What is the diagnostic approach for costochondritis?

Diagnosis of Costochondritis

Costochondritis is primarily diagnosed through a careful physical examination, with localized tenderness over the costochondral junctions being the key diagnostic finding, without the need for diagnostic imaging in most cases. 1

Clinical Presentation and Diagnostic Approach

History

• Anterior chest wall pain that:
  • Worsens with movement, deep breathing, or coughing
  • May be sharp, aching, or pressure-like
  • Typically affects multiple ribs (most commonly 2nd to 5th costochondral junctions)
  • Often unilateral but can be bilateral
  • Duration typically ranges from days to weeks

Physical Examination

• Key diagnostic finding: Reproducible tenderness on palpation of affected costochondral junctions 1, 2
• Pain reproduction with movement of upper body or arms
• Absence of overlying skin changes (erythema, warmth) in non-infectious cases
• No crepitus or swelling in typical cases

Differential Diagnosis

Before diagnosing costochondritis, rule out serious causes of chest pain:

• Cardiac conditions (myocardial infarction, angina)
• Pulmonary conditions (pulmonary embolism, pneumonia, pneumothorax)
• Gastrointestinal conditions (esophageal reflux, esophageal spasm)
• Musculoskeletal conditions (rib fracture, intercostal muscle strain)

Diagnostic Algorithm

1. Initial evaluation:

   • Focused history and physical examination with palpation of chest wall
   • If tenderness is reproducible over costochondral junctions and no red flags present → diagnosis of costochondritis likely

2. For patients >35 years or with cardiac risk factors:

   • ECG and possibly chest radiograph to rule out cardiac causes 2
   • Consider cardiac workup if clinically indicated by age or risk factors

3. For patients with atypical features or red flags:

   • Fever, localized swelling, erythema → consider infectious costochondritis 3
   • Trauma history → consider rib fracture
   • Persistent symptoms despite treatment → consider further evaluation

Role of Imaging

• Chest radiography: Not routinely needed but may help rule out other conditions 1
• CT scan: Not indicated for uncomplicated costochondritis 1
• Bone scintigraphy: Not recommended as it lacks specificity for costochondritis diagnosis 4
  • A study showed that both patients with clinically diagnosed costochondritis and control subjects showed increased technetium uptake at costochondral junctions 4

Special Considerations

Infectious vs. Non-infectious Costochondritis

• Infectious costochondritis is rare but serious
• Suspect if fever, localized swelling, erythema, or purulent discharge present 3
• May require imaging (CT/MRI) and cultures to confirm diagnosis

Atypical Costochondritis

• Consider when symptoms persist beyond expected timeframe (>6 weeks)
• May benefit from referral to physical medicine and rehabilitation for specialized evaluation 5

Tietze Syndrome vs. Costochondritis

• Tietze syndrome: costochondritis with visible swelling at the affected joint
• Costochondritis: no visible swelling

Common Pitfalls in Diagnosis

1. Failure to exclude cardiac causes: Always consider cardiac etiologies in patients with risk factors
2. Over-reliance on imaging: Diagnosis is primarily clinical; imaging rarely changes management in uncomplicated cases
3. Missing infectious costochondritis: Can lead to serious complications if not identified and treated promptly
4. Attributing all chest wall pain to costochondritis: Consider full differential diagnosis

In summary, costochondritis remains a clinical diagnosis based on reproducible tenderness over costochondral junctions, with imaging studies primarily used to exclude other conditions rather than to confirm the diagnosis.