What is costochondritis, its typical presentation, how to differentiate it from serious causes, and how is it managed?

What is Costochondritis?

Costochondritis is a benign, self-limiting inflammation of the costochondral junctions (where ribs meet costal cartilage) or chondrosternal joints (where costal cartilages meet the sternum), characterized by reproducible chest wall tenderness on palpation—it is a diagnosis of exclusion after ruling out life-threatening cardiac, pulmonary, and vascular causes. 1, 2

Clinical Presentation

• Pain characteristics: Typically described as stinging (53%) or pressing (35%), most commonly retrosternal (52%) or left-sided (69%), affecting ribs 2-7 3
• Hallmark finding: Reproducible tenderness to palpation of the affected costochondral or chondrosternal joints 2, 4
• Temporal pattern: Symptoms often occur more than once daily (63%), with many patients experiencing chronic symptoms lasting >6 months (55%) 3
• Pain behavior: Sharp, stabbing pain that worsens with inspiration, palpation, or chest wall movement markedly reduces the probability of cardiac ischemia 2

Critical Differentiation from Life-Threatening Causes

Before diagnosing costochondritis, you must exclude acute coronary syndrome, aortic dissection, pulmonary embolism, and esophageal rupture—particularly in patients >35 years or with cardiac risk factors. 2, 4

Red Flags Requiring Immediate Cardiac Evaluation

• Severe prolonged chest pain of acute onset (unless clearly traumatic) requires immediate hospital care 1
• Associated symptoms: Cold sweat, nausea, vomiting, syncope, anxiety/fear indicate potential serious pathology 1
• Pain that interrupts normal activity warrants urgent evaluation 1
• Age >35 years or any cardiac risk factors: Obtain ECG within 10 minutes 2, 4

Features Suggesting Benign Musculoskeletal Origin

• Pain affected by palpation, breathing, turning, twisting, or bending has the highest diagnostic value against angina 1
• Pain generated from multiple sites or well-localized on the chest wall 1
• Pain that varies with body position or food intake 1
• Accompanied by local tenderness on examination 1

Critical Pitfall to Avoid

Do not use nitroglycerin response as a diagnostic criterion—relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain. 2 Additionally, coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness, so serious cardiac conditions can coexist with musculoskeletal findings 2, 4.

Diagnostic Approach

Initial Assessment

• History and physical examination: Document reproducible pain by palpation over costal cartilages—this is usually sufficient in children, adolescents, and young adults 4
• ECG: Mandatory within 10 minutes for patients >35 years or with cardiac risk factors 2, 4
• Chest radiography: Useful as initial imaging to exclude rib fractures, infection, or neoplasm, though it may miss costochondral abnormalities 3

Advanced Imaging (When Indicated)

• Ultrasound: Higher sensitivity than CT for detecting costochondral involvement 3
• Bone scintigraphy: Highly sensitive (100%) for detecting sternoclavicular joint inflammation and osseocartilaginous disease, though insufficient specificity to differentiate inflammatory processes from bone tumors 3
• CT with 3D reconstructions: Higher sensitivity and specificity for differentiating primary chest wall tumors from Tietze syndrome 3
• MRI: Useful for evaluating extent of disease and detecting systemic inflammatory conditions 1

Important Differential Diagnoses

• Tietze syndrome: Localized inflammation with visible swelling at the costochondral junction—this is distinct from costochondritis 1, 5, 3
• Sternoclavicular joint inflammation: NOT costochondritis—consider spondyloarthritis, SAPHO syndrome, septic arthritis, or rheumatoid arthritis 5, 3
• Slipping rib syndrome: Pain associated with ribs subluxing from the joint 3
• Spondyloarthritis: Costochondritis affects 30-60% of patients with axial spondyloarthritis and may be the first disease manifestation 3

Management

First-Line Pharmacological Treatment

Initiate a 1-2 week course of NSAIDs for pleuritic-type pain or when there is an underlying inflammatory component. 2

• NSAIDs: First-line therapy for 1-2 weeks 2
• Acetaminophen: Alternative if NSAIDs are contraindicated 2
• Topical analgesics: Lidocaine patches provide localized pain relief with minimal systemic effects 2

Second-Line Options for Refractory Cases

• Low-dose colchicine: Add if symptoms persist despite NSAID therapy 2
• Local corticosteroid injections: Consider for refractory cases directed to the affected costochondral junction 3
• Analgesics (tramadol): Can be added for residual pain when NSAIDs are insufficient or contraindicated 3

Non-Pharmacological Approaches

• Ice packs or heat application: Use in conjunction with drug therapy 2
• Stretching exercises: Progressive significant improvement demonstrated in clinical trials (p<0.001) 6
• Osteopathic manipulation techniques: May be useful for rib dysfunction, especially in atypical costochondritis 7
• Activity modification: Advise patients to avoid activities that produce chest muscle overuse 4

Critical Management Pitfalls

Do not use systemic corticosteroids for isolated costochondritis—there is no evidence supporting their use. 3

Monitoring and Follow-Up

• Reassessment: Required to rule out other potential causes if pain persists beyond expected self-limited course 2
• Typical course: Usually self-limited and resolves in a couple of weeks 7, 4
• Atypical costochondritis: Pain persisting beyond typical timeframe requires multimodal approach and consideration of alternative diagnoses 7

Special Populations

• Spondyloarthritis patients: Multimodal therapy including cognitive behavioral therapy and low-dose amitriptyline for fibromyalgia overlap 3
• Inflammatory arthritis patients: NSAIDs remain first-line but monitor disease activity with composite measures 3
• Post-radiation patients: Chest wall edema, cortical thinning, and osteosclerosis may precede rib fractures (average 21 months post-therapy) 1