Costochondritis

Costochondritis is characterized by localized chest wall tenderness caused by inflammation of the costochondral and/or sternocostal joints. Costochondritis typically occurs in individuals > 40 years of age and is more common in women than in men. The etiology is unknown. Diagnosis is clinical, based primarily on reproducible pain upon palpation of the affected joints, and is supported with physical examination maneuvers. Diagnostic testing is performed to rule out other causes of chest pain. The condition is usually self-limited, with pain resolution typically occurring within weeks and a low likelihood of recurrence. Management includes analgesics and application of heat.

• Peak incidence: 40–50 years of age ^[1][2]
• ♀ > ♂ ^[1][2]

Epidemiological data refers to the US, unless otherwise specified.

• Unknown
• Associated with excessive or repetitive exercise and with minor chest wall trauma ^[2][3]

• Sharp, well-localized chest pain ^[1][4]
  • Reproducible on palpation of affected joints
  • Typically affects multiple sites (unilateral or bilateral) between 2nd and 5th costochondral and/or sternocostal joints
• Exacerbating movements include: ^[3][4]
  • Deep breaths
  • Coughing
  • Upper body movements
• May be preceded by exercise, chest wall trauma, or coughing ^[2]

The absence of local signs of inflammation (e.g., swelling and erythema) can help distinguish costochondritis from Tietze syndrome. ^[1][4]

• Clinical diagnosis, primarily based on: ^[1]
  • Reproducible pain on palpation
  • Positive results of provocative tests to reproduce pain, e.g.: ^[4]
    • Crowing rooster maneuver
    • Crossed-chest adduction maneuver
• Exclusion of other causes of chest pain
  • Perform a thorough clinical evaluation (including cardiac examination and pulmonary examination).
  • Consider diagnostic studies, e.g.: ^[1][3]
    • ECG if concern for cardiovascular causes of chest pain (e.g., existing CAD or risk factors for CAD) ^[2][3]
    • CXR in patients with pulmonary symptoms (e.g., dyspnea) or signs of infection (e.g., fever)
    • Further imaging if concern for neoplasm ^[4]

Pain on chest wall palpation does not exclude an underlying cardiac cause. Most patients require diagnostic studies, including ECG, to exclude immediately life-threatening causes of chest pain. ^[1][3]

See “Differential diagnosis of chest pain.”

The differential diagnoses listed here are not exhaustive.

General principles ^[1][4]

• Treatment is supportive. ^[1][3]
• Reassure patients that costochondritis is benign and self-limited.
• Symptoms usually resolve within weeks, and recurrence rates are low.

Supportive care ^[1][4]

• Reduction of activities that provoke symptoms ^[3]
• Analgesia as needed, e.g.:
  • Acetaminophen or NSAIDs (e.g., naproxen, ibuprofen)
  • Topical analgesics (e.g., diclofenac gel, lidocaine patch, capsaicin cream)
  • Local corticosteroid or lidocaine injections may be considered for refractory pain. ^[2][3]
• Application of heat or ice packs
• Cough suppressants may be considered for coughing that exacerbates chest pain.
• Physical therapy (e.g., stretching exercises)