What is the management and treatment of Tietze's disease (costochondritis)?

Management and Treatment of Tietze's Syndrome (Costochondritis)

The most effective treatment for Tietze's syndrome is a combination of oral corticosteroids and NSAIDs, which significantly improves pain and quality of life compared to NSAIDs alone. 1

Diagnosis and Clinical Presentation

Tietze's syndrome is a benign, self-limiting inflammatory condition affecting the costochondral, sternoclavicular, or costosternal joints, characterized by:

• Localized pain and tenderness at the costochondral junctions (typically ribs 3-7)
• Swelling at the affected joint (distinguishing it from simple costochondritis)
• Pain that may mimic more serious conditions like cardiac, pulmonary, or abdominal disorders
• Absence of purulent character 2

Diagnostic Approach

1. Physical examination:

   • Tenderness on palpation of costochondral joints 3
   • Focal swelling at the affected joint
   • Pain reproduction with palpation

2. Imaging studies (when diagnosis is uncertain):

   • Ultrasound: Higher sensitivity (92.3%) and specificity (64.3%) than other modalities for differentiating Tietze's syndrome from chest wall tumors 3
   • CT scan: May help exclude other serious conditions but has lower specificity for Tietze's syndrome 3
   • Bone scan: Highly sensitive for detecting inflammatory conditions but insufficient specificity for differentiating Tietze's syndrome from bone tumors 3

Treatment Algorithm

First-Line Treatment

1. Pharmacological therapy:

   • Oral corticosteroids + NSAIDs: Prednisolone 40 mg daily for 1 week, followed by 20 mg daily for 1 week, then 10 mg daily for 1 week, combined with NSAIDs for 3 weeks 1
   • This combination provides superior pain relief (65.4% reduction vs. 46.7% with NSAIDs alone) and improved quality of life 1

2. Non-pharmacological interventions:

   • Stretching exercises: Progressive stretching of the chest wall muscles has shown significant improvement in pain compared to conventional treatment alone 4
   • Local heat application: Provides symptomatic relief

Second-Line Treatment

1. Injection therapy (for refractory cases):
   • Ultrasound-guided corticosteroid injection: Direct injection into the affected costochondral joint 5
   • Provides rapid pain relief and reduction in swelling

Third-Line Treatment

1. Surgical intervention (rarely needed):
   • Reserved for cases resistant to all conservative measures 2

Duration of Treatment and Follow-up

• Tietze's syndrome is typically self-limiting but may persist for weeks to months
• Benefits of steroid treatment extend beyond the treatment period, with significant differences in pain scores maintained at 6.5 months post-treatment 1
• Follow-up should be scheduled at 3 weeks after initiating treatment to assess response

Differential Diagnosis

Important conditions to rule out include:

• Acute coronary syndrome
• Pulmonary embolism
• Aortic dissection
• Pneumothorax
• Pneumonia
• Esophageal disorders
• Herpes zoster 3

Clinical Pearls and Pitfalls

Pearls:

• Pain relief with local anesthetic infiltration can be both diagnostic and therapeutic 6
• Improvement in pain and quality of life may occur even without visible resolution of joint swelling 1

Pitfalls:

• Mistaking Tietze's syndrome for a serious cardiopulmonary condition, leading to unnecessary testing
• Failing to distinguish between simple costochondritis (no swelling) and Tietze's syndrome (with swelling)
• Delaying appropriate treatment, which can prolong patient discomfort

Special Considerations

• Tietze's syndrome may be associated with SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis) in some cases 3
• Consider referral to a specialist center for difficult-to-treat cases, especially when diagnosis remains uncertain 3
• Patients should be informed that symptoms may recur in the future, even after successful treatment 3