Costochondritis
1 Search Strategy
2 Definition/Description
3 Clinically Relevant Anatomy
4 Epidemiology /Etiology
5 Characteristics/Clinical Presentation
6 Differential Diagnosis
7 Diagnostic Procedures
8 Outcome Measures
9 Examination
10 Medical Management
11 Physical Therapy Management
12 Key Research
13 Resources
14 Clinical Bottom Line
15 Recent Related Research (from Pubmed)
16 References
• 1 Search Strategy
Pubmed
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Search criteria : costochondritis/treatment/outcome/tietze/Costochondritis + medical management/ Anatomy chest wall/ Costochondritis + physical therapy/ Diagnosis costochondritis/ diagnosis Tietze’s syndrome / Costochondrite
• 2 Definition/Description
Costochondritis is a self-limited condition defined as painful chronical inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall.45 It is a clinical diagnosis and does not require specific diagnostic testing in the absence of concomitant cardiopulmonary symptoms or risk factors.
Costochondritis is often confused with Tietzen syndrome. The difference is that there is a presence of swelling over the affected joints, a swelling occurs underneath sternum and/or a reddening of the skin on the painful spot, it’s called Tietze's syndrome52,53,54,55,45
Palpation of the affected chondrosternal joints of the chest wall elicits tenderness.45
Pain is reproduced by palpation of the affected cartilage segments and may radiate on the chest wall.46
Tietze syndrome is an inflammatory process causing visible enlargement of the costochondral junction.1 This disease causes severe pain when coughing and heavy breathing. The Tietze's syndrome is not life-threatening or contagious but it is a fastidious and painful disease.52,51 Costochondritis54 and the Tietze's syndrome are often mistaken one for the other but in fact they are two different diseases. 56
• 3 Clinically Relevant Anatomy
The skeleton of the thoracic wall consists of the sternum anteriorly, the spinal collum (12 thoracic vertebrae) posteriorly and bounded by 12 paired ribs and costal cartilages.42
Ribs consist of bone and cartilage, with cartilage serving as an elastic bridge between the bony portion of the rib and the sternum.
There are three types of ribs: the first seven pairs of ribs are called ‘true ribs’ because they are directly attached to the sternum. The eight to tenth pairs of ribs are called ‘false ribs’ because they are not attached to the sternum but they are attached to each other. Finally the eleventh and twelfth are called ‘floating ribs’ because they are only attached posteriorly to the vertebrae.43
Each rib is attached posteriorly with the spinal collum: rib 1 is attached by vertebrae 1, rib 2 is attached to vertebrae 2 and so on.43
Anteriorly, the costal cartilage of the first rib connects with the manubrium via a rigid fusion of bone and cartilage.
The next seven pairs of ribs articulate with the sternum via cartilage at synovial-lined joints.
Ribs eight through 10 attach 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.2,1
The ribs move with respiration and with truncal motion or movement of the upper extremities. Mostly the intercostal nerves supply the innervation of the thoracic wall.
The muscles of the chest wall have influence on the expansion of the chest wall. The inspiratory muscles (e.g. scalene muscles, m. sternocleidomastoideus) expand the chest volume by elevating the rib cage. The expiratory muscles (e.g. rectus abdominis) decrease lung volumes by constricting the ribcage downwards.42
• 4 Epidemiology /Etiology
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
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
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.57 Both diseases can start either acute or progressively at any age.
• 5 Characteristics/Clinical Presentation
The cartilage connects sternum with costae and clavicula, and makes the movement of the thorax possible while breathing49,51. Elevation of the ribs and expansion of the rib cage result from the co-ordinated action of the rib cage muscles. 41 The inflammation of the cartilage of one or more costae causes a red, warm swelling of the cartilage. This will be both visible and palpable51,55. 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. 55,56,52,49 Pain occurring during the palpation of the painful spot suggests costochondritis but the pain could also have a cardiac origin56,52 tumor 52,53,49. From the pain of inflammation, the normal movement in joints is disrupted, the movements of the shoulder crepitates and pain may occur. 49,51,52 52 Complaints occur gradually and can disappear spontaneously after some days but it may take years to disappear. 49,58 Even after a spontaneously healing, the complaints can return on the same place or another spot around the costae. 49,55
The examinisation findings included hypomobility of the upper thoracic spine, costovertebral joints, and lateral ribs. Interventions included postural exercises and manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility.40
Clinically, the syndrome is 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
• 6 Differential Diagnosis
Costochondritis also known as
• Costosternal chondrodynia: Tietze’s syndrome variant 34
• Parasternal chondrodynia 35
• Anterior chest wall syndrome 35
• In the medical world costochondritis is often mistaken for the Tietze syndrome, a similar but rarer disorder involving swelling of a single costal cartilage, usually of the second rib.14, 35
Costochondritis can sometimes be mistaken for a separate condition called Tietze’s syndrome, as it also involves inflammation of the costochondral joint and can cause very similar symptoms. Costochondritis should be distinguished from other, more serious causes of chest pain. 35
The symptoms and signs of Tietze’s syndrome may occur in all arthropathies involving the anterior chest wall, particularly in seronegative spondylarthropathy and rheumatoid arthritis. Luckily these are distinguished easily by their other clinical features. Other skeletal causes sometimes mistaken for Tietze’s syndrome are:
• xiphoidalgia: painful swelling and discomfort of the xiphoid process of the sternum38
• slipping rib syndrome: hypermobility of the anterior ends of the false rib costal cartilages 39
Besides these pathologies, there are many other diseases to consider in the differential diagnosis, such as:
• multiple myeloma: a malignancy of mature plasma cells 39
• primitive neoplasms of the bone and soft tissues
• chondrosarcoma of the chondrocostal joints
• breast and lung tumours with extension to the costal cartilage
• metastases of breast, kidney, and prostate neoplasms59.
Consequently malignancy should always be kept in mind in the differential diagnosis of Tietze’s syndrome. The use of appropriate other investigations such as electrocardiography60,51, CT-scan61,53, MRI53,60,62… is necessary.
Tietze's syndrome, a non-suppurative, tender swelling of the anterior chest wall, is a disorder of uncertain etiology and pathology, not to be associated with constitutional disturbances, and of a prolonged fluctuating course. Familiarity with the uniform clinical manifestations of this relatively frequent entity makes its recognition fairly simple. The therapeutic approach includes reassurance of the patient as to the benign nature of this condition, along with supportive measures chiefly to allay pain. 36
However, Tietze’s syndrome is much less common than costochondritis, and it tends to cause chest swelling in addition to the other symptoms, whereas costochondritis does not.36
Tietze syndrome and costochondritis 35
Feature Tietze syndrome Costochondritis
Prevalence Rare More common
Age Younger than 40 years Over 40 years
Number of sites affected One (in 70 percent of the patients) More than one (in 90 percent of the patients)
Costochondral junctions most commonly affected Second and third Second to fifth
Local swelling Present Absent
| Tietze syndrome and costochondritis 35 | ||
| Feature | Tietze syndrome | Costochondritis |
| Prevalence | Rare | More common |
| Age | Younger than 40 years | Over 40 years |
| Number of sites | Affected one (in 70 percent of the patients) | More than one (in 90 percent of the patients) |
| Costochondral junctions most commonly affected | Second and third | Second to fifth |
| Local swelling | Present | Absent |
• 7 Diagnostic Procedures
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, but CT cannot image bilateral involvement in one patient.28 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
In patients with signs and symptoms of chest wall inflammation, scintigraphy is the most direct route to the diagnosis of costochondritis. Bone scintigraphy delineates both the extent of individual costochondral lesions and their multiplicity.28
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
Routine laboratory testing is not necessary in patients with suspected costochrondritis unless there the diagnosis is uncertain or when there are sings of inflammation.
Costochondritis gives chestpains which are orginated in the anterior chest wall and which may radiate into the chest, back, or abdomen. It is possible to reproduce this pain by palpating the affected costal cartilage.Costochondritis was diagnosed only when palpation of the rib cartilage(s) clearly reproduced the patient's pain.47
Consider further testing to rule out cardiac causes if clinically indicated by age or cardiac risk status.48
• 8 Outcome Measures
Patient-specific functional scale ( PSFS) : 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
The Global rating of change (GROC): To measure the patient’s subjective rate of improvement, the groc has been stated to be reliable .15
Measurement of thoracic and cervical mobility : to measure the mobility of the spine. This is a relevant measurement in costochondritis, because of the inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall, which can cause loss of mobility in the spinal area.65
These five tests are most valuable :
- Rotation of the thoracolumbar spine (TR) : TR had 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 ranks, but poor correlation with spinal changes
- The Schober test
- Thoracolumbar flexion
- Occiput-to-wall distance64
• 9 Examination
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 The palpable anterior chest wall tenderness does not include swelling, heat or erythema. Associated restriction of corresponding costovertebral and costotransverse joints may be discovered on joint play assessment, such as by motion palpation.
There is also loss of normal spinal movement associated with chest pain.27
-palpation: palpation should be performed with 1 digit, on the anterior, posterior and lateral side of the chest, the clavicula,the cervical and thoracic spine. When on the affected area reveals a reproducable pain this might suggest Costochondritis but it cannot entirely conclude it.15
- Motion palpation : motion palpation is a manual process of moving a joint into its maximal end range of motion, after which it is challenged with a light springing movement. This end point of joint movement forms the basis for determining the normal or abnormal joint play. When the motion palpation is reduced, the joint is considered fixated or hypokinetic.27
In a small number of patients the cardiac pain is due to cardiac causes.in 3-6% of the patients with pain to palpation a myocard infarction has occurred.patients older then 35 and with a history of cardiac problems have a higher risk.they should reveive a ecg and chest radiography.15
• 10 Medical Management
The treatment of costochondritis consists of conservative management and is usually sympotamatic.29,30 Conservative management can be useful in attempting to resolve the condition and managing pain.30 (LOE : 4)
The management includes reassurance, local injections and topical or oral analgesics.29 (LOE : 4) The aim of reassurance is reducing anxiety and changing beliefs and behaviours. Reassurance consists of affective reassurance (showing empathy) and cognitieve reassurance (providing education and explanations).66 (LOE : 2A)
Local injections with steroid in the joint, tendon sheath or around the nerve, inhibits the inflammation. This reduces the swelling and the pain and allows the patient to move better again. It is proved to be clinically safe and effective in the treatment of patients with Tietze’s syndrome.31 (LOE : 2B)
The conservative treatment also includes: ice, acupuncture, manual therapy, exercise prescription and prescription of other drugs including sulfasalazine.30
Cold therapy and acupuncture were used to decrease the local inflammation and providing analgesia.30 The drug sulfasalazine may have an additional long-term benefit in the management of costochondritis. This drug has an anti-inflammatory action.32 (LOE : 2C)
Currently, there have been no clinical trials of treatment for costochondritis.33 (LOE : 2C)
• 11 Physical Therapy Management
The treatment of Tietze’s syndrome is not yet perfect, because there is a lack of literature33. It is not known weather the disease is dealt definitely or not.[3] For now, trustworthy clinical studies on the treatment of Tietze's syndrome are lacking [8][4][6]. Treatment is usually directed at pain relief with acetaminophen, nonsteroidal anti-inflammatory drugs when safe and appropriate, or other analgesics. Applying heat with compresses or heating pads can help, particularly in the case of muscle overuse. Minimizing activities that provoke the symptoms (e.g., reducing the frequency or intensity of exercise or work activities) or using cough suppressants may also help relieve symptoms15 (LOE:5)
From the article of Karen Hudes where she reported a case study we can conclude that a course of trigger point therapy can reduce pain. This included cross fiber friction massage an ischemic compression to the intercostal musculature. In addition to this we can also use high velocity, low amplitude mobilisation of the rib in a posterior to anterior direction while the patient is in a supine position to create a cavitation. We can also use oscillation of the ribs in a posterior to anterior motions with a contact on the dorsal surface of the rib adjacent to the thoracic spinal articulation. Also the patient can instructed to use ice pack that will be wrapped in a light towel. This ice packed must be applied on the sternum for a duration of ten minutes. After 10 minutes will be followed by a 20 minutes rest, this process will be repeating 4 cycles.18 (LOE: 4)
From the article of Donald Aspergen at al. who studied a case of a young (21 year) female volleyball player we can found follow instruction to the rehabilitation. They used HVLA like they do in the article of Karen Hudes, Graston technique, and Kinesio taping methods. The Graston technique was applied on the chondrosternal joint of the concerned rib, this is a soft tissue technique to relax the chondrosternal musculatuur. Kinesio tape was applied in 2 strips. The first strip was applied vertically on the chondrosternal joint and the second strip was applied horizontally on the concerned rib.
-> By following these instructions the pain was improved by 70% after two weeks of treatment.26 (LOE: 4)
What exercise?
After 6,7 visit we can ad rehabilitative exercises like:
• A un-weighted supine arm pushes to activate the pectoral musculature and seated in-weighted plusses
• Wall push ups and progressed to full push ups and plusses at visit 8
-> The patient was instructed to begin with 5-10 repetitions of each exercise. This exercise were tolerance progressing to 3 sets of 10 repetitions each.
If following this instructions the patient showed a 80% improvement in symptoms and a reduction of the VAS- score on pain.18 (LOE: 4)
From the article of G. Rovetta et al. we can concluded that stretching of the pectoral muscle have a positive effect on the reducing of pain. It must be down in a correct way to be effective. Patients must place their forearm with elbow bent around 90° on wall or backside of a doorway and the elbow must be at least at shoulder height.23 (LOE: 3A)
The physiotherapist can:
- Reassure the patient by explaining the condition 8,4
- Instruct a good body position and give exercise advice. Patients need a good balance between exercise and rest.8,10,7,6
- Use heat pads on the costosternal joint and massage to help against the overloading of muscles and to lessen the pain. 8,1,6
- Conservative treatment involving use of nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics, as necessary.23
- Mobilize spine and ribs to avoid rigidity of the thorax and to reduce complaints. 10,3
- Teach the patient breathing exercises3
- Cough suppressants may be beneficial if cough is an aggravating factor.23
- Learn the patient to cope with pain. 8,6
- Exercise for shoulder and back can be provocative, therefore only when the complaints have disappeared, they can be applied3
It is urgent to work on literature studies for the physical treatment of costochondritis, because there is at this moment no literature study for this treatment.33
• 12 Key Evidence
ANNE M. PROULX. Costochondritis: Diagnosis and Treatment. Am Fam.Physician. 2009 Sep 15; 80(6):617-620.15
• 13 Resources
Resources we used for pictures :
- Fig 1 & 2 : From THIEME Atlas of Anatomy, General Anatomy and Musculoskeletal System, © Thieme 2005, Illustration by Karl Wesker
- Fig 3 : Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. Apr-Jun 2009;31(2):169-71
Books :
(43) Schunke M. et al. ; Anatomische atlas : Prometheus, algemene anatomie en bewegingsapparaat ; Bohn Stafleu van Loghum houten ; 2010 ; tweede druk ; p130-133
(44) Schunke M. et al. ; Anatomische atlas : Prometheus, algemene anatomie en bewegingsapparaat ; Bohn Stafleu van Loghum houten ; 2010 ; tweede druk ; p142-157
• 14 Clinical Bottom Line Missing information
Costochondritis is defined as painful chronic inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall.Costochondritis is often confused with Tietzen syndrome. The difference is that in Tiete’s syndrome there is a presence of swelling over the affected joints.45 Costochondritis and the Tietze's syndrome are often mistaken one for the other but in fact they are two different diseases.8
The diagnosis of costochrondritis can be made by bone scan or bone scintigraphy. It can also be examined by palpation of the affected costal cartilage. Patients older than 35 years have a higher risc of cardiac problems. These patients should recieve a radiography of the chest.28,47
Currently, there have been no clinical trials of treatment for costochondritis.33 The treatment of costochondritis consists of conservative management and is usually sympotamatic.29,30
The therapy consist of cross fiber frictions, HVLA, stretching of the pectoral muscles, kinesiotaping, graston techniques and pectoral muscle strength exercises.
• 15 Recent Related Research (from Pubmed)
http://www.ncbi.nlm.nih.gov/pubmed/22787240
http://www.ncbi.nlm.nih.gov/pubmed/19827277
http://www.ncbi.nlm.nih.gov/pubmed/17360222
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140236
• 16 References
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