What is the approach to evaluating costochondral pain?

Examination of Costochondral Pain

The diagnosis of costochondral pain is primarily made through careful physical examination, with tenderness of the costochondral joints being the key diagnostic finding. 1

Physical Examination Approach

• Perform a focused cardiovascular examination initially to rule out serious causes of chest pain such as ACS, aortic dissection, pulmonary embolism, or esophageal rupture 1
• Palpate the costochondral joints systematically to identify areas of tenderness, which is the hallmark finding in costochondritis 1, 2
• Document reproducible pain by palpation over the costal cartilages, which is usually sufficient for diagnosis in younger patients 2
• Look for visible or palpable swelling at the costochondral junction, which may indicate Tietze syndrome (costochondritis with swelling) 3, 4
• Assess for pain exacerbation with deep breathing, coughing, or movement, which is characteristic of pleuritic chest pain 5
• Check for friction rub, which may indicate pleural or pericardial involvement rather than costochondral pain 5

Diagnostic Considerations

• For patients older than 35 years or with cardiac risk factors, obtain an ECG to rule out cardiac causes 1, 2
• Chest radiography may be useful as an initial imaging test to evaluate for specific etiologies (fractures, infection, neoplasm) or conditions that may simulate chest wall pain 1
• Ultrasound can be helpful in detecting costochondral abnormalities not visible on radiographs, with higher sensitivity than CT for detecting costochondral involvement 1, 3
• Consider rib series radiographs for focal chest wall pain to assess for rib fracture or other rib lesions 1
• Note that chest radiographs may be insensitive to detect abnormalities of the rib cartilages, costochondral junctions, and chest wall soft tissues 1

Distinguishing Features from Other Chest Pain

• Costochondritis pain is typically sharp, reproducible with palpation, and localized to the costochondral junctions 2
• Anginal pain from coronary artery disease is usually described as pressure or heaviness rather than sharp or stabbing 5
• Pleuritic pain worsens with respiration and may be accompanied by a pleural friction rub 5
• Pain that is reproducible with chest wall palpation suggests musculoskeletal origin but does not completely rule out serious conditions (7% of patients with reproducible pain on palpation may have acute coronary syndrome) 5

Important Caveats

• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 2
• Most (42%) nontraumatic musculoskeletal chest wall pain has been attributed to costochondritis 1
• Costochondritis is usually self-limited and benign but must be distinguished from more serious causes of chest pain 2
• Anterior chest wall pain affects 30-60% of those with axial spondyloarthritis and may be the first manifestation of disease in 4-6% of patients 1

Treatment Considerations

• Traditional treatment includes acetaminophen or anti-inflammatory medications, avoidance of activities that produce chest muscle overuse, and reassurance 2
• Stretching exercises have shown progressive significant improvement in patients with costochondritis compared to control groups 6
• For persistent cases (atypical costochondritis), consider manipulative therapy, instrument-assisted soft tissue mobilization, and stretching 7
• Ultrasound-guided corticosteroid injection may be beneficial in resistant cases, particularly for Tietze syndrome 3

By following this systematic approach to examining costochondral pain, clinicians can effectively diagnose this common condition while ensuring that more serious causes of chest pain are appropriately ruled out.