How do you diagnose costochondritis?

Diagnosing Costochondritis

Costochondritis is primarily diagnosed through clinical examination showing tenderness of costochondral joints, without the need for imaging in most cases. 1, 2

Clinical Examination

• Key diagnostic criteria:

  • Localized pain and tenderness at costochondral, sternocostal, or sternoclavicular joints 2
  • Pain reproducible by palpation of the affected area 3
  • Most commonly involves the 2nd-3rd costochondral junctions 2
  • Absence of visible swelling (distinguishes from Tietze's syndrome, which presents with swelling) 2

• Physical examination findings:

  • Direct palpation of costochondral joints elicits tenderness 1
  • Pain typically worsens with deep breathing, coughing, or trunk movements 2
  • Examination is otherwise normal in uncomplicated cases 1

Differential Diagnosis

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

1. Cardiac causes:

   • ECG should be performed, especially in patients >35 years or with cardiac risk factors 3, 1
   • Patients with ACS may present with diaphoresis, tachypnea, tachycardia, hypotension 1

2. Pulmonary causes:

   • Pulmonary embolism: typically presents with tachycardia, dyspnea, pain with inspiration 1
   • Pneumothorax: presents with dyspnea, pleuritic pain, unilateral absence of breath sounds 1
   • Pneumonia: presents with fever, localized chest pain, regional dullness to percussion 1

3. Other musculoskeletal causes:

   • Tietze's syndrome: similar to costochondritis but with visible swelling 2
   • Herpes zoster: pain in dermatomal distribution with characteristic rash 1

Diagnostic Approach

1. Initial assessment:

   • Detailed history focusing on pain characteristics, aggravating/relieving factors
   • Physical examination with reproduction of pain on palpation of costochondral joints

2. For patients <35 years without cardiac risk factors:

   • If physical examination confirms reproducible tenderness over costochondral joints
   • And no concerning symptoms (fever, dyspnea, etc.)
   • Diagnosis can be made clinically without further testing 3

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

   • ECG (within 10 minutes of presentation) 2, 3
   • Consider chest radiography to exclude other pathologies 1, 2
   • Further cardiac testing if clinically indicated 3

Imaging Studies

• Chest radiography:

  • Should be normal in costochondritis 2
  • Used primarily to exclude other conditions 1, 2
  • Not required for diagnosis in young, otherwise healthy patients 3

• Advanced imaging:

  • Generally not needed for diagnosis 1
  • Consider if malignancy or infection is suspected 2
  • Ultrasound may be more sensitive than CT for chest wall involvement 2
  • Bone scintigraphy is highly sensitive but lacks specificity 2

Important Considerations

• Costochondritis is a diagnosis of exclusion 4
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 3
• Red flags requiring immediate attention: severe shortness of breath, hypotension, tachycardia, fever with purulent sputum 2
• Elderly patients may have atypical presentations and require higher suspicion for serious conditions 2

By following this diagnostic approach, costochondritis can be accurately diagnosed while ensuring that more serious causes of chest pain are not missed.