What diagnosis and treatment are indicated for bilateral sternal chest pain that worsens with respiration and speech, is reproducible on costochondral junction palpation, and is associated with a normal electrocardiogram, normal high‑sensitivity troponin, negative D‑dimer, and normal erythrocyte sedimentation rate?

Diagnosis: Costochondritis

This patient has costochondritis, a benign musculoskeletal condition characterized by reproducible chest wall tenderness on palpation of the costochondral junctions, with normal cardiac workup including ECG, troponin, D-dimer, and ESR. 1

---

Immediate Cardiac Exclusion (Already Completed)

• A normal ECG combined with pleuritic chest pain (sharp, worsens with breathing and talking) makes acute coronary syndrome unlikely, though cardiac troponin measurement remains essential because up to 5% of patients with normal ECG still have ACS. 1, 2

• High-sensitivity troponin has been appropriately obtained and is normal, effectively ruling out myocardial injury. 1, 2

• Negative D-dimer makes pulmonary embolism and aortic dissection highly unlikely. 2

• Normal ESR argues against inflammatory conditions such as acute pericarditis or systemic rheumatologic disease. 1

---

Diagnostic Confirmation of Costochondritis

• Reproducible pain on palpation of the costochondral junctions is the hallmark physical finding that confirms costochondritis. 1, 3, 4

• Pain that worsens with breathing, talking, chest wall movement, turning, or twisting is characteristic of musculoskeletal chest pain rather than cardiac ischemia. 1, 2, 3

• Bilateral sternal chest pain localized to the costochondral junctions is typical; costochondritis accounts for approximately 43% of chest pain presentations in primary care when cardiac causes are excluded. 2, 4

• The condition is usually self-limited and benign, though symptoms can persist for weeks to months in some patients. 4, 5

---

Treatment Algorithm

First-Line Pharmacologic Management

• Prescribe NSAIDs (ibuprofen 600–800 mg three times daily) for 1–2 weeks as first-line therapy. 3, 4

• If NSAIDs are contraindicated, use acetaminophen as an alternative analgesic. 3, 4

• Consider topical analgesics such as lidocaine patches for localized pain relief with minimal systemic effects. 3

Second-Line Therapy for Persistent Symptoms

• Add low-dose colchicine (0.6 mg twice daily) if symptoms persist despite adequate NSAID therapy. 3

Non-Pharmacologic Measures

• Apply ice packs or heat to the affected area for symptomatic relief. 3

• Advise temporary avoidance of activities that exacerbate chest wall pain, such as heavy lifting, repetitive upper extremity movements, or severe coughing. 4, 6

• Provide reassurance that the condition is benign and typically self-resolves. 4

---

Follow-Up and Monitoring

• Reassess in 1–2 weeks to evaluate treatment response. 3

• If pain persists beyond 4–6 weeks despite appropriate therapy, consider re-evaluation to rule out atypical costochondritis or other underlying causes. 3, 7

• In patients older than 35 years or those with cardiovascular risk factors, outpatient stress testing or coronary CT angiography within 72 hours may be considered to address residual cardiovascular risk, even when initial cardiac workup is normal. 2

---

Critical Pitfalls to Avoid

• Do not rely on nitroglycerin response to differentiate cardiac from musculoskeletal chest pain, as esophageal spasm and other non-cardiac conditions may also improve with nitroglycerin. 1, 2

• Do not dismiss cardiac causes solely because chest wall tenderness is present; up to 7% of patients with reproducible chest wall tenderness still have acute coronary syndrome. 2

• Do not assume all reproducible chest wall pain is benign in patients with cardiovascular risk factors; coronary artery disease is present in 3–6% of adult patients with chest pain and chest wall tenderness. 4

• Recognize that approximately 13% of patients with pleuritic-type chest pain have acute myocardial ischemia, so cardiac evaluation must precede a diagnosis of costochondritis. 2

---

Special Considerations

• Women and Hispanic patients have higher rates of costochondritis presentation in emergency settings. 5

• Approximately 55% of patients may still experience chest pain at 1-year follow-up, though only one-third will have persistent definite costochondritis. 5

• Infectious costochondritis is rare but should be considered if there is fever, purulent drainage, or failure to respond to standard therapy; this requires surgical debridement and prolonged antibiotic therapy. 8