Costochondritis is caused by inflammation at the cartilage of the chest wall, where the ribs meet the sternum, causing chest pain that can last for a few days up to a few weeks; it is called a "self-limited" disease since it usually resolves on its own. The most critical issue in diagnosing costochondritis is ruling out more serious causes of chest wall pain, including cardiac (heart) causes.
What are the chest wall structures involved in costochondritis?
Costochondritis comes from the English words “costo," meaning anatomy or ribs, "chondral," referring to cartilage, and "itis," meaning inflammation. Thus, costochondritis is inflammation (swelling) at the joint where the ribs meet the cartilage of the sternum (breastbone).
How common is costochondritis?
Even though the epidemiology (statistics) is not well established, a study done in the Annals of Internal Medicine found that 30% of adult emergency room visits for chest pain were due to costochondritis.
What are the symptoms of costochondritis?
Understanding the difference between chest pain from costochondritis and chest pain from cardiac (heart) causes is crucial. However, if you are experiencing chest pain, and are unsure, seek immediate medical attention.
In costochondritis, the pain worsens with specific movements and positions, whereas cardiac pain is not affected by movement or position. Occasionally, costochondritis pain occurs with a deep breath, cough, or sneeze. Both cardiac and costochondritis pain can be dull or sharp.
The best way to determine the difference between chest pain of cardiac origin vs. costochondritis (or other musculoskeletal disorders) is to place pressure on the area where the pain originates. If pressure on that site causes the same pain, it is called reproducible, which usually means the cause of the pain is musculoskeletal.
To be thorough, we will mention other symptoms of cardiac pain, including nausea, vomiting, shortness of breath, pain on exertion, fever, and cough.
What causes costochondritis?
There is no clear-cut identifiable cause of costochondritis, but it is associated with several conditions, including autoimmune disorders, physical strain, or chest wall trauma.
What is Tietze syndrome, and how is it related to costochondritis?
Tietze syndrome is a rare condition that causes sudden onset of sharp chest wall pain; however, there are differences from costochondritis. First, costochondritis mainly affects people over forty, while Tietze syndrome usually affects those younger than forty. Second, costochondritis can occur in more than one location, while Tietze syndrome usually occurs in just one place. Third, costochondritis affects ribs 2-5, while Tietze affects ribs 2-3. Finally, costochondritis is without swelling, while Tietze syndrome includes swelling.
What is the diagnostic workup for chest wall pain?
- The history is taken to learn about recent illnesses, coughing, sneezing, or strenuous physical activity.
- A physical exam with particular attention to the heart, lungs, and the painful area.
- Complete blood work is recommended. In addition, troponin, a cardiac biomarker, is a sensitive and specific test currently used to detect cardiac ischemia (heart attack).
- An electrocardiogram (EKG) is valuable for checking the heart's electrical functioning, including rate and rhythm. When there is a lack of blood flow to certain areas of the heart (ischemia), it usually shows up on EKG.
- Plain x-rays of the chest and ribs. The chest x-ray (CXR) will show the heart, lungs, and ribs; however, a set of specialized rib x-rays may be done. Plain x-rays evaluate for bony abnormalities, including fracture, osteoarthritis, rheumatoid arthritis, osteoporosis (thinning of the bones), and sometimes joint inflammation can be visualized.
- Computed tomography (CT or CAT) scans evaluate soft tissue structures not seen on x-rays, including the muscles, tendons, and ligaments. The CT scans take cross-sectional images and produce three-dimensional (3D) views.
- An echocardiogram (cardiac echo or just echo) is a special ultrasound that helps evaluate the heart's functioning in real time. It shows the contraction of the heart muscle and blood flow.
What is the treatment of costochondritis?
Medications. Over-the-counter acetaminophen (Tylenol) can help with the pain but needs to be used carefully since liver disease can result from excessive use.
Nonsteroidal anti-inflammatory drugs (NSAIDs) decrease inflammation by inhibiting the chemicals that cause inflammation. Furthermore, NSAIDs help with swelling and chronic pain.
NSAIDs can be by prescription or by taking a high enough dose of over-the-counter (OTC) strength. Over-the-counter NSAIDs include aspirin, ibuprofen (Advil), and naproxen (Aleve). In addition, numerous prescription NSAIDs are being used today, such as Celebrex, Voltaren (diclofenac), Ansaid, Meloxicam, and others. However, caution must be used with all NSAIDs since they can cause gastrointestinal (GI) irritation, leading to stomach ulcers and bleeding.
Several anti-depressant medications are used for chronic pain, especially if the pain interferes with sleep. One example is amitriptyline, brand name Elavil.
Physical therapy (PT) can help, especially if there is poor posture or body mechanics (functioning). In addition, PT can use modalities such as electrical stimulation and ultrasound to help relieve symptoms.
Minimize the activities that cause the costochondritis pain. If something you are doing is causing or aggravating the pain, we recommend you cease that activity.
Hot and cold therapy can be highly effective. The old-fashioned theory is to use ice for the first 24 hours, then use heat, which still is valid for the first 24 hours. However, after the first 24 hours, some people still respond better to ice as opposed to heat.
In rare cases, which do not respond to the above treatments or resolve independently, an injection directly into the site can help. The injection is usually a mixture of a numbing agent, like lidocaine, combined with a corticosteroid.
A rib belt is a special kind of brace, similar to a low back brace but not as thick; it can be helpful to provide support until the symptoms subside.
Costochondritis is caused by inflammation where the rib’s cartilage and sternum (breastbone) meet; its cause is unknown.
The most important part of the costochondritis workup and diagnosis is differentiating it from more serious conditions, such as cardiac (heart) issues.
The diagnostic workup of costochondritis includes lab work (for cardiac issues), plain x-rays, an electrocardiogram (EKG), and an occasional echocardiogram (echo).
Costochondritis usually resolves on its own; however, some cases require treatment with medications, ice, heat, physical therapy, and a support brace (rib belt).
Disla, E., H. R. Rhim, A. Reddy, I. Karten, and A. Taranta, ‘Costochondritis. A Prospective Analysis in an Emergency Department Setting’, Archives of Internal Medicine, 154.21 (1994), 2466–69 <https://doi.org/10.1001/archinte.154.21.2466>
Proulx, Anne M., and Teresa W. Zryd, ‘Costochondritis: Diagnosis and Treatment’, American Family Physician, 80.6 (2009), 617–20
Schumann, Jessica A., Tanuj Sood, and John J. Parente, ‘Costochondritis’, in StatPearls (Treasure Island (FL): StatPearls Publishing, 2022) <http://www.ncbi.nlm.nih.gov/books/NBK532931/> [accessed 17 September 2022]