How do you diagnose costochondritis?

Diagnosing Costochondritis

Costochondritis is diagnosed primarily through physical examination, with the hallmark finding being reproduction of pain on palpation of the affected costochondral junctions, without the need for diagnostic imaging in most cases. 1

Diagnostic Approach

Clinical Evaluation

• Key Physical Examination Finding:
  • Focal tenderness over specific rib cartilage junctions that reproduces the patient's pain 1
  • Pain typically located at the costochondral or chondrosternal junctions, most commonly affecting the 3rd-7th ribs 2

Differential Diagnosis

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

1. Cardiac Causes:

   • ECG should be performed in all patients >35 years or with cardiac risk factors 1
   • Note that coronary artery disease can be present in 3-6% of adults with chest wall tenderness 2

2. Pulmonary Causes:

   • Consider pneumothorax, pulmonary embolism, or pneumonia 1

3. Other Musculoskeletal Conditions:

   • Tietze's syndrome (distinguished by visible swelling at the costochondral junction) 1
   • Herpes zoster 1
   • Infectious osteomyelitis 1

Diagnostic Testing

• For young, otherwise healthy patients:

  • Physical examination alone is usually sufficient 1

• For patients >35 years or with cardiac risk factors:

  • ECG (mandatory) 1
  • Chest radiography (to exclude other pathologies) 1

• When malignancy or infection is suspected:

  • Advanced imaging such as ultrasound, MRI, or CT may be considered 1
  • Bone scintigraphy is highly sensitive for detecting costochondral inflammation but lacks specificity 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 (possible pneumothorax) 1

Diagnostic Algorithm

1. Perform careful palpation of the chest wall to identify tender costochondral junctions
2. If pain is reproduced with palpation in a young, healthy patient without risk factors → diagnose costochondritis
3. If patient is >35 years or has cardiac risk factors → perform ECG and consider chest X-ray
4. If any cardiopulmonary symptoms are present → perform appropriate cardiac and pulmonary evaluation
5. If diagnostic uncertainty remains or if symptoms are severe/persistent → consider advanced imaging

Common Pitfalls to Avoid

• Missing cardiac causes: Never assume chest pain is costochondritis without appropriate cardiac evaluation in at-risk patients
• Overdiagnosis: Avoid labeling all chest wall pain as costochondritis without proper examination
• Delayed diagnosis: Be aware that costochondritis is often a diagnosis of exclusion 3
• Inadequate follow-up: Persistent symptoms may require reevaluation, as chronic costochondritis (lasting >2-3 months) is considered atypical 3

Remember that costochondritis is typically self-limiting but can become chronic in some cases, with studies showing that up to 55% of patients may still experience chest pain one year after diagnosis 4.