What are the causes of costochondritis in a patient with a history of trauma, physical activity, or pre-existing conditions such as arthritis or fibromyalgia?

Causes of Costochondritis

Costochondritis is primarily caused by trauma to the chest wall, repetitive physical strain, post-surgical complications, or may occur as part of systemic inflammatory conditions, though in many cases no specific trigger is identified. 1

Primary Etiologic Categories

Trauma and Physical Strain

• Direct chest wall trauma initiates the inflammatory process at the costochondral junctions, representing a common precipitating factor 1
• Repetitive movements such as heavy lifting and severe coughing episodes can trigger costochondritis 2
• Physical exertion and activities causing chest muscle overuse are well-documented causes 2, 3
• Approximately 10% of noncyclical chest pain cases are related to trauma 4

Post-Surgical and Iatrogenic Causes

• Post-operative complications including infection or hematoma formation can lead to costochondritis 1
• Pain is more common in patients who had postoperative infection or hematoma, or when surgical incisions cut across Langer lines of tension 4
• Breast implants, especially those placed in a subpectoral location, can be associated with costochondral pain 4
• Postsurgical pain may result from scar formation, nerve regeneration, or focal nerve injury due to ischemia, radiation, or lymphedema 4

Infectious Causes (Rare but Important)

• Infectious costochondritis usually develops when infection spreads directly from a postoperative wound or adjacent foci 2
• Pseudomonas aeruginosa and other bacterial pathogens can cause infectious costochondritis with sternal osteomyelitis, though this is uncommon 2
• Tubercular costochondritis is an extremely rare form of extrapulmonary tuberculosis affecting the ribs, accounting for only 1-2% of musculoskeletal TB cases 5

Systemic Inflammatory Conditions

• Axial spondyloarthritis: Anterior chest wall pain affects a significant percentage of patients with this condition and may be the first disease manifestation 6
• SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) is a chronic, relapsing condition that often involves the sternoclavicular joints and can present with costochondritis 6
• Fibromyalgia and fibromyositis are associated with musculoskeletal chest wall pain that may mimic or coexist with costochondritis 4

Idiopathic Cases

• Most cases (approximately 42% of nontraumatic musculoskeletal chest wall pain) are attributed to costochondritis without a clearly identifiable cause 7, 6
• The condition represents inflammation of the costochondral or chondrosternal joints where the underlying trigger remains unclear in many patients 1

Contributing and Modifying Factors

Psychological Factors

• Stress may amplify pain perception through dysregulation of the brain-gut axis and altered visceral perception, though stress itself is not a direct cause 1
• Psychological factors including depression, anxiety, and general distress are associated with how patients experience and report musculoskeletal pain 1

Mechanical Factors

• Rib fractures and other chest wall injuries can lead to secondary costochondritis 4
• Pectoral muscle strains or spasms and entrapment of the lateral cutaneous branch of the third intercostal nerve can cause or contribute to symptoms 4

Critical Clinical Pitfall

Do not assume all reproducible chest wall tenderness is benign costochondritis—serious cardiac conditions can coexist with musculoskeletal findings, particularly in patients over 35 years or those with cardiac risk factors 7. Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 3.