What causes costochondritis?

Causes of Costochondritis

Costochondritis is primarily caused by inflammation of one or more ribs and/or cartilages, which can result from physical exertion, repetitive movements, severe coughing, or in rare cases, infection. 1

Primary Causes

Non-infectious Causes (Most Common)

• Physical/Mechanical Factors:
  • Repetitive movements (especially lifting heavy objects)
  • Physical exertion or overuse of chest muscles
  • Severe or prolonged coughing episodes 1, 2
  • Trauma to the chest wall 3
  • Rib dysfunction requiring manipulation 4

Infectious Causes (Less Common)

• Direct Infection:
  • Bacterial infection (e.g., Pseudomonas aeruginosa) 2
  • Spread from postoperative wounds or adjacent tissues
  • Rarely occurs without spread from adjacent tissues 2

Other Contributing Factors

• Inflammatory Conditions:
  • Systemic inflammatory disorders
  • Autoimmune conditions that can affect cartilage 5
  • Relapsing polychondritis (rare autoimmune disorder affecting cartilage) 5

Pathophysiology

Costochondritis involves inflammation at the junction between:

• The ribs and their costal cartilages (costochondral junctions)
• The costal cartilages and the sternum (chondrosternal joints) 3

The inflammation causes localized pain and tenderness that can be reproduced by palpation of the affected area. This is the hallmark diagnostic finding for costochondritis 1.

Epidemiology

• Accounts for approximately 42% of non-traumatic musculoskeletal chest wall pain 1
• Typically self-limiting in most cases, resolving within weeks 3
• When symptoms persist beyond the expected timeframe, it's termed "atypical costochondritis" 4

Diagnostic Approach

1. Physical Examination:

   • Reproduction of pain with palpation of affected costochondral junctions 1
   • Focal tenderness over specific rib cartilage junctions 5

2. Rule Out Serious Conditions:

   • Cardiac causes (especially in patients >35 years or with risk factors)
   • Pulmonary causes (pneumothorax, pulmonary embolism, pneumonia)
   • Gastrointestinal causes 1

3. Diagnostic Testing (when indicated):

   • ECG to exclude cardiac causes
   • Chest radiography to exclude other pathologies (especially in patients >35)
   • Advanced imaging (ultrasound, MRI, CT) if malignancy or infection is suspected 1

Management Considerations

1. First-Line Treatment:

   • NSAIDs for 1-2 weeks 1
   • Activity modification to avoid chest muscle overuse 3

2. For Persistent Pain:

   • Low-dose colchicine for severe pain 1
   • Stretching exercises (shown to significantly improve pain compared to standard care) 6
   • Manual therapy techniques including soft tissue mobilization 4

3. For Infectious Cases:

   • Appropriate antibiotics based on culture results
   • Surgical debridement may be necessary for infectious costochondritis 2, 7

Clinical Pearls and Pitfalls

• Important Distinction: Costochondritis differs from Tietze's syndrome, which involves localized inflammation at one or more joints between the rib and costal cartilage with associated swelling 5, 1

• Red Flags Requiring Immediate Attention:

  • Severe shortness of breath
  • Hypotension or tachycardia
  • Fever with purulent sputum
  • Signs of cardiac tamponade
  • Unilateral absence of breath sounds 1

• Key Pitfall: Remember that coronary artery disease can be present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 3