How do you assess for costochondritis?

Assessment of Costochondritis

Costochondritis is diagnosed primarily by demonstrating reproducible tenderness to palpation of the costochondral joints, which is the hallmark physical finding that distinguishes this condition from other causes of chest pain. 1, 2

Initial Clinical Assessment

Physical Examination Technique

• Systematically palpate each costochondral junction from ribs 2-7, applying firm pressure to identify focal areas of tenderness that reproduce the patient's pain 2, 3
• The pain must be reproducible with direct palpation of the affected costochondral or chondrosternal joints 1, 4
• For patients with pain over ribs 6 and 7, focus careful examination on these specific costochondral junctions 2
• Assess whether pain worsens with deep breathing, coughing, or chest wall movement, which is characteristic of musculoskeletal chest pain 3

Key Distinguishing Features

• Chest tenderness on palpation markedly reduces the probability of acute coronary syndrome 1
• Pain is typically described as stinging (53%) or pressing (35%), commonly retrosternal (52%) or left-sided (69%) 2
• Symptoms often occur more than once daily (63%), with many patients experiencing chronic symptoms lasting >6 months (55%) 2
• The examination should be otherwise normal—no friction rub (which would suggest pericarditis), no pulse differentials (which would suggest aortic dissection), and no abnormal heart sounds 1

Mandatory Cardiac Exclusion

When to Obtain ECG

• For patients older than 35 years or with any cardiac risk factors, obtain an ECG to rule out cardiac causes before diagnosing costochondritis 5, 4
• An ECG should be acquired and reviewed within 10 minutes of arrival for any patient with acute chest pain 1
• In the office setting, if an ECG is unavailable, the patient should be referred to the emergency department 1

High-Risk Features Requiring Further Workup

• Diaphoresis, tachypnea, tachycardia, hypotension, or abnormal heart sounds suggest acute coronary syndrome and require immediate cardiac evaluation 1
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 4
• Any patient with cardiopulmonary symptoms should have both an ECG and possibly chest radiography 4

Imaging Considerations

When Imaging is Indicated

• Chest radiography may be useful as an initial imaging test to evaluate for specific etiologies that may simulate chest wall pain, such as pneumonia, pneumothorax, or rib fractures 5, 3
• Consider rib series radiographs for focal chest wall pain to assess for rib fracture or other rib lesions 3
• Ultrasound can detect costochondral abnormalities not visible on radiographs, with higher sensitivity than CT for detecting costochondral involvement 5, 3
• Bone scintigraphy may be useful for patients with undifferentiated costochondral pain and swelling, though it cannot differentiate inflammatory processes from bone tumors 5

When Imaging is NOT Routinely Needed

• In children, adolescents, and young adults without cardiac risk factors, history and physical examination documenting reproducible pain by palpation are usually all that is needed 4
• Costochondritis is often a diagnosis of exclusion after ruling out serious causes 6

Important Differential Diagnoses to Consider

Conditions That May Mimic Costochondritis

• Tietze syndrome: involves localized inflammation with visible swelling of at least one costochondral joint, unlike costochondritis which typically lacks swelling 5
• Slipping rib syndrome: characterized by pain associated with ribs subluxing from the joint 5
• SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis): a chronic, relapsing condition often involving sternoclavicular joints 5
• Anterior chest wall pain in axial spondyloarthritis: may be the first manifestation of disease in some patients 2, 3

Life-Threatening Causes to Exclude

• Acute coronary syndrome, pulmonary embolism, aortic dissection, and esophageal rupture must be ruled out before diagnosing costochondritis 1, 5
• Pericarditis presents with chest pain that increases in the supine position and may have a friction rub 1
• Pneumothorax may be accompanied by pleuritic chest pain and unilateral absence of breath sounds 1

Common Pitfalls

• Do not assume costochondritis based solely on age—even young patients can have cardiac disease, and 3-6% of adults with chest wall tenderness have coronary artery disease 4
• Reproducible chest wall tenderness does not completely rule out serious conditions—it markedly reduces probability but does not eliminate it 1, 3
• Most nontraumatic musculoskeletal chest wall pain (42%) is attributed to costochondritis, making it a common diagnosis, but this should not lead to premature closure 2, 5
• At 1-year follow-up, 55% of patients with costochondritis still suffer from chest pain, though only one-third still have definite costochondritis, indicating the condition can be chronic 7