What is Costochondritis
Costochondritis is an inflammatory condition of the costochondral junctions (where ribs meet cartilage) or chondrosternal joints of the anterior chest wall, characterized by reproducible chest wall tenderness on palpation of the affected joints. 1
Clinical Definition and Pathophysiology
Costochondritis represents inflammation of one or more ribs and/or their cartilages, accounting for approximately 42% of all nontraumatic musculoskeletal chest wall pain. 1, 2 The hallmark physical finding is tenderness to palpation of the costochondral joints, typically affecting ribs 3-7, most commonly on the left side or retrosternally. 3
The condition involves inflammation at the junction where the ribs articulate with the costal cartilage, distinguishing it from related conditions:
- Tietze syndrome involves localized inflammation with visible swelling at one or more costochondral junctions 1, 2
- Costochondritis presents with inflammation but typically without visible swelling 1
Clinical Presentation
Pain characteristics:
- Described as stinging (53%) or pressing (35.1%) in quality 3
- Commonly retrosternal (52%) or left-sided (69.2%) 3
- Sharp, stabbing pain that worsens with inspiration or palpation 3
- Occurs more than once daily in 62.9% of patients 3
- Chronic symptoms lasting >6 months occur in 55.4% of cases 3
Key diagnostic feature: Pain is reproducible with palpation of the affected costochondral joints, which markedly reduces the probability of cardiac ischemia. 3, 4
Etiology and Risk Factors
Common causes include:
- Physical exertion and repetitive movements (such as heavy lifting) 5
- Severe coughing 5
- Trauma to the chest wall 6
- Post-surgical complications including infection or hematoma formation 6
- Approximately 10% of cases are trauma-related 6
Associated conditions:
- Affects 30-60% of patients with axial spondyloarthritis and may be the first disease manifestation 2
- More common in women (69% vs 31%) and Hispanics (47% vs 24%) 7
- Associated with fibromyalgia in only 8% of cases 7
Diagnostic Approach
Critical first step: Rule out life-threatening causes first in patients >35 years or with cardiac risk factors—obtain an ECG within 10 minutes to exclude acute coronary syndrome, aortic dissection, pulmonary embolism, or esophageal rupture. 3 Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness. 4
Physical examination:
- Systematic palpation of costochondral joints (ribs 3-7) to elicit reproducible tenderness 3
- For pain over ribs 6 and 7, focus examination on these specific costochondral junctions 3
Imaging considerations:
- Chest radiography as initial imaging to exclude rib fractures, infection, or neoplasm (though may miss costochondral abnormalities) 2
- Ultrasound has higher sensitivity than CT for detecting costochondral involvement 2
- Bone scintigraphy is highly sensitive for osseocartilaginous disease but lacks specificity 2
- CT shows higher sensitivity and specificity for differentiating primary chest wall tumors from Tietze syndrome 2
- MRI useful for evaluating extent of inflammation and systemic inflammatory conditions 1
Critical pitfall: Do not use nitroglycerin response as a diagnostic criterion—relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain. 3 Do not assume all reproducible chest wall tenderness is benign, as serious cardiac conditions can coexist with musculoskeletal findings. 3
Natural History
Costochondritis is usually self-limited and benign, with spontaneous resolution seen in most cases at 1 year. 4, 7 However, at one-year follow-up, 55% of patients may still experience chest pain, though only one-third retain definite costochondritis. 7 When symptoms do not self-resolve, the condition is referred to as atypical costochondritis and is associated with high medical expenses and psychological burden. 8
Distinction from Infectious Costochondritis
Infectious costochondritis is a separate entity that develops when infection spreads from postoperative wounds or adjacent foci, or rarely from hematogenous spread. 5 This requires debridement and prolonged antibiotic therapy rather than anti-inflammatory treatment. 5 Blood cultures, elevated inflammatory markers, and imaging showing bone destruction help distinguish infectious from non-infectious costochondritis. 5