What is the diagnosis and treatment for a patient with costochondral pain, chest tightness described as band-like, and numbness in bilateral lower limbs?

Differential Diagnosis and Management Approach

This presentation requires urgent evaluation to exclude life-threatening causes before attributing symptoms to costochondritis, as the combination of chest pain with bilateral lower limb numbness suggests potential spinal or systemic pathology rather than isolated musculoskeletal chest wall pain. 1

Critical Red Flags in This Presentation

The bilateral lower limb numbness is not consistent with isolated costochondritis and demands immediate investigation for:

• Spinal cord compression at thoracic level (band-like chest tightness is a classic dermatomal pattern) 1
• Aortic dissection extending to spinal arteries (can cause both chest pain and neurological deficits) 1
• Multiple sclerosis or transverse myelitis (band-like sensation with bilateral lower extremity involvement) 1
• Epidural abscess or hematoma (progressive neurological symptoms with chest/back pain) 1

Immediate Diagnostic Workup Required

First-Line Testing (Within 10 Minutes)

• ECG to exclude STEMI, pericarditis, or pulmonary embolism patterns 1
• Vital signs assessment for tachycardia, tachypnea (present in >90% of PE cases), hypotension, or fever 1
• Focused neurological examination including lower extremity strength, sensation, reflexes, and rectal tone to assess for spinal cord involvement 1

Urgent Imaging

• MRI of thoracic spine is the priority imaging modality given bilateral lower limb numbness with band-like chest tightness, as this pattern suggests spinal cord pathology 1
• Chest radiograph to evaluate for pneumothorax, pneumonia, widened mediastinum, or rib abnormalities 1
• CT chest with contrast if aortic dissection suspected (sudden onset, pulse differential) or if MRI unavailable 1

Laboratory Testing

• Cardiac troponin measured immediately to exclude myocardial injury 1
• D-dimer if pulmonary embolism in differential (though pleuritic features not prominent here) 2
• Inflammatory markers (ESR, CRP) if infectious or inflammatory etiology suspected 3, 4

Physical Examination Findings to Differentiate Causes

Cardiac Causes (Must Exclude First)

• ACS: Diaphoresis, tachycardia, hypotension, S3 gallop, new mitral regurgitation murmur (examination may be normal in uncomplicated cases) 1
• Pericarditis: Friction rub, pain worse supine and improved sitting forward 1, 2
• Aortic dissection: Pulse differential between extremities (30% sensitivity), sudden "ripping" pain radiating to back 1

Pulmonary Causes

• Pulmonary embolism: Tachycardia and dyspnea in >90%, pleuritic pain, accentuated P2 1, 2
• Pneumothorax: Unilateral absent breath sounds, hyperresonance to percussion, dyspnea 1, 2
• Pneumonia: Fever, localized pleuritic pain, dullness to percussion, egophony, friction rub 1, 2

Musculoskeletal Causes (Diagnosis of Exclusion)

• Costochondritis: Tenderness to palpation over costochondral joints, reproducible pain with chest wall pressure 1
• Critical caveat: 7% of patients with reproducible chest wall tenderness still have acute coronary syndrome, so palpable tenderness does NOT exclude cardiac pathology 2, 5

Neurological Causes (High Priority Given Bilateral Lower Limb Symptoms)

• Spinal cord compression: Sensory level at chest (band-like), lower extremity weakness, hyperreflexia, Babinski sign, sphincter dysfunction 1
• Herpes zoster: Dermatomal pain distribution, vesicular rash (may precede rash by days), unilateral and does not cross midline 1, 6

Management Algorithm

If Life-Threatening Cause Identified

• Activate emergency transport via EMS to closest ED if evaluated in office setting 1
• Do not delay transfer for additional testing in outpatient settings 1

If Spinal Cord Pathology Suspected

• Emergent neurosurgical consultation for potential decompression 1
• High-dose corticosteroids if transverse myelitis suspected (after infectious causes excluded) 1
• Urgent MRI thoracic spine is diagnostic test of choice 1

If Cardiac/Pulmonary Causes Excluded and Costochondritis Diagnosed

• NSAIDs (ibuprofen or naproxen) as first-line treatment where safe and appropriate 7, 5, 8
• Acetaminophen as alternative if NSAIDs contraindicated 5
• Activity modification to avoid chest muscle overuse 5, 8
• Manual therapy and soft tissue mobilization may provide benefit in refractory cases 7, 8
• Reassurance with thorough explanation of benign nature 5

Critical Pitfalls to Avoid

• Never assume costochondritis without excluding cardiac causes, especially in patients >35 years or with cardiac risk factors 5
• Do not rely on nitroglycerin response as diagnostic criterion—relief does not confirm or exclude ischemia 2
• Do not dismiss bilateral neurological symptoms as unrelated to chest pain—this combination demands spinal imaging 1
• Avoid attributing all symptoms to anxiety without objective testing, as serious pathology can coexist with reproducible chest wall tenderness 2, 5
• Do not perform delayed transfer from office to ED for troponin testing—transport immediately if ACS suspected 1

Disposition Decision

This patient requires emergency department evaluation given the atypical combination of costochondral pain with bilateral lower limb numbness, which is not explained by isolated musculoskeletal chest wall pathology and raises concern for spinal cord involvement or systemic disease. 1

Only after comprehensive workup excludes life-threatening and neurological causes can costochondritis be diagnosed and managed conservatively. 1, 5