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[[File:Costochondritis.jpg|thumb|333x333px|<ref>https://images.onhealth.com/images/slideshow/xl-sq-promos/chest-pain-costochondritis.jpg</ref>]]
== 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 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, <ref name=":1">Verdon F., Burnand B., Herzig L., Junod M., Pécoud A., Bernard F., Chest wall syndrome among primary care patients: a cohort study, Fam Pract., 2010 Aug; 27(4):363-9</ref> <ref>Hoogendoorn R.J., Brinkman J.M., Visser O.J., Paul M.A., Wuisman P.I., Sternal pain: not always harmless, Ned Tijdschrift Geneeskd. 2004 Dec 11;148(50):2469-74
</ref> <ref>American acadamy of family physicians, Costochondritis: What you need to know, Am Fam Physicians, Sept 2009, 15;75(10):1</ref> <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>


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.
== &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.  


[[Tietzes|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.<ref name=":1" /> Costochondritis and Tietze's syndrome are often mistaken for each other, but the two very different conditions. <ref name=":0" />
According to their attachment to the sternum, the ribs are classified into 3 groups: true, false, and floating ribs.
[[File:Thoracic Wall.jpg|thumb|380x380px|<ref>https://image.slidesharecdn.com/lecture2thoracicwall-111026230654-phpapp02/95/lecture-2-thoracic-wall-diaphragm-3-728.jpg?cb=1319670479</ref>]]
# 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" />


== Clinically Relevant Anatomy ==  
== 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>.


The thoracic wall consists of the sternum anteriorly, the spinal column (12 thoracic vertebrae) posteriorly, bounded by 12 paired ribs and 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. 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.<ref>Schunke M. et al. ; Anatomy Atlas: Anatomy and general movement; Bohn Stafleu van Loghum houten ; 2010; p130-133 </ref> 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.
=== Epidemiology ===
[[File:Breathing.jpg|left|thumb|Mechanism of action for inhalation and exhalation]]
The epidemiology of costochondritis is not well established.  
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.&nbsp;The lowest two ribs do not articulate with any structure anteriorly.<ref>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.</ref><br><span>The ribs move with respiration and with truncal motion or movement of the upper extremities.&nbsp;The intercostal nerves supply the innervation of the thoracic wall. </span><span>The inspiratory muscles</span> <span>(</span><span>e</span><span>xternal intercostals, diaphragm) e</span><span>xpand the chest volume by elevating the rib cage.</span> <span>and</span> <span>the </span><span>expiratory muscles</span> <span>(intercostals, intercostals intimi an</span><span>d</span> <span>succostals) d</span><span>ecrease lung volume by</span> <span>depressing </span><span>the ribcage.</span><ref name=":3" />
* 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" />
== Epidemiology /Aetiology ==
* 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" />.
Costochondritis can affect children as well as adults. Approximately 14% of adolescents present with costochondritis in out patients.<ref>Pantell RH, Goodman BW Jr. Adolescent chest pain: a prospective study. Pediatrics. 1983;71(6):881-887</ref> 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.<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>
 
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.<ref>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</ref> <ref>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</ref>  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.<ref>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.
</ref> 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).<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>
 
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. <ref>Anthony S. Fauci, Carol A. Langford. Harrison’s rheumatology. Second edition. 2010. McGraw-Hill Education
</ref> Both conditions can be of an acute or insidious onset at any age.<br>


== Characteristics/Clinical Presentation ==
== Characteristics/Clinical Presentation ==
Cartilage connects the sternum with the ribs and the clavicle making movement of the thorax possible while breathing <ref name=":4">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389</ref> Elevation of the ribs and expansion of the rib cage result from the coordinated action of the rib cage muscles. <ref name=":5">Han J N et al.; Respiratory function of the rib cage muscles; European Respiratory Journal ISSN 0903 1993. </ref> Inflammation of the cartilage of one or more ribs causes reddening, a temperature increase and swelling of the cartilage, which is both visible and palpable <ref name=":2" /> 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. <ref name=":0" /> <ref name=":2" /> <ref name=":1" /> Pain on palpation is indicative of costochondritis, but it  could also be of cardiac origin <ref name=":1" /> <ref name=":0" /> or a tumor <ref name=":6">Hoogendoorn R.J., Brinkman J.M., Visser O.J., Paul M.A., Wuisman P.I., Sternal pain: not always harmless, Ned Tijdschrift Geneeskd. 2004 Dec 11;148(50):2469-74</ref> <ref name=":1" /> <ref name=":4" />. 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. <ref name=":4" /> <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" /> <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" />
[[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" />.


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.<ref name=":5" />
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>


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 coughing, sneezing and chest movements <ref name=":7">Motulsky AG, Rhon RJ. Tietze’s syndrome. J Am Med Assoc 1953;152:504–6.
== Evaluation ==
</ref>. There are no systemic symptoms or adenopathy. <ref>Martino F, D’Amore M, Angdelli G, Macarini L, Cantatore FP. Echographic study of Tietze’s syndrome. Clin Rheumatol 1991;10:2–4.
Costochondritis is usually self-limited and benign - should be distinguished from other, more serious causes of chest pain.
</ref>
* [[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>


== Differential Diagnosis ==
== Differential Diagnosis ==
Costochondritis is also known as;
The differential diagnosis for costochondritis is rather long. Some of the diagnoses included are associated with major morbidity and mortality. eg
* Costosternal chondrodynia, a Tietze’s syndrome variant <ref>André J.; A Variant of Tietze’s Syndrome Occurring After Reconstructive Breast Surgery; Aesth. Plast. Surg. 1998 22:430–432</ref>
* [[Acute Coronary Syndrome]] (ACS)
* Parasternal chondrodynia <ref name=":0" />
* [[Pneumothorax]]
* Anterior chest wall syndrome
* [[Pneumonia]]
 
* [[Pulmonary Embolism]]
Costochondritis should be distinguished from other, more serious causes of chest pain.&nbsp;<ref name=":0" />
* [[Tietzes|Tietze’s]] syndrome, much less common than costochondritis, and it tends to cause chest swelling in addition to the other symptoms,
 
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 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>
* 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>
* [[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>
Other diseases to consider in differential diagnosis:mul
* Tiple myeloma: a malignancy of mature plasma cells <ref name=":8" />
* Primitive neoplasms of the bone and soft tissues <ref>Fioravanti, A., Tofi, C., Volterrani, L. and Marcolongo, R. (2002), Malignant lymphoma presenting as Tietze's syndrome. Arthritis Care &#x26; Research, 47: 229–230</ref>
* Chondrosarcoma of the chondrocostal joints
* Breast and lung tumours with extension to the costal cartilage
* Metastases of breast, kidney, and prostate neoplasms <ref>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</ref>
 
Malignancy is a cause that should be excluded. The use of appropriate diagnostic investigations such as electrocardiography<ref name=":4" />, CT, MRI is necessary. <ref name=":6" />
 
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. 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.<ref name=":7" />
 
<sup></sup>
 
{| width="400" border="1" cellpadding="1" cellspacing="1"
|-
| Tietze syndrome and costochondritis <ref name=":0" />
|
|
|-
| Feature
| Tietze syndrome
| Costochondritis
|-
| Prevalence
| Rare<span class="Apple-tab-span" style="white-space:pre"> </span>
| 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
|}
 
<sup></sup>
 
== 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.<ref>Massie, James D. M.D; Bone Scintigraphy and Costochondritis; Journal of Thoracic Imaging, 1993 </ref> 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.
 
Patients older than 35 years 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.<ref name=":0" /><br>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 ==
== 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
[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


[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 .<ref name=":0" />  
[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" />  
 
Measurement of thoracic and cervical mobility: This is a relevant measure with costochondritis as the inflammation of the costochondral joints or the anterior chest wall can cause a reduction in mobility of the spinal area.<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> 


These five most valid tests are:
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.
* 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
* [[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]
* [http://www.physio-pedia.com/Schober_test The Schober test]
* Thoracolumbar flexion
* Thoracolumbar flexion
* 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>
* [[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>


== Examination ==
== Examination ==
Patients with Costochondritis will present with chest pain that is reproducable by palpation of the affected area, with ribs 2 to 5 mostly affected. Aggravating factors can be slouching or exercise. It often occurs after a recent illness with coughing or after intense exercise and it mostly of unilateral origin.<ref name=":0" /> 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.<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>
[[File:Katherine-hanlon-QgcdtM9rA5s-unsplash.jpg|alt=|right|frameless]]
 
Patients with Costochondritis will present with:
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 reproducable pain which might suggest Costochondritis, but it cannot entirely concluded.<ref name=":0" />
* Chest pain reproducible by palpation of the affected area, with ribs 2 to 5 mostly affected.  
 
* Aggravating factors can be slouching or exercise.  
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" />
* 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.  
Cardiac causes should be ruled out in patients who present with a high risk.
* 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.


== Medical Management ==
== 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>  to resolve the condition and manage pain.<ref>Hudes k. et al. ; Low-tech rehabilitation and management of a 64 year old male patient with acute idiopathic onset of costochondritis ; J Can Chirpr Assoc. ;2008 ;52(4) : 224-8 </ref> Management includes reassurance, local injections and topical or oral analgesics.<ref name=":12" /> The aim of reassurance is to reduce anxiety and to change beliefs and behaviours.<ref>Pincus T. et al.; Cognitive and affective reassurance and patient outcomes in primary care : A systematic review; Pain ; 2013; 154(11) : 2407-2416 </ref>
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>   


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> 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>  
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>


== Physical Therapy Management ==
== Physical Therapy Management ==
Minimising activities that provoke the symptoms (e.g. reducing the frequency or intensity of exercise or work activities) or using cough suppressants may help relieve symptoms <ref name=":0" />
May Include:
 
[[File:Toa-heftiba-a9pFSC8dTlo-unsplash.jpg|right|frameless]]
A course of trigger point therapy can help to reduce pain. This includes cross fibre friction massage and ischemic compression to the intercostal musculature and high velocity, low amplitude mobilisation of the rib in a posterior to anterior direction while the patient is in a supine position to create cavitation.  Ice application may also be useful.<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>
* 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>
[[File:Graston Technique.jpg|thumb|300x300px|Graston Technique <ref>https://image.slidesharecdn.com/lecture2thoracicwall-111026230654-phpapp02/95/lecture-2-thoracic-wall-diaphragm-3-728.jpg?cb=1319670479</ref>]]
''Donald Aspergen at al''. suggest using the Graston technique and Kinesio taping. The Graston technique is used on the chondrosternal joint of the concerned rib to relax the chondrosternal musculatuur. Kinesio tape is applied in 2 strips; the first strip goes vertically on the chondrosternal joint and the second strip is applied horizontally.  Pain was improved by 70% after two weeks of treatment.<ref name=":9" />
 
Appropriate, progressive exercise and stretches are also useful for improving symptoms. They can begin with simple mobility exercises progressing to body weight as tolerated <ref name=":13" />as well as stretches for the pectoralis major for example.<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> Treatment can also include mobilisation of the spine and ribs to avoid the thorax becoming stiff and to reduce symptoms. <ref name=":11" />
 
Education should be part of the treatment programme to reassure the patient by explaining the condition <ref name=":10" />
 
== Key Evidence ==
ANNE M. PROULX. Costochondritis: Diagnosis and Treatment. Am Fam.Physician. 2009 Sep 15; 80(6):617-620.
 
== Resources ==
Resources for pictures : <br>- Fig 1 &amp; 2 : From THIEME Atlas of Anatomy, General Anatomy and Musculoskeletal System, © Thieme 2005, Illustration by Karl Wesker<br>- 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<br>  


* 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> ==
== Clinical Bottom Line <u></u> ==
Costochondritis is defined as painful chronic inflammation of costochondral junctions of the ribs or chondrosternal joints of the anterior chest wall and it is often confused with Tietzen syndrome. Diagnosis is confirmed by a scan or bone scintigraphy and by a physical assessment of the affected costal cartilage.  
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.
Currently, there have been no clinical trials of treatment for costochondritis.<ref name=":14">Anne M. et al ; Costochondritis : diagnosis and treatment ; AM Fam Physician. ;2009 ; 15 ;80(6) :617-620 </ref> The treatment of costochondritis consists of conservative management and is usually symptomatic <ref name=":13" />  
* 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).


Treatment protocol consists of cross fibre frictions, HVLA, stretching of the pectoral muscles, kinesio taping, Graston techniques and pectoral muscle strength exercises. <u></u><br>
<u></u>


== References  ==
== References  ==
<references />
<references />
[[Category:Conditions]]
[[Category:Conditions]]
[[Category:Thoracic Spine - Conditions]]
[[Category:Thoracic Spine]]
[[Category:Thoracic Spine]]
[[Category:Thoracic Spine - Conditions]]

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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