What are the causes, diagnosis, and treatment options for a patient with costochondritis, considering their medical history, including any history of gastrointestinal bleeding, kidney disease, or allergies to nonsteroidal anti-inflammatory drugs (NSAIDs), and potential underlying conditions such as osteoarthritis or Tietze's syndrome?

Costochondritis: Causes, Diagnosis, and Treatment

Causes

Costochondritis is primarily caused by physical exertion, repetitive movements (such as lifting heavy objects), and severe coughing. 1 The condition represents inflammation of the costochondral junctions of ribs or chondrosternal joints of the anterior chest wall. 1

• The etiology is typically mechanical overuse or strain of the chest wall structures 1
• Unlike infectious costochondritis, the common form is not caused by infection and does not involve bacterial pathogens 2
• Risk factors include activities producing chest muscle overuse 1

Diagnosis

The diagnosis is made clinically through history and physical examination documenting reproducible pain by palpation over the costal cartilages. 1

Clinical Presentation

• Palpation of affected chondrosternal joints elicits tenderness 1
• Pain is reproducible with direct pressure over the costal cartilages 1
• Tietze syndrome, a variant, presents with visible joint swelling in addition to pain 3, 4

Age-Specific Diagnostic Approach

• For children, adolescents, and young adults: History and physical examination with reproducible palpation tenderness are usually sufficient 1
• For patients older than 35 years, those with coronary artery disease history or risk factors, and any patient with cardiopulmonary symptoms: Obtain electrocardiogram and possibly chest radiograph 1

Critical Pitfall

Coronary artery disease is present in 3 to 6 percent of adult patients with chest pain and chest wall tenderness to palpation. 1 This makes cardiac evaluation essential in higher-risk populations despite the presence of chest wall tenderness.

Additional Testing When Indicated

• Consider further cardiac testing if clinically indicated by age or cardiac risk status 1
• Seated motion palpation can identify spontaneous and motion-involved pain areas 5
• Imaging (X-ray, ECG, cardiac Doppler ultrasound) and myocardial enzyme testing help rule out serious cardiopulmonary diseases 5

Treatment

Traditional practice is to treat with acetaminophen or anti-inflammatory medications where safe and appropriate, advise patients to avoid activities that produce chest muscle overuse, and provide reassurance. 1

First-Line Treatment

• Acetaminophen is the preferred initial analgesic as it does not cause gastric injury 6
• NSAIDs can be used where safe and appropriate 1
• Activity modification to avoid chest muscle overuse 1
• Patient reassurance that the condition is benign and self-limited 1

NSAID Use Considerations

For patients requiring NSAIDs who have gastrointestinal risk factors, use non-selective NSAIDs plus a gastroprotective agent (proton pump inhibitor), or a selective COX-2 inhibitor. 7

• Ibuprofen at low doses (1.2 g daily) is recommended as initial NSAID therapy 7
• PPIs reduce NSAID-induced ulcer risk by approximately 90% 7
• For high GI risk patients, consider COX-2 selective inhibitors combined with PPIs 6
• Critical warning: NSAIDs should be avoided in patients with history of GI bleeding, and if absolutely necessary, must be combined with PPI gastroprotection 6

Special Considerations for Specific Populations

Patients with inflammatory bowel disease (ulcerative colitis): Short-term treatment with selective COX-2 inhibitors appears safe, while non-selective NSAIDs may exacerbate underlying disease 7

Patients with kidney disease: NSAIDs carry cardiorenal adverse event risks and should be used cautiously 7

Patients with NSAID allergies: Use acetaminophen as the primary analgesic 6

Advanced Treatment for Tietze Syndrome

For Tietze syndrome with significant pain and quality of life impairment, adding short-term oral corticosteroids (prednisolone 40 mg daily for 1 week, then 20 mg daily for 1 week, then 10 mg daily for 1 week) to NSAID treatment provides superior pain relief compared to NSAIDs alone. 3

• This regimen showed 46.8% pain reduction at week 1 versus 17.7% with NSAIDs alone (p < 0.001) 3
• Pain improvement was maintained at median 6.5 months follow-up with 25.8% greater reduction in the steroid group 3
• Quality of life improvement was significant at 3 weeks (p < 0.001) 3
• Side effects were minimal (mild GI upset in steroid group, mild nausea in NSAID group) 3

Alternative Interventions

• Local anesthetic infiltration to affected joints provides prompt, complete, and prolonged relief in 87.5% of cases 4
• Physiotherapy and rest may provide symptomatic benefit 7

Treatment Duration

• Costochondritis is usually self-limited and benign 1
• Continue treatment until symptoms resolve, typically weeks rather than months 7

When to Suspect Infectious Costochondritis

• Presence of purulent drainage, fever, or systemic symptoms suggests infectious etiology requiring antibiotics and possible surgical debridement 2
• This is rare and typically occurs in postoperative settings or immunocompromised patients 2