What is Costochondritis?
Costochondritis is an inflammatory condition of the costochondral junctions (where ribs meet cartilage) or chondrosternal joints of the anterior chest wall that causes localized chest pain reproducible by palpation over the affected costal cartilages 1.
Clinical Characteristics
Costochondritis is the most common cause of nontraumatic musculoskeletal chest wall pain, accounting for approximately 42% of cases 2. The condition presents with:
- Anterior chest wall pain that is sharp, stinging (53%), or pressing (35.1%)
- Tenderness on palpation of the affected costochondral or chondrosternal joints—this reproducible pain is the diagnostic hallmark
- Location: Most commonly retrosternal (52%) or left-sided (69.2%), with the left fourth sternocostal cartilage being the most frequently involved site 3
- Duration: More than half of patients experience chronic symptoms lasting >6 months 2
Demographics and Risk Factors
The condition shows distinct demographic patterns:
- Women are disproportionately affected (69% of cases) 4
- Hispanic populations have higher prevalence (47% vs 24% in controls) 4
- Can occur across all age groups, from adolescents 3 to older adults
Pathophysiology
Costochondritis is typically a benign, self-limited inflammatory condition—not an infection 5. The inflammation affects the cartilaginous structures of the chest wall without the swelling that characterizes Tietze syndrome (a related but distinct entity with visible swelling) 2.
Important Clinical Distinctions
Rule Out Cardiac Disease First
While costochondritis is usually benign, coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 1. The acute myocardial infarction rate is lower in costochondritis patients (6% vs 28% in other chest pain patients), but cardiac causes must still be excluded 4.
For patients >35 years, those with cardiac risk factors, or any patient with cardiopulmonary symptoms, obtain an ECG and possibly chest radiograph before attributing pain solely to costochondritis 1.
Infectious Costochondritis
Rare infectious forms exist, typically from:
- Direct spread from postoperative wounds
- Hematogenous seeding (Pseudomonas aeruginosa 5, Salmonella 6, tuberculosis 7)
- These require imaging (CT/MRI) and targeted antibiotic therapy, sometimes with surgical debridement
Diagnosis
The diagnosis is primarily clinical 1:
- Reproducible pain by palpation over costal cartilages
- No imaging required in children, adolescents, and young adults with typical presentation
- Physical examination documenting tenderness at costochondral junctions is usually sufficient
When to Image
Imaging is indicated when 2:
- Suspected infection (fever, purulent drainage, immunocompromised state)
- Concern for malignancy
- Atypical presentation
- Failure to respond to conservative treatment
- Bone scintigraphy is 100% sensitive for sternoclavicular joint inflammation and useful for screening occult disease
- CT better characterizes deep compartments and osseous involvement
- MRI shows high intensity on fat-suppressed T2-weighted images in inflammatory areas
Associated Conditions
Costochondritis may be:
- An early manifestation of spondyloarthritis (affects 30-60% of patients with axial spondyloarthritis) 2
- Associated with SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis) 2
- Linked to fibromyalgia in only 8% of cases 4
- Post-viral (including post-COVID-19) 8
Treatment and Prognosis
Treatment is conservative 1:
- Acetaminophen or NSAIDs (where safe and appropriate)
- Avoid activities causing chest muscle overuse
- Reassurance about the benign nature
Prognosis: Most cases are self-limited, though at 1-year follow-up, 55% of patients still report chest pain, with only one-third having persistent definite costochondritis 4. Spontaneous resolution occurs in most cases.
Key Clinical Pitfalls
- Do not assume all reproducible chest wall pain is benign costochondritis—cardiac disease coexists in a small but significant percentage
- Elevated inflammatory markers (ESR mean 44 mm/h) can occur with costochondritis and do not necessarily indicate infection 4
- Persistent or worsening symptoms warrant imaging to exclude infectious, neoplastic, or rheumatologic causes
- Unilateral left-sided pain is more common than bilateral, which can mimic cardiac pain 3