Tietzes

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Search Strategy

Pubmed: key words: Tietze, Tietze syndrome, costochondritis

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 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 erytocryryte rate and more morning stiffness. (Lawless, 2015, Jensen et al.,, 2010, LOE: 3A)
With Tietze syndrome a local swelling is visible of the involved costal cartilages and patients complain of chest wall pain. (Frontera,2015, Jensen et al.,, 2010, LOE: 3A)

[Costochrondritis|Costochondritis] is a painful chronical inflammation of the cartilage of one or more costae at
the transition between sternum and costae. (Fam et al, 1985, LOE: 2A; Thongngarm et al., 2001, LOE: 3B)Only when a swelling occurs underneath sternum and/or a reddening of the skin at the painfull spot, it's called Tietze's syndrome. (Verdon et al., 2010, LOE: 2B; Hoogendoorn et al., 2004, LOE: 3B; Hurst,2001) 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 painful condition.(Verdon et al., 2010, LOE: 2B) Costochondritis and the Tietze's syndrome are often confused but in fact they are two different diseases. (Proulx et al.,2009,LOE:2A)

Clinically Relevant Anatomy

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. (Paulsen, 2011)

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. (Fam et al, 1985, LOE: 2A)

Epidemiology /Etiology

The etiology of Tietze syndrome is unknown but Tietze syndrome is often associated in acute cases associated with viral respiratory tract infections. Also, microtraumas to the costosternal joints underlie the Tietze syndrome.(Frontera, 2015, Wildman, 2011)

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. (Frontera, 2015)

Characteristics/Clinical Presentation

The cartilage connects sternum with costae and clavicula, and makes the movement of the thorax possible while breathing.(Fam et al., 1985, LOE: 2A)
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.(Hurst,2001) 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. (Fam et al., 1985, LOE: 2A; Verdon et al., 2010, LOE: 2B; Hurst,2001; Proulx et al., 2009,LOE: 2A)  Pain occurring during the palpation of the painful spot suggests costochondritis but the pain could also have an origin as cardiac tumor(Verdon et al., 2010, LOE: 2B; Proulx et al., 2009,LOE:2A).

 From the pain of inflammation, the normal movement in joints is disrupted, the movements of the shoulder crepitates and pain may occur.. (Fam et al., 1985, LOE: 2A; Verdon et al., 2010, LOE: 2B) Complaints occur gradually and can disappear spontaneously after some days but it may take years to disappear..(Fam et al., 1985, LOE: 2A; Gregory et al.,2002,LOE:2A) Even after a spontaneously healing, the complaints can return on the same place or another spot around the costae.(Fam et al., 1985, LOE: 2A; Hurst,201)
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. (Geddes et al, 1945, LOE: 3B)

Differential Diagnosis

Possible differential diagnoses are: (Fioravanti et al., 2002, LOE: 2C; Fam et al, 1985, LOE: 2A)

- Seronegative spondyloarthropathy

- Spondyloarthropathy--AS
- 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

The use of the appropriate investigations such as electrocardiography (Fam A.G et al., 1985, LOE: 2A), CT-scan (Hoogendoorn et al., 2004, LOE: 3B; Hamburg C. et al., 1987, LOE: 3B), MRI (Hoogendoorn et al., 2004, LOE: 3B; Fam A.G et al., 1985, LOE: 2A; Volterrani L. et al., 2008, LOE: 2B),… 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.’ (Gregory et al., 2002, LOA:1A)

Outcome Measures

- Visual_Analogue_Scale
- Numeric_Pain_Rating_Scale
- Short-form_McGill_Pain_Questionnaire

Examination

You can notice on the physical examination a slight firm swelling on the involved site and sometimes a local heat. The region is very sensitive. A spontaneous pain originate after local palpation of this area. (Frontera, 2015)

By palpation of the m. pectoralis major, m. pectoralis minor and the sternum a tenderness can be notice. (Frontera, 2015, Waldman, 2002)
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.( Jensen, 2010, LOE: 3A)
Patients with Tietze’s syndrome can be imitated in activities of daily living like: ironing, lifting, combing and brushing hear… But normally the disability of Tietze’s syndrome is minor. (Frontera, 2015, Jensen, 2010, LOE: 3A)
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. (Fam et al, 1985, LOE: 2A; Thongngarm et al., 2001, LOE: 3B) If there is also a swelling present or a spot which is very painful, you can speak of Tietze’s syndrome. (Verdon et al., 2010, LOE: 2B; Hoogendoorn et al., 2004, LOE: 3B; Hurst,2001)

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.

Physical Therapy Management

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. (Hiramuro-shoji et al, 2003, LOE: 3B, Gerald, 2005, LOE: 2C) ( For now, trustworthy clinical studies on the treatment of Tietze's syndrome are lacking.(Verdon et al., 2010, LOE: 2B; Proulx et al., 2009,LOE:2A).

The physiotherapist can:

- Reassure the patient by explaining the condition. (Verdon et al., 2010, LOE: 2B; Proulx et al.,2009,LOE:2A)

- Instruct a good body position and give exercise advise. Patients need a good balance between exercise and rest. (Hurst,2001; Proulx et al.,2009,LOE:2A; Gregory et al.,2002, LOE:2A) 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. (Aeschlimann et al., 1990, LOE: 3A)

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. (Waldman et al., 2002)

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. (Rovetta et al., 2009, LOE 2B)

- Use heat/ cold pads and massage to help against the overloading of muscles and to lessen the pain. (Fam et al., 1985, LOE: 2A; Proulx et al.,2009,LOE:2A) 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. (Rovetta et al., 2009, LOE: 2B, Kayser, 1965, LOE:3A)

- Mobilize spine and ribs to avoid rigidity of the thorax and to reduce complaints. (Gregory et al.,2002, LOE:2A)
- Teach the patient breathing exercises http://www.physio-pedia.com/Respiratory_Muscle_Training
- Learn the patient to cope with pain. (Proulx et al.,2009,LOE:2A)
- Exercise for shoulder and back can be provocative, therefore only when the complaints have disappeared, they can be applied.

On the painful area they can use transcutaneous electrical stimulation and electroacupuncture. The acupuncture needle is placed within the involved spinal segment. Than low-frequency electrical currents are applied on the inserted needle. (Imamura, 2000)

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. (Richard et al, 2012, LOE:3B)

Key Research

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Resources

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Clinical Bottom Line

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References

1. Rovetta G., et al., Stretching exercises for costochondritis pain, G Ital Med Lav Ergon, 31(2):169-71, 2009. Level of evidence: 2B
2. Aeschlimann A., Kahn MF., Tietze's syndrome: a critical review, Clin Exp Rheumatol, 8(4):407-12, 1990. Level of evidence: 3A
3. Anthony S. Fauci, Carol A. Langford. Harrison’s rheumatology. Second edition. 2010. McGraw-Hill Education
4. 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. 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
Level of evidence: 2C
6. Frontera, W. R. (2015). Essentials of physial medicine and rehabilitation: muskuloskeletal disorders, pain, and reabilitation. Philadelphia: Elsevier. (p582-587)
7. Geddes A.K., Tietze’s syndrome, Can med assoc J, 53;571-3, 1945. Level of evidence: 3B
8. 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
9. 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
10. 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
Level of evidence: 3B
11. Hiramuro-shoji F., et al., Atraumatic conditions of the sternoclavicular joint, J shoulder elbow surg, 12:79-88, 2003. Level of evidence: 3B
12. 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
Level of evidence: 3B
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; 52(4):224–228.
Level of evidence: 3B
14. Hurst J.W., Morris D.C., Williams B.R. “Chest Pain” in patients with costochondritis or Tietze's syndrome, Wiley-Blackwell, 2001, p23-29
15. Imamura ST., et al., syndrome de tietze, Cossermeli W., Terapêutica em reumatologia, Sao Paulo, lemos editorial, p773-777, 2000.
16. Jensen Stochkendahl M, Wulff Christensen H., Chest pain in focal musculoskeletal disorders, Medical Clinics of North America;Elsevier,2010.
Level of evidence: 3A
17. Kayser HL., Tietze’s syndrome: review of the literature, Am J med, 21:982-9, 1965. Level of evidence: 3A
18. Lawless, C. E. (2011). sports cardiology essentials; evaluation, managment and case studies. springer.
19. Paulsen, F. (2011). Sobotta, Atlas of Human anatomy. Elsevier.
20. Proulx A.M., Zryd T.W., Costochondritis; Diagnosis and Treatment, Am Fam Physician, 2009 Sep 15;80(6):617-20
Level of evidence: 2A
21. 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)
22. 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
23. 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
Level of evidence: 2B
24. 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
Level of evidence: 2B
25. Waldman SD. (2002). Tietze syndrome, in: Atlas of common pain syndromes. Philadelphia. P. 158-160
26. Wildman. (2011). Pain managment. Elsevier.