>
* Dry needling can help to reduce pain levels, however this treatment should only be performed by a qualified and experienced provider<ref>Richard B, Westrick P., Evaluation and treatment of musculoskeletal chest wall pain in military athlete. The International Journal of Sports Physical Therapy, 2012, Volume 7(3) Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362990/ (last accessed 30.4.2020)</ref><br>
== Clinical Bottom Line <u></u> ==
Costochondritis should be a diagnosis of exclusion. Rule out other causes of chest pain that are associated with increased morbidity and mortality.
* Patients typically present with chest pain worse with breathing, and it is often positional.
* Costochondritis is a self-limited disease.  
* It should be reproducible on a physical exam, and the patient's vital signs should be within normal limits. If ordered, labs, ECG, and chest x-ray should also be normal.
* Diagnosis is confirmed by a scan or bone scintigraphy and by a physical assessment of the affected costal cartilage.
* The treatment of costochondritis consists of conservative management and is usually symptomatic <ref name=":13" />.
* Physiotherapy is often ordered if the condition does not respond to treatment (see physiotherapy section for details).  


Clinically, the syndrome is characterized by inflammation of the costal cartilage .It is associated with 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)<br> <br><u>• 6 Differential Diagnosis<br></u>  
<u></u>


Costochondritis also known as costosternal syndrome, parasternal chondrodynia, or anterior chest wall syndrome. In the medical world costochondritis is often confused with Tietze syndrome, a similar but rarer disorder involving swelling of a single costal cartilage, usually of the second rib.14
== References  ==
 
<references />
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 sometimes mistaken for Tietze’s syndrome skeletal causes are xiphoidalgia and slipping rib syndrome. Besides these pathologies, there are many other diseases to consider in the differential diagnosis, such as multiple myeloma, primitive neoplasms of the bone and soft tissues, chondrosarcoma of the chondrocostal joints, breast and lung tumors with extension to the costal cartilage, as well as metastases of breast, kidney, and prostate neoplasms [11]. Consequently malignancy should always be kept in mind in the differential diagnosis of Tietze’s syndrome. The use of the appropriate other investigations such as electrocardiography [[12] [3], CT-scan [13] [5], MRI [5] [12] [14]… is necessary.
[[Category:Conditions]]
 
[[Category:Thoracic Spine - Conditions]]
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[[Category:Thoracic Spine]]
 
[[Category:Thoracic Spine - Conditions]]
<u>• 7 Diagnostic Procedures</u>
 
Patients with fever, chest wall swelling, cough or other respiratory issues should first have a chest examination. With computer tomography (CT) can delineate a pathology in costal cartilages and rule out underlying pathologies like tumors. CT is only reserved for cases where is high suspicion of neoplastic processes or infections. Nuclear scanning with Technetium 99 scitigraphy is not usefull for identifying costochrondritis. There is also one case report who have found sings of inflammation on gallium or bone scanning.15<br>Patients older than 35 years old who have a history with coronary artery disease, and patients with cardio pulmonary symptoms should have electrocardiography and possibly chest radiography. Further testing should be considered for ruling out a cardiac cause if clinically indicated by age or risk status.15<br>Routine laboratory testing is not necessary in patients with suspected costochrondritis unless there the diagnosis is uncertain or when there are signs of inflammation.
 
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<u>• 8 Outcome Measures</u>  
 
VAS&nbsp;:The use of the VAS can be used to asses pain before and after the treatment,During rest and during inhale/exhale exercise. .another case study examined the cervical spine mobility.17,18<br>Patient-specifiv functional scale ( PSFS)&nbsp;: specific questionnaires for costochondritis have not yet been assembled in the literature, but the PSFS has been stated to be a valid, reproducable, and responsive outcome measure for patients with neck pain, back pain, and upper quarter complaints19<br>The Global rating of change (GROC): To measure the patient’s subjective rate of improvement, the GROC has been stated to be reliable .19
 
<br><u>• 9 Examination</u><br>Patients with Costochondritis will show chest pain that is reproducable by palpation of the affected area, mostly rib 2 to 5.and in most patients several ribs are affected.Other aggrevations are couching or exercise.It occurs often after a recent illness with coughing or a heavy exercise.most of the times it is unilateral.15
 
-palpation: palpation should be performed with 1 digit, on the naterior, 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
 
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
 
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<u>• 10 Medical Management</u>
 
The first line treatment for peripheral enthesitis are local corticosteroid injections when only a few entheses are involved. When there is an inadequately respons to local corticosteroid injections by patients with multiple peripheral enthesitis , oral NSAIDs should be used. There is no evidence for the efficacy of sulfasalazine and methotrexate for the treatment of peripheral enthestis. The optimal treatment of costochrondritis has not been established.
 
<br> <br><u>• 11 Physical Therapy Management</u>
 
The treatment of Tietze’s syndrome is not yet perfect. It is not known weather the disease is dealt definitly or not.[3] For now, trustworthy clinical studies on the treatment of Tietze's syndrome are lacking [8][4][6]. <br>There are no randomized controlled trials or even quasiexperimental trials testing different interventions. Only case reports, case series, retrospective studies and expert opinion are available for both conservative and pharmaceutical interventions. <br>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 (Level of evidence:5)
 
The use of high-velocity, low-amplitude manipulation applied to the associated hypokinetic costovertebral, costotransverse, and intervertebral zygapophyseal thoracic joints improves the pain level, as well as instrument-assisted soft tissue mobilization using the Graston technique26 (Level of evidence:4)
 
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Recommendations for the management of Costochondritis:*
 
- Reassure the patient by explaining the benign nature of the condition. what should he/she say? [8] [4]<br>- Correction of muscle imbalances through cervical and thoracic region, including<br>pectoralis muscles. <br>- Reinforcement of correction via postural re-education and exercise can decrease loads placed on the joints of the anterior chest wall.17 (Level of evidence 4)<br>Patients need a good balance between exercise and rest.[8][10][7][6]<br>
 
- Conservative treatment involving use of nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics, as necessary.23<br>- Mobilize spine and ribs to avoid rigidity of the thorax and to reduce complaints. [10][3]<br>- Teach the patient breathing exercises [3]<br>- Cough suppressants may be beneficial if cough is an aggravating factor.23<br>- Learn the patient to cope with pain. [8][6]<br>- Exercise for shoulder and back can be provocative, therefore only when the complaints have disappeared, they can be applied<br>[3]<br>* No strong recommendation were made for the physical therapy management of Costochondritis. The evidence supporting these interventions demonstrated only a small or moderate effect size.
 
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<u>• 12 Key Evidence</u>
 
ANNE M. PROULX. Costochondritis: Diagnosis and Treatment. Am Fam.Physician. 2009 Sep 15; 80(6):617-620.15
 
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<u>• 13 Resources</u>
 
http://www.ncbi.nlm.nih.gov/pubmed/22787240<br>http://www.ncbi.nlm.nih.gov/pubmed/19827277<br>http://www.ncbi.nlm.nih.gov/pubmed/17360222
 
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<u>• 14 Clinical Bottom Line Missing information</u><br>There is too few high level evidence concerning the physical treatment of costochondritis, the recommended therapy consist out of analgetics and muscular training ,as well as decreasing the prococative activities.Most ofthe patients will have their pain resolvd within a year..However ,a lot of the study’s are outdated, we recommend to achieve newer ,more recent information about the treatmentof costochondritis
 
<br><u>• 15 Recent Related Research (from Pubmed)</u>
 
Ayloo A1, Cvengros T, Marella S.Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013 Dec;40(4):863-87, viii. doi: 10.1016/j.pop.2013.08.007.
 
Gandhi V1, Costello J. <br>Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: The use of corticosteroids in the management of costochondritis. Emerg Med J. 2012 Aug;29(8):686. doi: 10.1136/emermed-2012-201590.4.
 
<br>Grindstaff TL1, Beazell JR, Saliba EN, Ingersoll CD.<br>Treatment of a female collegiate rower with costochondritis: a case report. J Man Manip Ther. 2010 Jun;18(2):64-8. doi: 10.1179/106698110X12640740712653.
 
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<br><u>• 16 References</u><br> <br>1. Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 8th ed Philadelphia, Pa: Lippincott Williams &amp; Wilkins. 2003. (level 5)<br>2. Saltzman DA, Schmitz ML, Smith SD, Wagner CW, Jackson RJ, Harp S. The slipping rib syndrome in children. Paediatr Anaesth. 2001;11(6):740-743. (level 3A)<br>3. Fam AG. Approach to musculoskeletal chest wall pain. Prim Care. 1988;15(4):767-782. (level 2B)<br>4. Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil. 1992;73(2):147-149. (level 4)<br>5. Pantell RH, Goodman BW Jr. Adolescent chest pain: a prospective study. Pediatrics. 1983;71(6):881-887. (level 2B)<br>6. Costochondritis. Stedman's Online Medical Dictionary. http://www.stedmans.com/section.cfm/45. Accessed April 15, 2009. (level 5)<br>7. Kayser HL. Tietze's syndrome: a review of the literature. Am J Med. 1956;21(6):982-989. (level 1A)<br>8. Massin MM, Bourguignont A, Coremans C, Comté L, Lepage P, Gérard P. Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic. Clin Pediatr (Phila). 2004;43(3):231-238. (level 1B)<br>9. 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. (level 2B)<br>10. Buntinx F, Knockaert D, Bruyninckx R, et al. Chest pain in general practice or in the hospital emergency department: is it the same? Fam Pract. 2001;18(6):586-589. (level 2b)<br>11. Beck WC, Berkeheiser S. Prominent costal cartilages (Tietze’s syndrome). Surgery 1954;35:762–5. (level 4)<br>12. Motulsky AG, Rhon RJ. Tietze’s syndrome. J Am Med Assoc 1953;152:504–6. (level 1B)<br>13. Martino F, D’Amore M, Angdelli G, Macarini L, Cantatore FP. Echographic study of Tietze’s syndrome. Clin Rheumatol 1991;10:2–4. (level 5)<br>14. Fam AG. Approach to musculoskeletal chest wall pain. Prim Care. 1988;15(4):767-782 (Level 3A)<br>15)Proulx, A. M., &amp; Zryd, T. W. (2009). Costochondritis: Diagnosis and treatment. American Family Physician, 80(6), 617–620. doi:10.1016/S0015-1882(09)70196 (level 3A)<br>16)Freeston J1 Can early diagnosis and management of costochondritis reduce acute chest pain admissions?<br>2004, J Rheumatol. 2004 Nov;31(11):2269-71. (level 2B)<br> 17)Terry L Grindstaff.Treatment of a female collegiate rower with costochondritis: a case report. J Man Manip Ther. 2010 June; 18(2): 64–68. (Level 4)<br>18)Karen Hudes.Low-tech rehabilitation and management of a 64 year old male patient with acute idiopathic onset of costochondritis. J Can Chiropr Assoc. 2008 December; 52(4): 224–228. (LOE 4)(level 4)<br>19)Richard B. Westrick,.EVALUATION AND TREATMENT OF MUSCULOSKELETAL CHEST WALL PAIN IN A MILITARY ATHLETE. Int J Sports Phys Ther. 2012 June; 7(3): 323–332(LOE 4)(level 4)<br>20)Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil. 1992;73(2):147-149. (level 1B)<br>21) Disla E, Rhim HR, Reddy A, Karten I, Taranta A. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466-2469. (Level 2B)<br>22)Miller CD, Lindsell CJ, Khandelwal S, et al. Is the initial diagnostic impression of “noncardiac chest pain” adequate to exclude cardiac disease? [published correction appears in Ann Emerg MedCayley WE Jr. Diagnosing the cause of chest pain. Am Fam Physician. 2005;72(10):2012-2021.. 2005;45(1):87]. Ann Emerg Med. 2004;44(6):565-57 (level 2B)<br>23) Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. Apr-Jun 2009;31(2):169-71 (level 3A)<br>24. Disla E, Rhim HR, Reddy A, Karten I, Taranta A. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466-2469. (level 2B)<br>25.Biundo JJ Jr. Regional rheumatic pain syndrome. In: Schumachar R Jr, Klippel J, Robinson R, eds. Primer on the rheumatic diseases. Atlanta, GA: Arthritic Foundation, 1988:263–74. (Level 1B)<br>26. Aspegren D et al., Conservative treatment of a female collegiate volleyball player with costochondritis., J Manipulative Physiol Ther. 2007 May;30(4):321-5. (LOE 4)(Level 4)
 
27. D’Angelo, S., Padula, A., Nigro, A., Cantini, F., Matucci-Cerinic, M., Modena, V., … Olivieri, I. (2008). Italian evidence-based recommendations for the management of ankylosing spondylitis: The 3E Initiative in rheumatology. Clinical and Experimental Rheumatology, 26(6), 1005–1011. (Level 1B)<br>

Latest revision as of 12:51, 2 May 2024

Original Editor - Nick Demunter Top Contributors - Kim Jackson, Scott Cornish, Nick Demunter, Lucinda hampton, Adam Vallely Farrell, Laura Tighe, 127.0.0.1 and Lionel Geernaert

 Definition/Description[edit | edit source]


Costochondritis is a self-limiting condition defined as painful chronic inflammation of the costochondral junctions of ribs or chondrosternal joints of the anterior chest wall.[1]

  • 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 Tietze syndrome.
  • Palpation of the affected chondrosternal joints of the chest wall elicits tenderness [1] and pain is reproduced by palpation of the affected cartilage segments which may radiate out into the chest wall.

Clinically Relevant Anatomy[edit | edit source]

The thoracic wall consists of the

  • Sternum anteriorly,
  • 12 thoracic vertebrae posteriorly,
  • 12 paired ribs and associated costal cartilages.[2]

Ribs consist of bone and cartilage, with cartilage serving as an elastic bridge between the bony portion of the rib and the sternum.

According to their attachment to the sternum, the ribs are classified into 3 groups: true, false, and floating ribs.

  1. True ribs are the ribs that directly articulate with the sternum with their costal cartilages - ribs 1-7. They articulate with the sternum by the sternocostal joints. The first rib is an exception to that rule; it is a synarthrosis and the first rib could uniquely articulate with the clavicle by the costoclavicular joint
  2. The false ribs (8,9,10) are the ribs that indirectly articulate with the sternum, as their costal cartilages connect with the seventh costal cartilage by the costochondral joint.
  3. The floating ribs (11,12) do not articulate with the sternum at all (distal two ribs)[3].


The ribs move with respiration and with truncal motion or movement of the upper extremities.[2]

Aetiology[edit | edit source]

Costochondritis is inflammatory. It is caused by inflammation of the costal cartilages and their sternal articulations, also known as the costochondral junctions[4].

Epidemiology[edit | edit source]

The epidemiology of costochondritis is not well established.

  • In a small study published in 1994, there was a higher frequency of costochondritis seen in females and Hispanics.
  • In a group of 122 patients presenting to the emergency department with chest pain not due to malignancy, fever, or trauma, costochondritis was the diagnosis in 36 of the patients (30%)[4]
  • Can affect children as well as adults. A study of chest pain in an outpatient adolescent clinic found that 31 percent of adolescents had musculoskeletal causes, with costochondritis accounting for 14 percent of adolescent patients with chest pain[1].

Characteristics/Clinical Presentation[edit | edit source]

Ashkan-forouzani-oxaIBWkrGXE-unsplash.jpg

Consider pursuing other causes of chest pain prior to establishing a costochondritis diagnosis as Costochondritis is a diagnoses of exclusion. Cardiac and respiratory causes will need to be ruled out. If the patient complains of radiating pain, shortness of breath, dizziness, exertional chest pain, fever, or productive cough these are symptoms that may indicate different and more serious causes of chest pain. If there has been trauma an occult rib fracture should also be considered. If cardiopulmonary causes and trauma have been excluded the below findings should be present to varying degrees[4].

Possible findings include

  • Patient will give a history of the pain worsening with movement and certain positions. The pain will also typically be worse when the patient takes a deep breath.
  • Pain quality is variable, but it may be described as a sharp or dull pain.
  • Patients report a gradual or rapid onset of pain and swelling of the upper costal cartilage of the costochondral junction.
  • Pain is usually reproducible by mild-to-moderate palpation. Often, there is point tenderness where one or two ribs meet the sternum (a pitfall of the typical physical exam findings is that pain due to acute coronary syndrome can also be described as reproducible)[4].
  • Symptoms may occur gradually and can disappear spontaneously after a few days, but equally it may take years to disappear. [5] [6] Even after the symptoms have resolved, they may return at the same location or at another rib level. [7]
  • There may be hypomobility of the upper thoracic spine, costovertebral joints, and the lateral ribs.[8]

Evaluation[edit | edit source]

Costochondritis is usually self-limited and benign - should be distinguished from other, more serious causes of chest pain.

  • Coronary artery disease is present in 3 to 6 percent of adult patients with chest pain and chest wall tenderness to palpation.
  • History and physical examination of the chest that document reproducible pain by palpation over the costal cartilages are usually all that is needed to make the diagnosis in children, adolescents, and young adults.
  • Patients older than 35 years, those with a history or risk of coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiograph and possibly a chest radiograph[9]
  • Consider further testing to rule out cardiac causes if clinically indicated by age or cardiac risk status[9]

Differential Diagnosis[edit | edit source]

The differential diagnosis for costochondritis is rather long. Some of the diagnoses included are associated with major morbidity and mortality. eg

Outcome Measures[edit | edit source]

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.improvement .[1]

Measurement of thoracic and cervical mobility:[12]

  • 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 [13]

Examination[edit | edit source]

Patients with Costochondritis will present with:

  • Chest pain reproducible by palpation of the affected area, with ribs 2 to 5 mostly affected.
  • Aggravating factors can be slouching or exercise.
  • Often occurs after a recent illness with coughing or after intense exercise and it mostly of unilateral origin.[1]
  • May be an associated restriction of the corresponding costovertebral and costotransverse on examination.
  • Loss of normal spinal movement associated with the chest pain.[14]
  • Palpation should be performed with 1 digit, on the anterior, posterior, and lateral side of the chest, the clavicle, the cervical and thoracic spine. When on the affected area it reveals a reproducible pain which might suggest Costochondritis, but it cannot entirely concluded.[1]
  • 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 movement. When motion palpation is reduced, the joint is considered fixated or hypokinetic.[14]
  • Cardiac causes should be ruled out in patients who present with a high risk.

Medical Management[edit | edit source]

Treatment consists of conservative management and is usually symptomatic, [15]

Management includes

  • Reassurance
  • Topical or oral analgesics.[15]
  • Local injections with steroid into the joint, tendon sheath or around the nerve, inhibits inflammation, reduces swelling and pain to improve movement. [16]
  • If patients have severe or refractory costochondritis, refer for outpatient follow-up. Physical therapy is a treatment option for refractory costochondritis[4]
  • Alternative treatments may also include: ice, acupuncture, manual therapy, exercise, and other medications such as sulfasalazine which may have an additional long-term benefit in the management of costochondritis [17]

Physical Therapy Management[edit | edit source]

May Include:

Toa-heftiba-a9pFSC8dTlo-unsplash.jpg
  • Education - reassure the patient by explaining the condition [18]
  • Minimising activities that provoke the symptoms (e.g. reducing the frequency or intensity of exercise or work activities)
  • A course of trigger point therapy to reduce pain - eg.cross fibre friction massage
  • Heat or cold therapies can be used as conservative management strategies to reduce pain levels [19]
  • Postural exercises - Re-train proper posture in functional positions (Neuro-muscular control). Functional training is all about using the right muscles at the right time, to sustain the correct posture, in daily activities. Simple activities like eg. correct standing posture, sit to stand and walking up stairs all need be addressed to ensure correct technique and muscle recruitment.
  • Thoracic manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility[8]
  • Exercises in the range of motion should be induced as soon as possible. The patient may not have pain when he is doing the exercises eg.rotation exercises for thoracic spine. Do not invoke pain.
  • Progressive stretches. They can begin with simple mobility exercises as tolerated [19]eg [20] Stretching of the M. pectoralis major can be helpful (stretch the M. pectoralis major, stand in a corner for 10 sec with both of your hands against the wall (like when you do a push-up)repeat it a few times a day for 1 or 2 minutes).
  • Mobilisation of the spine and ribs to improve thorax mobility and to reduce symptoms. [21]
  • On the painful area they can use transcutaneous electrical stimulation and electroacupuncture. The acupuncture needle (also known as a solid filiform needle) is placed within the involved spinal segment. Than low-frequency electrical currents are applied on the inserted needle.[22]
  • Dry needling can help to reduce pain levels, however this treatment should only be performed by a qualified and experienced provider[23]

Clinical Bottom Line [edit | edit source]

Costochondritis should be a diagnosis of exclusion. Rule out other causes of chest pain that are associated with increased morbidity and mortality.

  • Patients typically present with chest pain worse with breathing, and it is often positional.
  • Costochondritis is a self-limited disease.
  • It should be reproducible on a physical exam, and the patient's vital signs should be within normal limits. If ordered, labs, ECG, and chest x-ray should also be normal.
  • Diagnosis is confirmed by a scan or bone scintigraphy and by a physical assessment of the affected costal cartilage.
  • The treatment of costochondritis consists of conservative management and is usually symptomatic [19].
  • Physiotherapy is often ordered if the condition does not respond to treatment (see physiotherapy section for details).

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 PROULX A and TERESA W.; Costochondritis: Diagnosis and Treatment; Am Fam Physician. 2009 Sep 15;80(6):617-620
  2. ↑ 2.0 2.1 Clemens WM. et al. ; Introduction to Chest Wall Reconstruction : Anatomy and Physiology of the Chest and Indications for Chest Wall Reconstruction ; Semin Plast Surg. ; 2011 ; 25(1) : 5-15
  3. ↑ Safarini OA, Bordoni B. Anatomy, Thorax, Ribs. InStatPearls [Internet] 2019 Feb 19. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK538328/ (last accessed 14.4.2020)
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Schumann JA, Parente JJ. Costochondritis.Available from:https://www.ncbi.nlm.nih.gov/books/NBK532931/ (last accessed 29.4.2020)
  5. ↑ Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389
  6. ↑ Gregory P.L., BISWAS A.C., Batt M.E.,Musculoskeletal problems of the chest wall in athletes, Sports Med., 2002;32(4):235-50.
  7. ↑ Hurst J.W., Morris D.C., Williams B.R. “Chest Pain” in patients with costochondritis or Tietze's syndrome, Wiley-Blackwell, 2001, p23-29
  8. ↑ 8.0 8.1 Han J N et al.; Respiratory function of the rib cage muscles; European Respiratory Journal ISSN 0903 1993. 
  9. ↑ 9.0 9.1 Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. American family physician. 2009 Sep 15;80(6):617-20.Available from:https://www.ncbi.nlm.nih.gov/pubmed/19817327 (last accessed 29.4.2020)
  10. ↑ Brian E Udermann et al.; Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report; J Athl Train. 2005 Apr-Jun; 40(2): 120–122
  11. ↑ Brenda M. Birmann et al.; Prediagnosis biomarkers of insulin-like growth factor-1, insulin, and interleukin-6 dysregulation and multiple myeloma risk in the Multiple Myeloma Cohort Consortium. Blood. 2012 Dec 13; 120(25): 4929–4937.
  12. ↑ FREESTON J; Can Early Diagnosis and Management of Costochondritis Reduce Acute Chest Pain Admissions?; The Journal of Rheumatology November 2004, 31 (11) 2269-2271
  13. ↑ Viitanena J, H. Kautiainena, J. Sunia, M. L. Kokkoa & K. Lehtinena; The Relative Value of Spinal and Thoracic Mobility Measurements in Ankylosing Spondylitis; Scandinavian Journal of Rheumatology; Volume 24, 1995 - Issue 2
  14. ↑ 14.0 14.1 Aspegren D; Conservative Treatment of a Female Collegiate Volleyball Player with Costochondritis ; Journal of Manipulative and Physiological Therapeutics ; May 2007 Volume 30, Issue 4, Pages 321–325 
  15. ↑ 15.0 15.1 Grindstaff L.T. et al. ; Treatment of a female collegiate rower with costochondritis : a case report ; J Man Manip Ther. ;2010 ;18(2) : 64-68 
  16. ↑ Kamel M. et al. ; Ultrasonographic assessement of local steroid injection in Tietze’s syndrome ; Br J Rheumatol ; 1997 ;36(5) : 547-50 
  17. ↑ Freeston J. et al. ; Can early diagnosis and management of costochondritis reduce acute chest pain admissions ?; J Rheumatol ; 2004 ; 31(11)-2269-71 
  18. ↑ Massin MM, Bourguignont A, Coremans C, Comté L, Lepage P, Gérard P. Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic. Clin Pediatr 2004;43(3):231-238
  19. ↑ 19.0 19.1 19.2 Hudes K, Low-tech rehabilitation and management of a 64 year old male patient with acute idiopathic onset of costochondritis. J Can Chiropr Assoc. 2008 December; 52(4): 224–228
  20. ↑ Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. Apr-Jun 2009;31(2):169-71 
  21. ↑ Buntinx F, Knockaert D, Bruyninckx R, et al. Chest pain in general practice or in the hospital emergency department: is it the same? Fam Pract. 2001;18(6):586-589.
  22. ↑ Imamura ST., et al., syndrome de tietze, Cossermeli W., Terapêutica em reumatologia, Sao Paulo, lemos editorial, p773-777, 2000.
  23. ↑ Richard B, Westrick P., Evaluation and treatment of musculoskeletal chest wall pain in military athlete. The International Journal of Sports Physical Therapy, 2012, Volume 7(3) Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362990/ (last accessed 30.4.2020)
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