What is the differential diagnosis, work‑up, and management for bilateral sternal tenderness that is provoked by coughing or deep breathing?

Bilateral Sternal Tenderness with Cough: Differential Diagnosis and Management

Most Likely Diagnosis

This presentation is most consistent with costochondritis, a benign self-limited inflammation of the costochondral or chondrosternal joints that characteristically produces reproducible chest wall tenderness on palpation and is often triggered by coughing or repetitive movements. 1

Differential Diagnosis

Musculoskeletal Causes (Most Common)

• Costochondritis: Tenderness of costochondral joints on palpation, pain reproduced by chest wall pressure, often bilateral, worsened by coughing or deep breathing 2, 1
• Tietze syndrome: Similar to costochondritis but with visible swelling of costochondral joints 2
• Chest wall strain: History of physical exertion, repetitive movements, or severe coughing episodes 1, 3

Cardiac Causes (Must Exclude)

• Pericarditis: Pleuritic chest pain that increases in supine position, may have friction rub on auscultation at left lower sternal border, fever 2, 4
• Acute coronary syndrome: Coronary artery disease is present in 3-6% of patients with chest pain and chest wall tenderness to palpation 1
• Myocarditis: Fever, chest pain, heart failure signs, S3 gallop 2

Pulmonary Causes

• Pleurisy: Sharp stabbing pain with breathing, may have associated chest wall tenderness due to spinal reflex mechanisms 5, 6
• Pulmonary embolism: Pleuritic pain, dyspnea, tachycardia in >90% of patients 2, 6
• Pneumonia: Fever, localized chest pain that may be pleuritic, regional dullness to percussion 2
• Pneumothorax: Dyspnea and pain on inspiration, unilateral absence of breath sounds 2

Infectious Musculoskeletal Causes (Rare)

• Infectious costochondritis with sternal osteomyelitis: Persistent symptoms, purulent drainage, requires imaging and surgical debridement 3

Critical Clinical Assessment

Immediate Red Flags Requiring Emergency Evaluation

• Diaphoresis, tachypnea, tachycardia, hypotension suggest acute coronary syndrome or pulmonary embolism 2
• Pulse differential between extremities suggests aortic dissection (present in 30% of cases) 2
• Unilateral absent breath sounds indicate pneumothorax 2
• Fever with friction rub suggests pericarditis or myopericarditis 2, 4

Key Historical Features That Lower Concern

• Pain affected by palpation, breathing, turning, twisting, or bending argues against angina 2
• Pain generated from multiple sites reduces likelihood of cardiac ischemia 2
• Local tenderness on chest wall examination is characteristic of costochondritis 2, 1

Diagnostic Workup Algorithm

Step 1: Risk Stratification by Age and Cardiac Risk

• Patients >35 years or any cardiac risk factors: Obtain ECG immediately to exclude STEMI or ischemic changes 2, 1
• Patients <35 years without cardiac risk factors and reproducible chest wall tenderness: ECG may be deferred if clinical picture clearly suggests costochondritis 1

Step 2: Physical Examination Findings

• Palpate costochondral and chondrosternal joints bilaterally: Reproducible tenderness confirms costochondritis 2, 1
• Auscultate for friction rub: Presence suggests pericarditis 2, 4
• Assess vital signs: Tachycardia, tachypnea, fever, or hypotension mandate further workup 2

Step 3: Imaging Based on Clinical Suspicion

• Chest radiograph indicated if: Fever, dyspnea, abnormal lung sounds, age >35 years, or any cardiopulmonary symptoms 2, 1
• ECG should be performed within 10 minutes if acute coronary syndrome suspected 2
• Cardiac troponin measurement if ACS cannot be excluded clinically 2

Step 4: Advanced Imaging When Indicated

• Echocardiography: If pericardial effusion or tamponade suspected (muffled heart sounds, elevated JVP, pulsus paradoxus) 4
• CT angiography: If pulmonary embolism suspected based on validated clinical decision rules 6
• MRI with fat-suppressed T2-weighted images: If infectious costochondritis suspected (persistent symptoms >3 weeks, purulent drainage, diabetes) 3

Management Based on Diagnosis

For Costochondritis (Most Likely)

• First-line treatment: Acetaminophen or NSAIDs (where safe and appropriate) for symptomatic relief 1
• Activity modification: Advise patients to avoid activities producing chest muscle overuse 1
• Reassurance: Explain benign self-limited nature of condition 1
• Discontinue NSAIDs immediately if any hemoptysis develops 7

For Pericarditis

• NSAIDs plus colchicine are first-line treatment for idiopathic or viral pericarditis 4
• Monitor for complications: Effusion, tamponade, or myopericarditis require echocardiography 4

For Infectious Costochondritis

• Antibiotic therapy based on culture results (e.g., cephalosporins or fluoroquinolones for Pseudomonas) 3
• Surgical debridement required for osteomyelitis with proper determination of extent using MRI, intraoperative palpation, and bone bleeding 3

Critical Pitfalls to Avoid

• Never assume benign musculoskeletal cause without ECG in patients >35 years or with cardiac risk factors, as coronary artery disease coexists in 3-6% of cases with chest wall tenderness 1
• Do not dismiss chest pain as purely musculoskeletal without chest radiograph if fever, dyspnea, or abnormal lung sounds present 7
• Recognize that pleurisy can cause chest wall tenderness through spinal reflex mechanisms, mimicking musculoskeletal pain 5
• Do not overlook pericarditis: Friction rub may be subtle and requires careful auscultation at left lower sternal border 2, 4
• Consider infectious costochondritis if symptoms persist >3 weeks, especially in diabetic patients or those with purulent drainage 3

When to Escalate Care

Immediate Emergency Department Transfer

• Clinical evidence of ACS or life-threatening causes (diaphoresis, hemodynamic instability, severe dyspnea) 2
• STEMI on ECG requires activation of catheterization lab 2
• Suspected cardiac tamponade (Beck's triad: hypotension, elevated JVP, muffled heart sounds) 4

Urgent Cardiology or Pulmonology Referral

• Abnormal ECG with ischemic changes or elevated troponin 2
• Pericardial effusion on imaging requires cardiology evaluation 4
• Suspected pulmonary embolism based on validated clinical decision rules 6

Follow-up Within 48-72 Hours

• Reassess all patients with presumed costochondritis to ensure clinical improvement 7
• Return immediately if: Fever develops, hemoptysis occurs, dyspnea worsens, or symptoms persist beyond 3 weeks 7, 3