What is the appropriate workup and treatment for costochondritis versus Tietze syndrome?

Costochondritis vs. Tietze Syndrome: Workup and Treatment

Key Clinical Distinction

Costochondritis and Tietze syndrome are distinct entities: costochondritis presents with tenderness at the costochondral junctions (ribs 3-7) without visible swelling, while Tietze syndrome involves localized inflammation with palpable swelling, most commonly at the second and third ribs. 1, 2

Diagnostic Workup

Initial Assessment and Cardiac Exclusion

• Obtain an ECG within 10 minutes for all patients >35 years or those with cardiac risk factors to exclude acute coronary syndrome, aortic dissection, pulmonary embolism, or esophageal rupture before diagnosing costochondritis. 3
• Sharp, stabbing pain that worsens with inspiration or palpation significantly reduces the probability of cardiac ischemia. 3
• 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 delay cardiac evaluation in high-risk patients, as coronary artery disease can coexist with musculoskeletal findings. 3

Physical Examination Findings

• Costochondritis: Reproducible tenderness on palpation of affected costochondral joints (typically ribs 3-7), most commonly left-sided (69%) or retrosternal (52%), with no visible swelling, rib mobility, clicking, or chest-wall asymmetry. 1, 3
• Tietze syndrome: Painful, localized inflammation with visible/palpable swelling at the costochondral, sternoclavicular, or costosternal junctions, typically involving the second and third ribs. 2, 4
• Pain characteristics: stinging (53%) or pressing (35%), occurring more than once daily (63%), with chronic course >6 months in 55% of cases. 1, 2

Imaging and Laboratory Studies

• Chest radiography is recommended as initial imaging to exclude rib fractures, infection, or neoplasm, though it may miss costochondral abnormalities. 2
• Ultrasound shows higher sensitivity than CT for detecting costochondral involvement and can identify abnormalities not visible on radiographs. 2
• CT demonstrates higher sensitivity and specificity for differentiating primary chest wall tumors from Tietze syndrome when swelling is present. 2
• Bone scintigraphy is 100% sensitive for detecting sternoclavicular joint inflammation but has insufficient specificity to differentiate inflammatory processes from bone tumors. 2
• Laboratory studies are generally not useful, though inflammatory markers may be modestly elevated. 1

Differential Diagnosis to Consider

• Slipping rib syndrome: Involves false ribs 8-10 with actual subluxation; dynamic ultrasound is the imaging modality of choice (89% detection rate, 100% negative predictive value). 1
• Sternoclavicular joint inflammation: This is a separate entity from costochondritis and should prompt consideration of spondyloarthritis, SAPHO syndrome, septic arthritis, rheumatoid arthritis, or neoplastic processes. 2
• Costochondritis affects 30-60% of patients with axial spondyloarthritis and may be the first disease manifestation. 2

Treatment Algorithm

First-Line Therapy

Initiate a 1-2 week course of NSAIDs as first-line treatment for both costochondritis and Tietze syndrome. 1, 3

Second-Line Therapy (If Symptoms Persist)

Add low-dose colchicine if symptoms persist despite NSAIDs. 1, 3

Alternative and Adjunctive Therapies

• Acetaminophen when NSAIDs are contraindicated. 1, 3
• Topical lidocaine patches for localized pain relief with minimal systemic effects. 1, 3
• Ice packs as supportive therapy in conjunction with pharmacological treatment. 1, 3
• Stretching exercises have shown progressive significant improvement compared to controls (p<0.001) and can be a useful adjunct. 5

Refractory Cases

• Local corticosteroid injections directed to the affected costochondral junction for refractory cases. 2
• Local anesthetic infiltration to the afflicted joints provides prompt, complete, and prolonged relief in 87.5% of cases. 6
• Do not use systemic corticosteroids for isolated costochondritis—there is no evidence supporting their use. 2
• Surgical management (complete resection of involved cartilage and adjacent rib) should be considered only in severe, medically refractory cases of Tietze syndrome that are resistant to all conservative therapies. 4

Monitoring

Reassess patients if pain persists to exclude other potential causes. 3

Critical Clinical Pitfalls

• Do not assume all reproducible chest wall tenderness is benign—serious cardiac conditions can coexist with musculoskeletal findings. 3
• Nitroglycerin response is unreliable for distinguishing cardiac from non-cardiac chest pain. 3
• Labeling sternoclavicular joint inflammation as costochondritis may lead to missed diagnoses of spondyloarthritis, SAPHO syndrome, or other serious conditions. 2
• In high-risk patients, cardiac evaluation must not be delayed even when musculoskeletal findings are present. 3