Tietzes: Difference between revisions

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add text here related to databases searched, keywords, and search timeline <br>  
== Definition/Description ==
In 1921, Tietze syndrome is described for the first time by Alexander Tietze, a German Surgeon. Tietzes syndrome usually affects the third, fourth and fifth [[Ribs|costochondral joint]]. The manubriosternal and xiphisternal joints are less frequently affected. Joint swelling distinguishes the condition from costochondritis. Tietze’s syndrome is supported by an elevated erythrocyte rate and more morning stiffness.<ref name=":0">Jensen Stochkendahl M, Wulff Christensen H., Chest pain in focal musculoskeletal disorders, Medical Clinics of North America;Elsevier,2010.Level of evidence: 3A
</ref><ref>Lawless, C. E. (2011). Sports Cardiology Essentials; Evaluation, Management and Case studies.</ref> With Tietze syndrome a local swelling of the involved costal [[Cartilage|cartilages]] is visible and patients complain of chest wall [[Pain-Modulation|pain]].<ref name=":1">Frontera, W. R. (2015). Essentials of physial medicine and rehabilitation: muskuloskeletal disorders, pain, and reabilitation. Philadelphia: Elsevier. (p 582-587)</ref><ref name=":0" />  


== Definition/Description ==
[[Costochrondritis|Costochondritis]] is a painful chronical inflammation of the cartilage of one or more costae at the transition between sternum and costae.<ref name=":3">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 1985; 133(5):379-389. Level of evidence: 2A</ref><ref name=":4">Thongngarm T., Lemos L.B., Lawhon N., Harisdangkul V., Malignant tumor with chest wall pain mimicking Tietze's syndrome, Clin Rheumatol., 2001; 20(4):276-8. Level of Evidence 3B</ref> Only when a swelling occurs underneath sternum and/or a reddening of the skin at the painful spot, it's called Tietze's syndrome.<ref name=":2">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. LOE: 2B</ref><ref name=":5">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 LOE: 3B</ref><ref name=":6">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>.


[[Costochondritis|Costochondritis]] is a painfull chronical inflammation of the cartilago of one or more costae at <br>the transition between sternum and costae.<ref name="Fam et al">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389.</ref><ref name="Thongnarm et al">Thongngarm T., Lemos L.B., Lawhon N., Harisdangkul V., Malignant tumor with chest wall pain mimicking Tietze's syndrome, Clin Rheumatol., 2001; 20(4):276-8</ref><ref name="Moin et al">Moin P., Vergouw M., Imanuel N., Hulshof D., 2005, Syndroom van Tietze, geraadpleegd op 26/12/2010, http://www.fysiotherapie-enschede.nl/content/ziektenbeelden3upo/Syndroom%20van%20Tietze.htm</ref> Only when a swelling occurs underneath sternum and/or a reddening of the skin at the painfull spot, it's called Tietze's syndrome<ref name="Verdon et al">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 name="Hoogendoorn et al">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="American academy of family physicians">American acadamy of family physicians, Costochondritis: What you need to know, Am Fam Physicians, Sept 2009, 15;75(10):1</ref><ref name="Hurst et al">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>. 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.<ref name="Verdon et al" /><ref name="Moin et al" /> Costochondritis<ref name="American academy of family physicians" /> and the Tietze's syndrome are often confused but in fact they are two different diseases. <ref name="Zryd et al" />  
Tietze's syndrome causes severe pain when coughing and deep breathing. It's not life-threatening or contagious but it is a fastidious and painful condition<ref name=":2" />. Costochondritis and the Tietze's syndrome are often confused but are two different diseases.<ref name=":7">Proulx A.M., Zryd T.W., Costochondritis; Diagnosis and Treatment, Am Fam Physician, 2009 Sep 15;80(6):617-20


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<ref>Anthony S. Fauci, Carol A. Langford. Harrison’s rheumatology. Second edition. 2010. McGraw-Hill Education</ref> . Both diseases can start either acute or progressively at any age<br><br>
Level of evidence: 2A
</ref><br><br>  


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


add text here
The thorax is part of the human body and is located between the neck and the abdomen. Our thorax is composed of the clavicula, sternum and 24 ribs, 12 ribs at each side. Ten of the 12 ribs are connected to the sternum by cartilage. The purpose of the cartilage is to make the thorax flexible during the respiration.<ref>Paulsen, F. (2011). Sobotta, Atlas of Human anatomy. Elsevier.</ref><br> <br>The ribs articulate posteriorly with the proc. transversii of the thoracic vertebrae. These junctions are called the costotransverse joints. The ribs also articulate with the body of the vertebrae. These articulations are called the costovertebral joints.<ref>Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 1985; 133(5):379-389.
 
Level of evidence: 2A
</ref><br>


== Epidemiology /Etiology  ==
== Epidemiology /Etiology  ==


add text here <br>  
The etiology of Tietze syndrome is unknown but Tietze syndrome is often associated to acute cases of viral respiratory tract infections. Also, microtraumas to the costosternal joints underlie the Tietze syndrome.<ref name=":1" /><ref>Wildman. (2011). Pain managment. Elsevier.</ref>Tietze syndrome can occur in children, infants, and adults. The ratio of men to women is 1:1. Lesions are in more than 80% of the patients single and unilateral.<ref name=":1" /><br><br>


== Characteristics/Clinical Presentation<br>  ==
== Characteristics/Clinical Presentation   ==


The cartilage connects sternum with costae and clavicula, and makes the movement of the thorax possible while breathing.<ref name="Fam et al">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389.</ref><ref name="Moin et al">Moin P., Vergouw M., Imanuel N., Hulshof D., 2005, Syndroom van Tietze, geraadpleegd op 26/12/2010, http://www.fysiotherapie-enschede.nl/content/ziektenbeelden3upo/Syndroom%20van%20Tietze.htm</ref> 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.<ref name="Moin et al">Moin P., Vergouw M., Imanuel N., Hulshof D., 2005, Syndroom van Tietze, geraadpleegd op 26/12/2010, http://www.fysiotherapie-enschede.nl/content/ziektenbeelden3upo/Syndroom%20van%20Tietze.htm</ref><ref name="Hurst et al">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 is pain with a varying intensity in the chest wall and this pain aggravated by movements of the torso, deep breathing, coughing and exertion.&nbsp;<ref name="Hurst et al">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><ref name="Zryd et al">Proulx A.M., Zryd T.W., Costochondritis; Diagnosis and Treatment, Am Fam Physician, 2009 Sep 15;80(6):617-20</ref><ref name="Verdon et al">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 name="Fam et al">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389.</ref> Pain occurring during the palpation of the painful spot suggests costochondritis but the pain could also have a cardiac origin<ref name="Zryd et al">Proulx A.M., Zryd T.W., Costochondritis; Diagnosis and Treatment, Am Fam Physician, 2009 Sep 15;80(6):617-20</ref><ref name="Verdon et al">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> tumor<ref name="Verdon et al">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 name="Moin et al">Moin P., Vergouw M., Imanuel N., Hulshof D., 2005, Syndroom van Tietze, geraadpleegd op 26/12/2010, http://www.fysiotherapie-enschede.nl/content/ziektenbeelden3upo/Syndroom%20van%20Tietze.htm</ref><ref name="Fam et al">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389.</ref> . From the pain of inflammation, the normal movement in joints is disrupted, the movements of the shoulder crepitates and pain may occur.<ref name="Fam et al">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389.</ref><ref name="Moin et al">Moin P., Vergouw M., Imanuel N., Hulshof D., 2005, Syndroom van Tietze, geraadpleegd op 26/12/2010, http://www.fysiotherapie-enschede.nl/content/ziektenbeelden3upo/Syndroom%20van%20Tietze.htm</ref><ref name="Verdon et al">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> Complaints occur gradually and can disappear spontaneously after some days but it may take years to disappear.<ref name="Fam et al">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389.</ref><ref name="Gregory et al">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 a spontaneously healing, the complaints can return on the same place or another spot around the costae.<ref name="Fam et al">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389.</ref><ref name="Hurst et al">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><br><br>
The cartilage connects sternum with costae and clavicule and makes the movement of the thorax possible while breathing.<ref name=":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.<ref name=":6" /> 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.<ref name=":3" /><ref name=":2" /><ref name=":6" /><ref name=":7" /> Pain occurring during the palpation of the painful spot suggests costochondritis but the pain could also have an origin as cardiac tumor<ref name=":2" /><ref name=":7" />


== Differential Diagnosis  ==
From the pain of inflammation, the normal movement in joints are disrupted, the movements of the shoulder crepitates and pain may occur.<ref name=":3" /><ref name=":2" /> Complaints occur gradually and can disappear spontaneously after some days but it may take years to disappear.<ref name=":3" /><ref name=":8">Gregory P.L., BISWAS A.C., Batt M.E.,Musculoskeletal problems of the chest wall in athletes, Sports Med., 2002;32(4):235-50.


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|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<ref>Fioravanti, A., Tofi, C., Volterrani, L. and Marcolongo, R. (2002), Malignant lymphoma presenting as Tietze's syndrome. Arthritis Care &amp;amp;amp; Research, 47: 229–230. doi: 10.1002/art.10401</ref>. 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[<ref name="Smythe et al">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389.</ref><ref name="Moin et al">Moin P., Vergouw M., Imanuel N., Hulshof D., 2005, Syndroom van Tietze, geraadpleegd op 26/12/2010, http://www.fysiotherapie-enschede.nl/content/ziektenbeelden3upo/Syndroom%20van%20Tietze.htm</ref>, CT-scan<ref name="Hamburg et al">Hamburg C., Abdalwahab I.F., Reliability of computed tomography in the initial diagnosis and follow-up evaluation of Tietze's syndrome: a case report with review of the literature, J Comput Tomogr., 1987;11(1):83-87</ref><ref name="Hoogendoorn et al">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>, MRI<ref name="Hoogendoorn et al">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="Smythe et al">Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 19851; 133(5):379-389.</ref><ref name="Volterrani et al">Volterrani L., Mazzei M.A., Giordano N., Nuti R., Galeazzi M., Fioravanti A., Magnetic resonance imaging in Tietze's syndrome, Clin Exp Rheumatol., Sept-Oct 2008; 26(5):848-53</ref>,… is necessary.<br><br>
Level of evidence: 2A
</ref> Even after a spontaneously healing, the complaints can return on the same place or another spot around the costae.<ref name=":3" /><ref name=":6" /> Patients with Tietze syndrome may experience functional limitations. The activity of the trunk and upper limb can be restricted. Daily activities like ironing, brushing hair, lifting something may be difficult.<ref>Geddes A.K., Tietze’s syndrome, Can med assoc J, 53;571-3, 1945. Level of evidence: 3B</ref>
 
== Differential Diagnosis ==
 
Possible differential diagnoses<ref name=":3" /><ref>Fioravanti, A., Tofi, C., Volterrani, L. and Marcolongo, R. (2002), Malignant lymphoma presenting as Tietze's syndrome. Arthritis Care &amp; Research, 47: 229–230. doi: 10.1002/art.10401 </ref> are: 
* Seronegative spondyloarthropathy
* <span class="CategoryTreeNotice">[[Spondyloarthropathy--AS]]</span>  
* [[RA_(Rheumatoid_Arthritis)]]
* Xiphoidalgia
* [[Slipping Rib Syndrome]]
* Myelomalacia
* Primitive neoplasms of the bone and soft tissue
* [[Chondrosarcoma]] of chondrocostal joints
* [[Costochondritis]]
* Tumors of the breasts and/or lungs with extension to the costal cartilage
* Metastases of breast, kidney, and prostate neoplasms
* Rib trauma and painful rib swelling
* [[Arthritis]] of:  
** Sternoclavicular joint
** Manubriosternal joint


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


add text here related to medical diagnostic procedures
The use of the appropriate investigations such as electrocardiography<ref name=":3" />, CT-scan<ref name=":5" /><ref>Hamburg C., Abdalwahab I.F., Reliability of computed tomography in the initial diagnosis and follow-up evaluation of Tietze's syndrome: a case report with review of the literature, J Comput Tomogr., 1987;11(1):83-87</ref>, MRI<ref name=":5" /><ref name=":3" /><ref>Volterrani L., Mazzei M.A., Giordano N., Nuti R., Galeazzi M., Fioravanti A., Magnetic resonance imaging in Tietze's syndrome, Clin Exp Rheumatol., Sept-Oct 2008; 26(5):848-53</ref> are necessary. These are used to rule out any kind of malignancy.  Research has shown that this diagnosis is one of exclusion. Plain radiographs are often normal but there may be a hotspot on bone scanning, CT scan may show sclerosis of the sternal manubrium, partial calcification of the costal cartilage and soft tissue swelling, biopsy of the costal cartilage may show chronic inflammation with fibrosis and ossification. Gallium scan has been reported as showing increased uptake as with costochondritis.<ref name=":8" />


== Outcome Measures  ==
== Outcome Measures  ==
 
* [[Visual_Analogue_Scale]]
add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]])
* [[Numeric_Pain_Rating_Scale]]
* [[Short-form_McGill_Pain_Questionnaire]]


== Examination  ==
== Examination  ==


add text here related to physical examination and assessment<br>  
On physical examination, a slight firm swelling on the involved site and sometimes a local heat. A spontaneous pain originate after local palpation of this area.<ref name=":1" />  By palpation of the  pectoralis major, pectoralis minor and the sternum, a tenderness can be notice.<ref name=":1" /><ref name=":9">Waldman SD. (2002). Tietze syndrome, in: Atlas of common pain syndromes. Philadelphia. P. 158-160</ref><br>Pain can be reproduced with retraction, protraction or elevation of the shoulder or deep inspiration. Tietze’s syndrome leads to a limitation of muscle strength and upper limb range of motion.<ref name=":0" /> Patients with Tietze’s syndrome can be limited in activities of daily living like: ironing, lifting, combing and brushing hair, but normally the disability of Tietze’s syndrome is minor.<ref name=":1" /><ref name=":0" /><br>When there is only an inflammation of the cartilage of one or more costae at the transition between the sternum and the costae, you can speak of [[costochondritis]]<ref name=":3" /><ref name=":4" />  If there is also a swelling present or a spot which is very painful, you can speak of Tietze’s syndrome.<ref name=":2" /><ref name=":5" /><ref name=":6" /> The video below further highlights the difference between the two conditions.
{{#ev:youtube|dYE8SUDJfx4|400}}<ref>Dr Donald A Ozello DC. Costochondritis and Tietze's Syndrome. Available from: http://www.youtube.com/watch?v=dYE8SUDJfx4[last accessed 19/10/2023]</ref>


== Medical Management <br>  ==
== Medical Management   ==


medical management generally consists of relative rest for 4–6 weeks, injections of anesthetic-corticosteroid, topical or oral analgesics, and prescription of other drugs including sulfasalazine or capsofungin combined with fluconazole.<ref name="Gregory et al">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><ref>14. 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; 52(4):224–228.</ref>  
Medical management generally consists of relative rest for 4–6 weeks, injections of anesthetic-corticosteroid, topical or oral analgesics, and prescription of other drugs including sulfasalazine or capsofungin combined with fluconazole.<ref name=":8" /><ref>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; 52(4):224–228.</ref>  


<br><br>
== Physical Therapy Management    ==


== Physical Therapy Management <br> ==
The treatment of Tietze’s syndrome is not yet perfect. It is not known whether the disease is dealt definitely or not. So the treatment of the Tietze syndrome is mostly symptomatic.<ref>Hiramuro-shoji F., et al., Atraumatic conditions of the sternoclavicular joint, J shoulder elbow surg, 12:79-88, 2003. Level of evidence: 3B</ref><ref>Gerald S. Tietze's syndrome: Report of two cases and review of the literature, J American college of rheumatology, Vol 5, 2005. Level of evidence: 2C</ref> For now, trustworthy clinical studies on the treatment of Tietze's syndrome are lacking.<ref name=":2" /><ref name=":7" />


The treatment of Tietze’s syndrome is not yet perfect. It is not known weather the disease is dealt definitly or not.<ref name="Moin et al" /> For now, trustworthy clinical studies on the treatment of Tietze's syndrome are lacking&nbsp; <ref name="Zryd et al">Proulx A.M., Zryd T.W., Costochondritis; Diagnosis and Treatment, Am Fam Physician, 2009 Sep 15;80(6):617-20</ref><ref name="Verdon et al" /><ref name="American academy of family physicians" />. <br><br>The physiotherapist can:<br>- Reassure the patient by explaining the condition <ref name="Zryd et al" /><ref name="Verdon et al" /><br>- Instruct a good body position and give exercise advise. Patients need a good balance between exercise and rest.<ref name="Zryd et al" /><ref name="Gregory et al" /><ref name="Hurst et al" /><ref name="American academy of family physicians" /><br>- Use heat pads and massage to help against the overloading of muscles and to lessen the pain.<ref name="Zryd et al" /><ref name="Fam et al" /><ref name="American academy of family physicians" /><br>- Mobilize spine and ribs to avoid rigidity of the thorax and to reduce complaints.<ref name="Gregory et al" /><ref name="Moin et al" /><br>- Teach the patient breathing excercises<ref name="Moin et al" /> <br>- Learn the patient to cope with pain.<ref name="Zryd et al" /><ref name="American academy of family physicians" /><br>- Exercise for shoulder and back can be provocative, therefore only when the complaints have disappeared, they can be applied<br><ref name="Moin et al" />
The physiotherapist can:  
* Reassure the patient by explaining the condition.<ref name=":2" /><ref name=":7" />


== Key Research  ==
* Instruct a good body position and give exercise advise. Patients need a good balance between exercise and rest.<ref name=":6" /><ref name=":7" /><ref name=":8" /> It is important that the physiotherapist gives good information about the posture of the patient during sitting and during daily activities. It’s also important that the patient avoids repetitive movements/ activities.<ref>Aeschlimann A., Kahn MF., Tietze's syndrome: a critical review, Clin Exp Rheumatol, 8(4):407-12, 1990. Level of evidence: 3A</ref>


add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  
* [[Therapeutic Exercise|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. If powerful exercises exacerbate the symptoms, you need to stop and avoid these kind of exercises.<ref name=":9" />  


== Resources <br> ==
* Stretching of the [[Pectoralis major|M. pectoralis major]] can be helpful. You can stretch the M. pectoralis major when you stand in a corner for 10 sec with both of your hands against the wall (like when you do a push-up). You need to repeat it a few times a day for 1 or 2 minutes.<ref name=":10">Rovetta G., et al., Stretching exercises for costochondritis pain, G Ital Med Lav Ergon, 31(2):169-71, 2009. Level of evidence: 2B</ref>  


add appropriate resources here <br>  
* Use [[Thermotherapy|heat]]/ [[Cryotherapy|cold]] pads and massage to help against the overloading of muscles and to lessen the pain.<ref name=":3" /><ref name=":7" />  Heat and cold pads are both equally effective. So the patient can choose which one he likes the most. In stead of using cold pads, the patient can also use Vapocoolant spray on the involved areas. This spray can relief the pain on the chest.<ref name=":10" /><ref>Kayser HL., Tietze’s syndrome: review of the literature, Am J med, 21:982-9, 1965. Level of evidence: 3A</ref>
* Mobilize spine and ribs to avoid rigidity of the thorax and to reduce complaints.<ref name=":8" />
* Teach the patient [[Respiratory Muscle Training|breathing exercises]].
* Teach the patient to [[Cognitive Behavioural Therapy|cognitive behavioural therapy]] and [[Pain Neuroscience Education (PNE)|pain neuroscience education]] to aid in coping  with pain.<ref name=":7" />
* Exercise for shoulder and back can be provocative, therefore only when the complaints have disappeared, they can be applied.


== Clinical Bottom Line  ==
* On the painful area they can use [[Transcutaneous Electrical Nerve Stimulation (TENS)|transcutaneous electrical stimulation]] and [[Acupuncture|electroacupuncture]]. The acupuncture 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>


add text here <br>
* [[Dry Needling]]: Musculoskeletal chest wall pain has traditionally been a difficult area to evaluate and treat. Injection therapy with local anesthetics or corticosteroids has been previously described as a treatment method for costochondral-related chest wall pain. Results of previous research studies have indicated that dry needling may be as effective as injection therapy for various conditions.<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). (Level of evidence : 3B) </ref><br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
 
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
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</div>  
== References  ==
== References  ==
 
<references />
see [[Adding References|adding references tutorial]].
[[Category:Thoracic Spine]]
 
[[Category:Joints]]  
<references />
[[Category:Pain]]
 
[[Category:Musculoskeletal/Orthopaedics‏‎]]
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Primary Contact]]
[[Category:Conditions]]
[[Category:Thoracic Spine - Conditions]]
[[Category:Thoracic Spine - Conditions]]
[[Category:Vrije Universiteit Brussel Project]]

Revision as of 13:53, 29 January 2024

Original Editors - Els Bernaers

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Definition/Description[edit | edit source]

In 1921, Tietze syndrome is described for the first time by Alexander Tietze, a German Surgeon. Tietzes syndrome usually affects the third, fourth and fifth costochondral joint. The manubriosternal and xiphisternal joints are less frequently affected. Joint swelling distinguishes the condition from costochondritis. Tietze’s syndrome is supported by an elevated erythrocyte rate and more morning stiffness.[1][2] With Tietze syndrome a local swelling of the involved costal cartilages is visible and patients complain of chest wall pain.[3][1]

Costochondritis is a painful chronical inflammation of the cartilage of one or more costae at the transition between sternum and costae.[4][5] Only when a swelling occurs underneath sternum and/or a reddening of the skin at the painful spot, it's called Tietze's syndrome.[6][7][8].

Tietze's syndrome causes severe pain when coughing and deep breathing. It's not life-threatening or contagious but it is a fastidious and painful condition[6]. Costochondritis and the Tietze's syndrome are often confused but are two different diseases.[9]

Clinically Relevant Anatomy[edit | edit source]

The thorax is part of the human body and is located between the neck and the abdomen. Our thorax is composed of the clavicula, sternum and 24 ribs, 12 ribs at each side. Ten of the 12 ribs are connected to the sternum by cartilage. The purpose of the cartilage is to make the thorax flexible during the respiration.[10]

The ribs articulate posteriorly with the proc. transversii of the thoracic vertebrae. These junctions are called the costotransverse joints. The ribs also articulate with the body of the vertebrae. These articulations are called the costovertebral joints.[11]

Epidemiology /Etiology[edit | edit source]

The etiology of Tietze syndrome is unknown but Tietze syndrome is often associated to acute cases of viral respiratory tract infections. Also, microtraumas to the costosternal joints underlie the Tietze syndrome.[3][12]Tietze syndrome can occur in children, infants, and adults. The ratio of men to women is 1:1. Lesions are in more than 80% of the patients single and unilateral.[3]

Characteristics/Clinical Presentation[edit | edit source]

The cartilage connects sternum with costae and clavicule and makes the movement of the thorax possible while breathing.[4] 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.[8] 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.[4][6][8][9] Pain occurring during the palpation of the painful spot suggests costochondritis but the pain could also have an origin as cardiac tumor[6][9]

From the pain of inflammation, the normal movement in joints are disrupted, the movements of the shoulder crepitates and pain may occur.[4][6] Complaints occur gradually and can disappear spontaneously after some days but it may take years to disappear.[4][13] Even after a spontaneously healing, the complaints can return on the same place or another spot around the costae.[4][8] Patients with Tietze syndrome may experience functional limitations. The activity of the trunk and upper limb can be restricted. Daily activities like ironing, brushing hair, lifting something may be difficult.[14]

Differential Diagnosis[edit | edit source]

Possible differential diagnoses[4][15] are:

Diagnostic Procedures[edit | edit source]

The use of the appropriate investigations such as electrocardiography[4], CT-scan[7][16], MRI[7][4][17] are necessary. These are used to rule out any kind of malignancy. Research has shown that this diagnosis is one of exclusion. Plain radiographs are often normal but there may be a hotspot on bone scanning, CT scan may show sclerosis of the sternal manubrium, partial calcification of the costal cartilage and soft tissue swelling, biopsy of the costal cartilage may show chronic inflammation with fibrosis and ossification. Gallium scan has been reported as showing increased uptake as with costochondritis.[13]

Outcome Measures[edit | edit source]

Examination[edit | edit source]

On physical examination, a slight firm swelling on the involved site and sometimes a local heat. A spontaneous pain originate after local palpation of this area.[3] By palpation of the pectoralis major, pectoralis minor and the sternum, a tenderness can be notice.[3][18]
Pain can be reproduced with retraction, protraction or elevation of the shoulder or deep inspiration. Tietze’s syndrome leads to a limitation of muscle strength and upper limb range of motion.[1] Patients with Tietze’s syndrome can be limited in activities of daily living like: ironing, lifting, combing and brushing hair, but normally the disability of Tietze’s syndrome is minor.[3][1]
When there is only an inflammation of the cartilage of one or more costae at the transition between the sternum and the costae, you can speak of costochondritis[4][5] If there is also a swelling present or a spot which is very painful, you can speak of Tietze’s syndrome.[6][7][8] The video below further highlights the difference between the two conditions.

[19]

Medical Management[edit | edit source]

Medical management generally consists of relative rest for 4–6 weeks, injections of anesthetic-corticosteroid, topical or oral analgesics, and prescription of other drugs including sulfasalazine or capsofungin combined with fluconazole.[13][20]

Physical Therapy Management[edit | edit source]

The treatment of Tietze’s syndrome is not yet perfect. It is not known whether the disease is dealt definitely or not. So the treatment of the Tietze syndrome is mostly symptomatic.[21][22] For now, trustworthy clinical studies on the treatment of Tietze's syndrome are lacking.[6][9]

The physiotherapist can:

  • Reassure the patient by explaining the condition.[6][9]
  • Instruct a good body position and give exercise advise. Patients need a good balance between exercise and rest.[8][9][13] It is important that the physiotherapist gives good information about the posture of the patient during sitting and during daily activities. It’s also important that the patient avoids repetitive movements/ activities.[23]
  • 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. If powerful exercises exacerbate the symptoms, you need to stop and avoid these kind of exercises.[18]
  • Stretching of the M. pectoralis major can be helpful. You can stretch the M. pectoralis major when you stand in a corner for 10 sec with both of your hands against the wall (like when you do a push-up). You need to repeat it a few times a day for 1 or 2 minutes.[24]
  • Use heat/ cold pads and massage to help against the overloading of muscles and to lessen the pain.[4][9] Heat and cold pads are both equally effective. So the patient can choose which one he likes the most. In stead of using cold pads, the patient can also use Vapocoolant spray on the involved areas. This spray can relief the pain on the chest.[24][25]
  • Mobilize spine and ribs to avoid rigidity of the thorax and to reduce complaints.[13]
  • Teach the patient breathing exercises.
  • Teach the patient to cognitive behavioural therapy and pain neuroscience education to aid in coping with pain.[9]
  • Exercise for shoulder and back can be provocative, therefore only when the complaints have disappeared, they can be applied.
  • Dry Needling: Musculoskeletal chest wall pain has traditionally been a difficult area to evaluate and treat. Injection therapy with local anesthetics or corticosteroids has been previously described as a treatment method for costochondral-related chest wall pain. Results of previous research studies have indicated that dry needling may be as effective as injection therapy for various conditions.[27]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Jensen Stochkendahl M, Wulff Christensen H., Chest pain in focal musculoskeletal disorders, Medical Clinics of North America;Elsevier,2010.Level of evidence: 3A
  2. ↑ Lawless, C. E. (2011). Sports Cardiology Essentials; Evaluation, Management and Case studies.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Frontera, W. R. (2015). Essentials of physial medicine and rehabilitation: muskuloskeletal disorders, pain, and reabilitation. Philadelphia: Elsevier. (p 582-587)
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 1985; 133(5):379-389. Level of evidence: 2A
  5. ↑ 5.0 5.1 Thongngarm T., Lemos L.B., Lawhon N., Harisdangkul V., Malignant tumor with chest wall pain mimicking Tietze's syndrome, Clin Rheumatol., 2001; 20(4):276-8. Level of Evidence 3B
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 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. LOE: 2B
  7. ↑ 7.0 7.1 7.2 7.3 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 LOE: 3B
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Hurst J.W., Morris D.C., Williams B.R. “Chest Pain” in patients with costochondritis or Tietze's syndrome, Wiley-Blackwell, 2001, p23-29
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Proulx A.M., Zryd T.W., Costochondritis; Diagnosis and Treatment, Am Fam Physician, 2009 Sep 15;80(6):617-20 Level of evidence: 2A
  10. ↑ Paulsen, F. (2011). Sobotta, Atlas of Human anatomy. Elsevier.
  11. ↑ Fam A.G., Smythe H.A.,Musculoskeletal chest wall pain, Can Med Assoc J. Sept 1985; 133(5):379-389. Level of evidence: 2A
  12. ↑ Wildman. (2011). Pain managment. Elsevier.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Gregory P.L., BISWAS A.C., Batt M.E.,Musculoskeletal problems of the chest wall in athletes, Sports Med., 2002;32(4):235-50. Level of evidence: 2A
  14. ↑ Geddes A.K., Tietze’s syndrome, Can med assoc J, 53;571-3, 1945. Level of evidence: 3B
  15. ↑ Fioravanti, A., Tofi, C., Volterrani, L. and Marcolongo, R. (2002), Malignant lymphoma presenting as Tietze's syndrome. Arthritis Care & Research, 47: 229–230. doi: 10.1002/art.10401 
  16. ↑ Hamburg C., Abdalwahab I.F., Reliability of computed tomography in the initial diagnosis and follow-up evaluation of Tietze's syndrome: a case report with review of the literature, J Comput Tomogr., 1987;11(1):83-87
  17. ↑ Volterrani L., Mazzei M.A., Giordano N., Nuti R., Galeazzi M., Fioravanti A., Magnetic resonance imaging in Tietze's syndrome, Clin Exp Rheumatol., Sept-Oct 2008; 26(5):848-53
  18. ↑ 18.0 18.1 Waldman SD. (2002). Tietze syndrome, in: Atlas of common pain syndromes. Philadelphia. P. 158-160
  19. ↑ Dr Donald A Ozello DC. Costochondritis and Tietze's Syndrome. Available from: http://www.youtube.com/watch?v=dYE8SUDJfx4[last accessed 19/10/2023]
  20. ↑ 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; 52(4):224–228.
  21. ↑ Hiramuro-shoji F., et al., Atraumatic conditions of the sternoclavicular joint, J shoulder elbow surg, 12:79-88, 2003. Level of evidence: 3B
  22. ↑ Gerald S. Tietze's syndrome: Report of two cases and review of the literature, J American college of rheumatology, Vol 5, 2005. Level of evidence: 2C
  23. ↑ Aeschlimann A., Kahn MF., Tietze's syndrome: a critical review, Clin Exp Rheumatol, 8(4):407-12, 1990. Level of evidence: 3A
  24. ↑ 24.0 24.1 Rovetta G., et al., Stretching exercises for costochondritis pain, G Ital Med Lav Ergon, 31(2):169-71, 2009. Level of evidence: 2B
  25. ↑ Kayser HL., Tietze’s syndrome: review of the literature, Am J med, 21:982-9, 1965. Level of evidence: 3A
  26. ↑ Imamura ST., et al., syndrome de tietze, Cossermeli W., Terapêutica em reumatologia, Sao Paulo, lemos editorial, p773-777, 2000.
  27. ↑ 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). (Level of evidence : 3B) 
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