Is this physical exam finding consistent with costochondritis?

Physical Exam Findings Consistent with Costochondritis

The physical exam finding of reproducible cartilaginous point tenderness at T4-T5 anteriorly is highly consistent with costochondritis, especially with normal strength, no deformities, and absence of other concerning findings. 1

Diagnostic Features of Costochondritis

Costochondritis is characterized by:

• Reproducible tenderness over costochondral junctions or chondrosternal joints
• Absence of swelling or erythema (which would suggest Tietze's syndrome)
• Normal muscle strength and tone
• Absence of joint effusions or other deformities
• No subcutaneous emphysema, crepitus, or paradoxical rib cage movements

The physical exam described shows:

• Reproducible cartilaginous point tenderness at T4-T5 anteriorly
• Normal strength (5/5 bilaterally)
• No obvious deformities
• Normal gait and station
• Good muscle tone
• No joint pain or effusion
• No subcutaneous emphysema or crepitus
• No paradoxical rib cage deformity or movements

These findings align perfectly with the diagnostic criteria for costochondritis 2, 1.

Diagnostic Approach

According to the American College of Radiology guidelines, costochondritis is readily diagnosed by physical examination without the need for diagnostic imaging in most cases 2. The hallmark finding is reproduction of pain with palpation of the affected costochondral junctions, which is present in this case.

The American College of Cardiology notes that costochondritis accounts for approximately 42% of nontraumatic musculoskeletal chest wall pain 2, 1.

Differential Diagnosis to Consider

While the findings strongly suggest costochondritis, it's important to rule out other conditions:

1. Tietze's syndrome: Distinguished from costochondritis by the presence of swelling at the costochondral junction (not present in this case) 1

2. Cardiac causes: Should be excluded, especially in patients >35 years or with cardiac risk factors 1, 3

3. Pulmonary causes: Such as pneumothorax, pulmonary embolism, or pneumonia (no evidence in this exam) 2

4. Infectious causes: Osteomyelitis typically presents with systemic symptoms (not described here) 1

Management Implications

The physical exam findings support a diagnosis of costochondritis, which typically warrants:

1. First-line treatment: NSAIDs for 1-2 weeks 1, 3
2. Alternative options: Acetaminophen or nonacetylated salicylates if NSAIDs are contraindicated 1
3. Physical therapy: Stretching exercises have shown significant improvement in pain reduction 4
4. Activity modification: Avoiding activities that produce chest muscle overuse 3

Clinical Course

Costochondritis is typically self-limiting, with most cases resolving within weeks to months. However, some cases may become chronic (atypical costochondritis) 5. In one study, 55% of patients still had chest pain at one-year follow-up, though only one-third still had definite costochondritis 6.

Key Takeaway

The physical exam finding of reproducible cartilaginous point tenderness at T4-T5 anteriorly, combined with normal strength and absence of other concerning findings, is highly consistent with a diagnosis of costochondritis. This condition can typically be diagnosed clinically without advanced imaging when the characteristic reproducible tenderness is present on examination.