What causes costochondritis in an adult with sudden sharp one-sided chest pain?

What Causes Costochondritis

Costochondritis is an inflammatory condition of the costochondral or chondrosternal joints whose exact cause is often unknown, but it commonly results from physical strain, repetitive movements, severe coughing, or chest wall overuse. 1

Primary Etiologic Mechanisms

Mechanical and Physical Causes

• Physical exertion and repetitive movements (such as lifting heavy objects) are the most commonly identified triggers for costochondritis 2
• Severe or persistent coughing can precipitate inflammation at the costochondral junctions 2
• Chest muscle overuse from activities that strain the anterior chest wall frequently leads to costochondral inflammation 1
• Occult or recent chest trauma, including rib fractures, may present as costochondritis even without a clear history of injury 3

Infectious Causes (Less Common)

• Direct spread from postoperative wounds or adjacent foci can cause infectious costochondritis, though this is uncommon 2
• Hematogenous seeding by organisms such as Pseudomonas aeruginosa can rarely cause infectious costochondritis with or without sternal osteomyelitis 2
• Enterovirus epidemic myalgia (pleurodynia/Bornholm disease) represents a viral cause of musculoskeletal chest pain that can mimic costochondritis 3

Associated Conditions

• Fibromyalgia is associated with costochondritis in only a minority of cases (8% in one emergency department study) 4
• Widespread pain syndromes are more common in patients with costochondritis (42%) compared to other chest pain patients (5%) 4
• Axial spondyloarthritis may present with anterior chest wall pain as the first manifestation of disease 3, 5
• SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) frequently involves the sternoclavicular joints and presents with anterior chest wall pain 3

Important Clinical Context

Idiopathic Nature

• Most cases are idiopathic, meaning no specific cause is identified despite thorough evaluation 1
• The condition is self-limited and benign in the majority of patients, though symptoms can persist for months 1, 4
• Spontaneous resolution occurs in most cases within one year, though 55% of patients may still experience some chest pain at one-year follow-up 4

Key Distinguishing Features from Infection

• Standard costochondritis is inflammatory but NOT infectious and responds to NSAIDs rather than antibiotics 2
• The absence of fever, purulent drainage, or systemic signs helps distinguish benign costochondritis from infectious causes 2

Demographic Patterns

• Women are disproportionately affected (69% in emergency department studies) compared to men (31%) 4
• Hispanic patients show higher frequency (47%) compared to other ethnic groups (24%) in some populations 4

Critical Pitfall to Avoid

Do not assume all reproducible chest wall tenderness is costochondritis without first excluding cardiac causes, particularly in patients over 35 years or those with cardiac risk factors, as coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 1, 6. The presence of costochondritis does not eliminate the possibility of concurrent serious cardiac conditions 6.