What is Tietze's syndrome?

Tietze's Syndrome: Diagnosis and Management

Tietze's syndrome is a musculoskeletal condition characterized by painful, localized inflammation with visible swelling at the costochondral junction, typically affecting the second and third ribs. 1

Clinical Presentation

• Key diagnostic features:

  • Localized pain and swelling at costochondral, sternoclavicular, or sternocostal joints
  • Visible swelling of the affected joint (distinguishing it from simple costochondritis)
  • Most commonly affects the second and third ribs on one side
  • Pain may be exacerbated by movement, coughing, or deep breathing

• Associated symptoms:

  • Tenderness over the affected area
  • Self-limiting inflammatory process
  • No purulent characteristics
  • May cause significant chest pain affecting daily activities 2

Diagnostic Approach

Physical Examination

• Tenderness of costochondral joints is the hallmark finding 1
• Visible swelling at the affected joint (distinguishing feature from costochondritis)
• Pain reproduction with palpation of the affected area

Laboratory Tests

• Inflammatory markers may be elevated
• No specific laboratory test confirms the diagnosis 2

Imaging Studies

• Initial imaging:
  • Chest X-ray is typically normal but helps exclude other conditions
  • CT has higher sensitivity (92.3%) and specificity (64.3%) for differentiating Tietze's syndrome from primary chest wall tumors 3
  • Bone scintigraphy is highly sensitive but has insufficient specificity for differentiating Tietze's syndrome from other bone tumors 1
  • MRI may confirm the diagnosis by showing inflammatory changes 4

Differential Diagnosis

Tietze's syndrome must be distinguished from:

1. Life-threatening conditions:

   • Acute coronary syndrome
   • Pulmonary embolism
   • Aortic dissection
   • Pneumothorax

2. Other musculoskeletal conditions:

   • Costochondritis (similar but without swelling)
   • Rheumatoid arthritis
   • Psoriatic arthritis
   • Ankylosing spondylitis

3. Infectious causes:

   • Infectious osteomyelitis (consider when systemic symptoms, fever, elevated inflammatory markers are present) 1

4. Neoplastic conditions:

   • Primary chest wall tumors (consider when swelling increases in size during follow-up) 3

Management

First-Line Treatment

• NSAIDs for 2-3 weeks to reduce inflammation and pain 5
• Local heat application
• Activity modification to avoid pain triggers

Second-Line Treatment

• Oral corticosteroids show significant benefit in improving pain and quality of life:
  • Prednisolone 40 mg daily for 1 week
  • Then 20 mg daily for 1 week
  • Then 10 mg daily for 1 week
  • Combined with NSAIDs for 3 weeks 5
  • This regimen showed 65.4% reduction in pain scores vs. 46.7% with NSAIDs alone at 3 weeks 5

Refractory Cases

• Local corticosteroid injections may be considered
• Surgical management through resection of involved cartilage and adjacent rib may be necessary in severe, medically refractory cases 6

Prognosis and Follow-up

• Generally benign and self-limiting condition

• Most patients improve with conservative treatment

• Regular follow-up is important to monitor for:

  • Response to treatment
  • Increasing size of swelling (may indicate underlying tumor)
  • Need for additional interventions

• Warning sign: If swelling doubles in size during follow-up, reevaluation with chest CT and early diagnostic biopsy should be considered to rule out primary chest wall tumors 3

Special Considerations

• Tietze's syndrome has been reported following COVID-19 infection 4
• Persistent symptoms despite appropriate treatment should prompt reevaluation for alternative diagnoses
• Bone scintigraphy and CT are not specific enough to definitively distinguish between Tietze's syndrome and malignant conditions 3