Investigations for Tietze Syndrome
Primary Diagnostic Approach
The diagnosis of Tietze syndrome is primarily clinical, based on physical examination findings of tenderness to palpation of the costochondral joints (typically the second and third ribs), with imaging studies reserved for ruling out alternative diagnoses or when the presentation is atypical. 1
Essential Physical Examination
- Palpate the costochondral joints systematically to identify localized tenderness, which is the hallmark finding that distinguishes Tietze syndrome from other causes of chest pain 1, 2
- Assess for visible or palpable swelling at the affected costochondral junction, as this differentiates Tietze syndrome from simple costochondritis (which lacks swelling) 3
- Focus examination on the second and third costochondral junctions, as these are the most commonly affected sites, though ribs 6-7 should also be examined 4, 2
- Reproduce the pain with direct palpation of the affected joint to confirm the musculoskeletal origin 2
Laboratory Testing
- Laboratory studies are not useful for establishing the diagnosis of Tietze syndrome, though inflammatory markers (CRP, ESR) may be elevated and support the inflammatory nature of the condition 1, 3
- Routine labs are primarily valuable for excluding other diagnoses rather than confirming Tietze syndrome 3
Electrocardiogram
- An ECG should be obtained to exclude acute coronary syndrome, particularly in patients presenting with chest pain where cardiac etiology has not been definitively ruled out 1
- The ECG should be acquired and reviewed within 10 minutes of presentation in acute settings 1
Imaging Studies
When to Image
- Imaging is not required for typical presentations where physical examination clearly demonstrates localized costochondral tenderness with swelling 3
- Obtain imaging when the diagnosis is uncertain, symptoms are severe or refractory, or when swelling increases over time 5
Imaging Modalities
Ultrasound is the preferred initial imaging modality when visualization is needed, as it can demonstrate costochondral joint swelling and guide therapeutic injections 6
Ultrasound has demonstrated utility in both diagnosis and treatment guidance, showing swelling of the affected costochondral joint 6
CT chest should be performed in patients with atypical features or when alternative diagnoses need exclusion, though it has only 92.3% sensitivity and 64.2% specificity for detecting chest wall tumors that may mimic Tietze syndrome 5
CT is particularly important for patients in whom swelling size doubles during follow-up, as this raises concern for underlying chest wall tumor 5
MRI can be used as an alternative imaging modality to visualize soft tissue inflammation and cartilage involvement 3
Bone scintigraphy has poor specificity (35.7%) for distinguishing Tietze syndrome from other chest wall pathology and should not be relied upon as a primary diagnostic tool 5
Critical Pitfall to Avoid
- Patients initially diagnosed with Tietze syndrome who show increasing swelling size over follow-up (mean 8.5 months) require re-evaluation with imaging and early diagnostic biopsy, as primary chest wall tumors (both benign and malignant) can mimic Tietze syndrome 5
- In one series, 13 of 27 patients (48%) with increasing swelling initially diagnosed as Tietze syndrome were ultimately found to have primary chest wall tumors (5 malignant, 8 benign) 5
Differential Diagnosis Considerations
- Physical examination findings help distinguish Tietze syndrome from other causes: tenderness of costochondral joints suggests Tietze syndrome (M94.0), while reproducible pain without joint-specific tenderness suggests myalgia (M79.1) 7
- Chest pain with inspiration markedly reduces the probability of acute coronary syndrome, supporting a musculoskeletal diagnosis 1