What is the pathophysiology, risk factors, and diagnosis of costochondritis?

Costochondritis: Pathophysiology, Risk Factors, and Diagnosis

Costochondritis is characterized by inflammation of the costochondral junctions or chondrosternal joints of the anterior chest wall, with the hallmark physical finding being tenderness to palpation of the affected joints. 1

Pathophysiology

• Costochondritis is primarily an inflammatory condition of the costochondral junctions of ribs or chondrosternal joints of the anterior chest wall 2
• The condition represents a form of musculoskeletal chest pain that accounts for approximately 42% of all nontraumatic musculoskeletal chest wall pain 1
• While it is inflammatory in nature, costochondritis is not typically infectious, distinguishing it from infectious costochondritis which involves pathogenic invasion of the cartilage and surrounding tissues 3
• The inflammatory process affects the junction between the ribs and their cartilage or between the cartilage and sternum, causing localized pain and tenderness 2

Risk Factors

• Female gender appears to be a significant risk factor, with women comprising approximately 69% of costochondritis cases 4
• Hispanic ethnicity has been associated with higher frequency of costochondritis 4
• Physical exertion, repetitive movements (such as lifting heavy objects), and severe coughing can precipitate costochondritis 3
• Anterior chest wall pain affects a significant percentage of those with axial spondyloarthritis and may be the first manifestation of disease in some patients 5
• Widespread pain syndromes may be associated with costochondritis, though only a minority of cases (approximately 8%) meet criteria for fibromyalgia 4

Clinical Presentation

• Pain is typically described as stinging (53%) or pressing (35.1%), and is commonly retrosternal (52%) or left-sided (69.2%) 1
• Symptoms often occur more than once daily (62.9%), with many patients experiencing chronic symptoms lasting >6 months (55.4%) 1
• Pain is typically reproducible with palpation of the affected costochondral joints 1
• Pain may be exacerbated by deep breathing, coughing, or movement, which is characteristic of pleuritic chest pain 5
• The condition is usually self-limiting, though some cases may persist as "atypical costochondritis" 6

Physical Examination Findings

• The hallmark physical finding is tenderness to palpation of the costochondral joints 1
• Systematic palpation of the costochondral joints should be performed to identify areas of tenderness 5
• Pain reproduction with palpation of the affected area is the key diagnostic feature 5
• Absence of friction rub helps differentiate costochondritis from pleural or pericardial involvement 5
• For patients with pain over ribs 6 and 7, careful examination should focus on these specific costochondral junctions 1

Diagnostic Approach

• Costochondritis is often a diagnosis of exclusion, requiring serious causes of chest pain to be ruled out first 6
• For patients older than 35 years or with cardiac risk factors, an ECG should be obtained to rule out cardiac causes 5
• Chest radiography may be useful as an initial imaging test to evaluate for specific etiologies or conditions that may simulate chest wall pain 5
• Ultrasound can be helpful in detecting costochondral abnormalities not visible on radiographs, with higher sensitivity than CT for detecting costochondral involvement 5
• Bone scintigraphy may be useful for the evaluation of patients with undifferentiated costochondral pain and swelling, as it is a highly sensitive indicator of osseocartilaginous disease, though its specificity is insufficient for differentiating inflammatory processes from bone tumors 7
• CT shows higher sensitivity (92.3% versus 84.6%) and specificity (64.3% versus 35.7%) for differentiating primary chest wall tumors from Tietze syndrome as an etiology of costochondral junction pain and swelling 7
• Laboratory tests are typically normal in uncomplicated costochondritis, though elevated sedimentation rates may be observed (mean 44 mm/h in one study) 4

Differential Diagnosis

• Coronary artery disease must be considered, as it is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 2
• Tietze syndrome, which involves localized inflammation of at least one joint between the rib and costal cartilage, often with visible swelling 7
• Slipping rib syndrome, characterized by pain associated with ribs subluxing from the joint 7
• Precordial catch syndrome (Texidor's twinge), characterized by brief, sharp discomfort associated with inspiration 7
• Infectious costochondritis, which typically develops when an infection spreads from a postoperative wound or adjacent foci 3
• SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis), a chronic, relapsing condition that often involves the sternoclavicular joints 7

Key Diagnostic Pearls

• History and physical examination documenting reproducible pain by palpation over the costal cartilages are usually sufficient for diagnosis in children, adolescents, and young adults 2
• Pain that is reproducible with chest wall palpation suggests musculoskeletal origin but does not completely rule out serious conditions 5
• Anginal pain from coronary artery disease is usually described as pressure or heaviness rather than sharp or stabbing, helping differentiate it from costochondritis 5
• The acute myocardial infarction rate is significantly lower in patients with costochondritis (6%) compared to other chest pain patients (28%) 4