Costochondritis

What is Costochondritis?

Chest pain may arise for many causes including those related to cardiovascular (heart), pulmonary (lungs), gastrointestinal, psychogenic (anxiety etc), musculoskeletal (muscles and joints) and miscellaneous or unknown causes.

Musculoskeletal problems are a common cause of chest pain and costochondritis is one such problem. Costo = ribs , chondro = cartilage and itis means inflammation. Together the term costochondritis signifies inflammation of the rib cartilages. It is also known as costosternal syndrome or anterior chest wall syndrome. The cause of pain in this condition is the inflammation of the rib cage at points where the cartilage connects to the ribs (costochondral junctions) or to the bone in the centre of the chest known as the sternum (chondrosternal joints). Of the 12 ribs one has, the second to fifth costochondral junctions are most commonly involved, and more than one site is affected in 90% of cases. It generally presents as sharp, aching, or pressure-like pain in the front of the chest, worse with movement, deep breathing, or exercise. In one study of adult patients presenting to an emergency department with chest pain, 30% had costochondritis but one needs to rule out heart problems as overlooking this can be dangerous.

A similar condition seen in younger individuals (less than 40 years of age) involving swelling of a second rib cartilage, or sometimes the third rib cartilage and is called Tietze syndrome. In this condition there is visible enlargement due to the inflammatory process which may result from infectious, rheumatologic, and neoplastic causes.  

 Who all are at risk of developing Costochondritis?

Costochondritis is more common in adults in the age group of 40-50 years although other age groups including children may also be affected. There is slight predominance in women (69%) vs. men (56%).  Factors associated with this condition include:

• Physical strain. Proposed mechanisms of injury include pull of surrounding musculature, repetitive arm movement to the opposite side (adduction),  and reduced mobility of posterior spinal structures such as that seen in conditions like ankylosing spondylitis. Often there is history of recent strenuous exercise/ new unaccustomed activities or physical activities that stress the upper extremity. 
• Trauma and chest surgery  and reparative microtrauma can predispose one to developing this condition. 
• Infections.  Viral respiratory infections and bacterial infections such as post-surgical ones are linked to costochondritis. There is sometimes a history of recent chest infection with coughing prior to onset of costochondritis. 
• Arthritis. Costochondritis can be associated with other rheumatological conditions such as seronegative arthropathies, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and other connective tissue syndromes. Many illnesses that have costochondritis as their feature e.g. Fibromyalgia, inflammatory bowel disease etc.
• Tumors. Both cancerous and non-cancerous tumours may lead to costochondritis especially those which involve spread to the ribs (metastasis) 
• Chest wall deformities. These may predispose to the development of costochondritis. 

What are the symptoms of Costochondritis?

Common symptoms include:

•  Pain – stabbing, sharp, aching, or pressure-like pain in the front of the chest. It may radiate to the back and may be present at more than one location, but most often is unilateral. The upper (second through fifth) ribs are most commonly involved.
• Pain may increase with upper body/trunk movements, deep breathing, coughing, stretching and exertional activities.
•  Tietze syndrome presents with visible edema at the involved joint(s) and is typically unilateral involving the second rib (majority) or third rib.
•  Local pressure on the involved joints causes pain (tenderness). Pain reproduced by chest wall palpation is considered atypical for a cardiac cause although does not exclude it. In one study, 12% of patients presenting to an emergency department with chest pain and noted to have chest wall tenderness also had heart attack (acute myocardial infarction). In other studies, coronary artery disease was present in 3 to 6 percent of adult patients with chest pain and chest wall tenderness.

 How is Costochondritis diagnosed?

The diagnosis of costochondritis is largely based on history and a physical examination. Local tenderness in anterior chest wall can raise suspicion as will other tests like crossed-chest adduction manoeuvres. As discussed previously it is important to rule out other serious conditions such as heart / lung problems.  

There are no laboratory tests or imaging tests findings specifically for the diagnosis of costochondritis. The diagnostic tests may be directed towards either ruling out other serious conditions or confirming the diagnosis/ evaluating for underlying conditions. Some of the tests include- chest radiograph, CT chest, MRI chest / chest wall, ultrasound scans, laboratory testing/screening patients for rheumatologic conditions, technetium 99 bone scintigraphy.

What are the treatment options in Costochondritis?

Although high-quality evidence is lacking, treatment options include local application of heat, oral or topical nonsteroidal anti-inflammatory drugs, local application of  numbing patches or creams, physical therapy, and injections. Medications such as anti-inflammatories should be used under medical supervision in the lowest dose and for the shortest duration possible, as long-term use is associated with risks.

The disease course is generally self-limiting with most patients getting better in a few weeks’ time. In one study 91% of patients with new-onset costochondritis had resolution of pain after three weeks of treatment with rest and nonsteroidal anti-inflammatory drugs. Symptoms usually resolve within one to two months but may last for up to one year. `those with persisting pain may require injections / further interventions. There is insufficient data to show recurrence rates of similar presentations.

Interventions/ injections for Costochondritis

Local anaesthetic and steroid injections are considered in cases of persisting pain or suboptimal response to non-invasive treatments. Using ultrasound guidance for performing injections is advisable as it can improve accuracy and reduce the chances of complications such as pneumothorax. It is not necessary to advance the needle into the joint and infiltration of the tissues over the joint is usually adequate for relief. Addition of steroids aid in reducing inflammation thus prolonging the effect of the injection. These injections also have a diagnostic role in confirming the source of pain.

PRP (Platelet Rich Plasma) injections. There is limited guidance available on the  use of platelet-rich plasma for costochondritis. PRP consists of growth factors isolated from one’s own blood. High concentration of platelets (containing the growth factors) are isolated from the blood and injected in the area of pain to provide a regenerative stimulus that promotes tissue repair and helps in providing pain relief. 

Other interventions such as intercostal nerve blocks, Dry Needling and  Acupuncture have also been used to manage the symptoms in costochondritis. 

For more information on treatment of Costochondritis,

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