What is costochondritis?

What is Costochondritis?

Costochondritis is a benign, self-limited inflammatory condition of the costochondral junctions or chondrosternal joints of the anterior chest wall, characterized by reproducible tenderness to palpation of the affected joints. 1, 2

Definition and Pathophysiology

• Costochondritis represents inflammation of one or more ribs and/or their cartilages at the junction with the sternum 1
• It accounts for approximately 42% of all nontraumatic musculoskeletal chest wall pain 2, 3
• The hallmark physical finding is tenderness to palpation of the costochondral joints, which distinguishes it from other causes of chest pain 1, 2

Clinical Presentation

Pain characteristics:

• Pain is typically described as stinging (53%) or pressing (35.1%) in quality 2
• Location is commonly retrosternal (52%) or left-sided (69.2%) 2
• Symptoms often occur more than once daily (62.9%) 2
• Many patients experience chronic symptoms lasting more than 6 months (55.4%) 2

Key distinguishing features:

• Pain is reproducible with palpation of the affected costochondral joints 1, 2
• Chest tenderness on palpation markedly reduces the probability of acute coronary syndrome 1
• The condition is usually self-limited and benign 4

Differential Diagnosis

Tietze syndrome:

• Involves localized inflammation of at least one joint between the rib and costal cartilage 1, 3
• Distinguished by visible swelling at the affected joint, which is absent in simple costochondritis 3
• Both conditions present with tenderness of costochondral joints 1

Other musculoskeletal causes to consider:

• Slipping rib syndrome (ribs subluxing from the joint) 1, 3
• Rib injury or sternal injury from trauma 1
• Intercostal myofascial injury 1
• Precordial catch syndrome (Texidor's twinge) - brief, sharp discomfort with inspiration 1

Critical Diagnostic Considerations

When to suspect cardiac causes instead:

• Patients older than 35 years should have an ECG to rule out cardiac causes 3, 4
• Those with cardiac risk factors require ECG evaluation 3, 4
• Important caveat: 7% of patients with reproducible chest wall tenderness may still have acute coronary syndrome 5
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 4

Red flags requiring urgent evaluation:

• Diaphoresis, tachypnea, tachycardia, or hypotension suggest acute coronary syndrome 1
• Dyspnea with pain on inspiration may indicate pulmonary embolism 1, 5
• Fever with pleuritic chest pain suggests pericarditis, myocarditis, or pneumonia 1
• Unilateral absence of breath sounds indicates pneumothorax 1

Etiology

Common causes:

• Physical exertion and repetitive movements (such as lifting heavy objects) 6
• Severe coughing 6
• Chest muscle overuse 4

Rare infectious form:

• Infectious costochondritis usually develops when infection spreads from postoperative wounds or adjacent foci 6
• Can be associated with sternal osteomyelitis, particularly in diabetic patients 6
• Requires debridement and prolonged antibiotic therapy rather than simple anti-inflammatory treatment 6

Association with Systemic Disease

• Anterior chest wall pain affects a significant percentage of patients with axial spondyloarthritis 2, 3
• May be the first manifestation of spondyloarthritis in some patients 2, 3
• SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) should be considered in chronic, relapsing cases involving the sternoclavicular joints 3