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Inflammation in the chest area: Costochondritis | NHS inform

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Costochondritis | NHS inform

Costochondritis is the medical term for inflammation of the cartilage that joins your ribs to your breastbone (sternum). This area is known as the costochondral joint.

Cartilage is tough but flexible connective tissue found throughout the body, including in the joints between bones. It acts as a shock absorber, cushioning the joints.

Costochondritis may improve on its own after a few weeks, although it can last for several months or more. The condition doesn’t lead to any permanent problems, but may sometimes relapse.

Tietze’s syndrome

Costochondritis may be confused with a separate condition called Tietze’s syndrome. Both conditions involve inflammation of the costochondral joint and can cause very similar symptoms.

However, Tietze’s syndrome is much less common and often causes chest swelling, which may last after any pain and tenderness has gone.

Costochondritis also tends to affect adults aged 40 or over, whereas Tietze’s syndrome usually affects young adults under 40.

As the conditions are very similar, most of the information below also applies to Tietze’s syndrome.

Signs and symptoms

When the costochondral joint becomes inflamed it can result in sharp chest pain and tenderness, which may develop gradually or start suddenly.

The pain may be made worse by:

  • a particular posture – such as lying down
  • pressure on your chest – such as wearing a seatbelt or hugging someone
  • deep breathing, coughing and sneezing
  • physical activity

When to seek medical help

It can be difficult to tell the difference between the chest pain associated with costochondritis and pain caused by more serious conditions, such as a heart attack.

However, a heart attack usually causes more widespread pain and additional symptoms, such as breathlessness, nausea and sweating.

If you, or someone you’re with, experiences sudden chest pain and you think there’s a possibility it could be a heart attack, dial 999 immediately and ask for an ambulance.

If you’ve had chest pain for a while, don’t ignore it. Make an appointment to see your GP so they can investigate the cause.

Causes of costochondritis

Inflammation is the body’s natural response to infection, irritation or injury.

It’s not known exactly why the costochondral joint becomes inflamed, but in some cases it’s been linked to:

  • severe coughing – which strains your chest area
  • an injury to your chest
  • physical strain from repeated exercise or sudden exertion that you’re not used to – such as moving furniture
  • an infection – including respiratory tract infections (RTIs) and wound infections
  • wear and tear – your chest moves in and out 20 to 30 times a minute, and over time this motion can lead to discomfort in these joints

Diagnosing costochondritis

If you have symptoms of costochondritis, your GP will examine and touch the upper chest area around your costochondral joint. They’ll ask you when and where your pain occurs and look at your recent medical history.

Before a diagnosis can be confirmed, some tests may need to be carried out to rule out other possible causes of your chest pain.

These may include:

  • an electrocardiogram (ECG) – which records the rhythms and electrical activity of your heart
  • a blood test to check for signs of underlying inflammation
  • a chest X-ray

If no other condition is suspected or found, a diagnosis of costrochondritis may be made.

Treating costochondritis

Costochondritis often gets better after a few weeks, but self-help measures and medication can manage the symptoms.

Self-help

Costochondritis can be aggravated by any activity that places stress on your chest area, such as strenuous exercise or even simple movements like reaching up to a high cupboard.

Any activity that makes the pain in your chest area worse should be avoided until the inflammation in your ribs and cartilage has improved.

You may also find it soothing to regularly apply heat to the painful area – for example, using a cloth or flannel that’s been warmed with hot water.

Painkillers

Painkillers, such as paracetamol, can be used to ease mild to moderate pain.

Taking a type of medication called a non-steroidal anti-inflammatory drug (NSAID) – such as ibuprofen and naproxen – two or three times a day can also help control the pain and swelling. 

Aspirin is also a suitable alternative, but shouldn’t be given to children under 16 years old.

These medications are available from pharmacies without a prescription, but you should make sure you carefully read the instructions that come with them before use.

NSAIDs aren’t suitable for people with certain health conditions, including:

  • asthma
  • stomach ulcers
  • high blood pressure
  • kidney or heart problems

Contact your GP if your symptoms get worse despite resting and taking painkillers, as you may benefit from treatment with corticosteroids. 

Corticosteroid injections

Corticosteroids are powerful medicines that can help reduce pain and swelling. They can be injected into and around your costochondral joint to help relieve the symptoms of costochondritis.

Corticosteroid injections may be recommended if your pain is severe, or if NSAIDs are unsuitable or ineffective.

They may be given by your GP, or you may need to be referred to a specialist called a rheumatologist.

Having too many corticosteroid injections can damage your costochondral joint, so you may only be able to have this type of treatment once every few months if you continue to experience pain.

Transcutaneous electrical nerve stimulation (TENS)

TENS is a method of pain relief where a mild electric current is delivered to the affected area using a small, battery-operated device. 

The electrical impulses can reduce the pain signals going to the spinal cord and brain, which may help relieve pain and relax muscles.

They may also stimulate the production of endorphins, which are the body’s natural painkillers.

Although TENS may be used to help relieve pain in a wide range of conditions, it doesn’t work for everyone.

There isn’t enough good-quality scientific evidence to say for sure whether TENS is a reliable method of pain relief. Speak to your GP if you’re considering TENS.

Read more about transcutaneous electrical nerve stimulation (TENS).

Costochondritis – StatPearls – NCBI Bookshelf

Continuing Education Activity

Costochondritis is a benign cause of chest wall pain that results from inflammation of the costal cartilage, the cartilage that connect the ribs to the sternum. Patients often present with chest pain; therefore, other causes of chest pain must be excluded with history and physical exam. If the patient’s history and physical exam warrant additional workup, this should be done before the diagnosis of costochondritis is made. This activity reviews the evaluation, diagnosis, and management of costochondritis and highlights the role of the interprofessional team in the care of affected patients.

Objectives:

  • Describe the history and physical exam findings associated with costochondritis.

  • Explain how to rule out more grave causes of chest pain prior to diagnosing a patient with costochondritis.

  • Describe common treatments for costochondritis.

  • Explain the importance of collaboration amongst interprofessional teams when evaluating patients for costochondritis.

Access free multiple choice questions on this topic.

Introduction

Costochondritis is a chest wall pain caused by inflammation of the costal cartilages or the area where the ribs meet the sternum, known as sternal articulations. It is a benign cause of chest pain. Patients often present with the chief complaint of chest pain; therefore, other causes of chest pain must be excluded with history, physical exam, and/or diagnostic testing prior to a diagnosis of costochondritis.

Etiology

Costochondritis is inflammatory. It is caused by inflammation of the costal cartilages and their sternal articulations, also known as the costochondral junctions.

Epidemiology

The epidemiology of costochondritis is not well established. In a small study published in 1994, there was a higher frequency of costochondritis seen in females and Hispanics. In a group of 122 patients presenting to the emergency department with chest pain not due to malignancy, fever, or trauma, costochondritis was the diagnosis in 36 of the patients (30%).[1]

History and Physical

As with any chest pain, history of present illness, past medical history, social history, family history, and a review of systems are very important. Many deadly causes of chest pain should be ruled out prior to establishing a diagnosis of costochondritis. Consider whether the chest pain history is a concerning indicator of acute coronary syndrome, pulmonary embolism, aortic dissection, pneumonia, esophageal injury, pneumothorax, among others. If there was recent trauma or fall, consider an occult rib fracture.

Typically, if chest wall pain is due to costochondritis, the patient will give a history of the pain worsening with movement and certain positions. The pain will also typically be worse when the patient takes a deep breath. The pain quality is variable, but it may be described as sharp or dull pain.

If the patient complains of radiating pain, shortness of breath, dizziness, exertional chest pain, fever, productive cough, nausea, etc., these are worrisome for other causes of chest pain. Consider pursuing other causes of chest pain prior to establishing a costochondritis diagnosis.

A good heart and lung exam are important to help build your differential diagnosis when a patient complains of chest pain or chest wall pain. If a patient’s chest wall pain is due to costochondritis, the pain is usually reproducible by mild-to-moderate palpation. Often, there is point tenderness where one or two ribs meet the sternum. One pitfall of the typical physical exam findings is that pain due to acute coronary syndrome can also be described as reproducible.[2]

Vital signs are also important. Patients with costochondritis should present with normal vital signs. If your patient is tachycardic or hypotensive, this should raise the suspicion of an alternative diagnosis as the cause of your patient’s chest pain.[3]

Evaluation

The purpose of the evaluation is to determine other causes of chest pain. There is not a test to diagnose costochondritis.

Laboratory

Consider a workup for acute coronary syndrome, pneumonia, pulmonary embolism, among others if the patient’s history and physical exam warrant this workup. 

No laboratory evaluation is necessarily required to diagnose costochondritis. It is important to use the laboratory evaluation to evaluate for other diagnoses that are in your differential.

Radiology

A chest x-ray should be considered in all patients with chest wall pain or chest pain to rule out pneumonia, spontaneous pneumothorax, lung mass, among others. 

A normal chest x-ray will be seen with costochondritis.

Other Tests

An electrocardiogram (ECG) should also be considered in all patients with chest wall pain or chest pain to rule out abnormalities associated with infectious causes of chest pain, ischemia, among others.  

A normal electrocardiogram will be seen with costochondritis.[3][4]

Treatment / Management

The treatment for costochondritis is a nonsteroidal anti-inflammatory drug (NSAID).

Some consideration can be given to a course of naproxen or meloxicam because these are dosed twice daily and once daily, respectively. Other NSAIDs can also be used, including ibuprofen. The NSAID of choice is based on provider/patient preference.

NSAIDs are contraindicated in acute and chronic kidney disease.

It is also important to discuss with patients the risk of gastritis with chronic NSAID use. 

If patients have severe or refractory costochondritis, refer for outpatient follow-up. Physical therapy is a treatment option for refractory costochondritis.[5][3]

Differential Diagnosis

The differential diagnosis for costochondritis is rather long. Some of the diagnoses included are associated with major morbidity and mortality.

Acute Coronary Syndrome (ACS)

This diagnosis should be considered in any patient presenting with chest pain. If you feel the patient’s history and physical are concerning for ACS, consider an ECG and troponin level to assist in ruling out ACS. The patient should also be on continuous cardiac monitoring while in the emergency department.

Pneumothorax

Consider the patient population at risk for spontaneous pneumothorax. A chest x-ray and/or point-of-care ultrasound (POCUS) can be used to assist in evaluating the possibility of pneumothorax.

Pneumonia

If the patient is complaining of a productive cough and/or fever or is high risk for pneumonia, consider this on your differential diagnosis. Pneumonia can cause chest pain in addition to the other symptoms we associate with the diagnosis. A chest x-ray, complete blood count (CBC), and a basic metabolic panel (BMP) can be helpful when considering this as a differential diagnosis. Vital signs are also important when considering this diagnosis.

Aortic Dissection

This is a medical and possibly a surgical emergency. Consider a CTA to evaluate for aortic dissection if this is a concern based on the patient’s history and physical exam.

Pulmonary Embolism

Ask about pulmonary embolism (PE) risk factors, such as malignancy, recent travel, recent surgery, personal history of PE or deep vein thrombosis (DVT) and symptoms, such as shortness of breath. Tachycardia can also be a sign of a PE. Consider using a clinical decision rule, such as PERC and Well’s criteria when considering PE. A D-dimer and/or CTA can be helpful when evaluating for a PE if this is on your differential diagnosis. There may also be nonspecific ECG and POCUS changes seen.

Esophageal Perforation

The healthcare professional must have a high clinical suspicion for this diagnosis, and it is often due to an iatrogenic cause, such as a recent endoscopy.  This patient’s pain should be severe and unrelenting, and typically, they present in shock with abnormal vital signs.[6]

Prognosis

Costochondritis is a self-limited condition.

Complications

This is a self-limited disease. Patients may present with refractory or recurrent costochondritis. The most important part of the diagnosis of costochondritis is ensuring other, more deadly causes of chest pain have been ruled out.

Deterrence and Patient Education

Educate the patient on proper dosing of NSAIDs and the importance of not taking over-the-counter NSAIDs in addition to the prescription provided.

Educate the patient on return precautions, including worsening chest pain, shortness of breath, dizziness, and syncope.

Pearls and Other Issues

Costochondritis should be a diagnosis of exclusion. Rule out other causes of chest pain that are associated with increased morbidity and mortality. Patients typically present with chest pain worse with breathing, and it is often positional. It should be reproducible on a physical exam, and the patient’s vital signs should be within normal limits. If ordered, labs, ECG, and chest x-ray should also be normal. Costochondritis is a self-limited disease. The standard of care is treatment with NSAIDs. Consider ECG and chest x-ray in all patients who present with a chief complaint of chest pain.[6]

Enhancing Healthcare Team Outcomes

Because costochondritis is a diagnosis of exclusion, it can be helpful to involve specialists when ruling out other causes of chest pain. While providers often complete the initial read of the chest x-ray and the ECG, radiology, and cardiology will complete the official reads. It is not uncommon for occult, non-displaced rib fractures to be missed on a chest x-ray following trauma, such as a fall or car accident. If there are any questionable ECG findings, it is prudent to discuss these with a cardiologist or electrophysiologist before diagnosing a patient with costochondritis.

If costochondritis becomes refractory, consider referral to orthopedics and/or physical therapy to assist with treating the patient in an attempt to improve the patient’s pain. Clinicians may also consider referrals to other specialists to evaluate for other causes of chest pain at this time, including gastroenterology and cardiology. There may be a second diagnosis complicating the initial diagnosis of costochondritis.[5][7]

Review Questions

  • Access free multiple choice questions on this topic.

  • Comment on this article.

References

1.

Disla E, Rhim HR, Reddy A, Karten I, Taranta A. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994 Nov 14;154(21):2466-9. [PubMed: 7979843]

2.

Lanham DA, Taylor AN, Chessell SJ, Lanham JG. Non-cardiac chest pain: a clinical assessment tool. Br J Hosp Med (Lond). 2015 May;76(5):296-300. [PubMed: 25959942]

3.

Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013 Dec;40(4):863-87, viii. [PubMed: 24209723]

4.

McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013 Feb 01;87(3):177-82. [PubMed: 23418761]

5.

Zaruba RA, Wilson E. IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES. Int J Sports Phys Ther. 2017 Jun;12(3):458-467. [PMC free article: PMC5455195] [PubMed: 28593100]

6.

King JE, Magdic KS. Chest pain: a time for concern? AACN Adv Crit Care. 2014 Jul-Sep;25(3):279-83. [PubMed: 25054533]

7.

Gologorsky R, Hornik B, Velotta J. Surgical Management of Medically Refractory Tietze Syndrome. Ann Thorac Surg. 2017 Dec;104(6):e443-e445. [PubMed: 29153814]

Disclosure: Jessica Schumann declares no relevant financial relationships with ineligible companies.

Disclosure: Tanuj Sood declares no relevant financial relationships with ineligible companies.

Disclosure: John Parente declares no relevant financial relationships with ineligible companies.

Thoracic myositis – treatment in Moscow

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Myositis of the chest

Myositis of the chest is a pathology of the pectoral muscles, in which pain and tender lumps occur in the chest area. If the disease is not treated in a timely manner, it can give complications in the form of atrophy of muscle tissue, as well as disruption of the organs located in the chest. In some cases, chest myositis occurs without symptoms at all, but most patients still complain of limited mobility at the site of inflammation and pain. Myositis of the chest is a really serious disease that requires immediate treatment.

In our work, we focus on the general improvement of the patient’s body and the launch of self-healing processes. The attending physician provides deep contact with the patient, tracking his changes. Our approach does not involve taking pills and performing operations.

With any procedure, the patient receives not only treatment, but also attention: the doctor helps to cope with nervous tension and gives recommendations for self-help in the future.

The practices we use help to relax muscles that have been in hypertonicity for a long time, to restore joint mobility.

The methods of Tibetan medicine involve a longer, but at the same time the most gentle treatment, the principles of which are not aimed at eliminating the symptoms, but at working with the causes of the disease.

Why does myositis of the pectoral muscles occur?

Inflammatory process in the area of ​​the pectoral muscles can occur due to various diseases and external factors that affect the general health of a person. The reasons for the appearance of myositis, experts of traditional (Western) medicine include:

  • Infectious diseases. For example, influenza or SARS. Myositis can be the result of transferred viruses.
  • Physical activity. Some people suffer from myositis due to improperly structured workouts in the gym, while others daily lift weights at work, which leads to the onset of this disease.
  • Parasites. Parasitic myositis occurs rarely even if parasites live in the human body, which cause the disease.
  • Muscle injuries and bruises. It can be mechanical injuries or regular convulsions.
  • Bacteria can cause one of the most severe forms of myositis. In such cases, a purulent focus appears in the muscle tissue. This is accompanied by a deterioration in the general condition, severe pain, fever, weakness. The infection can also spread to other organs. For example, on the lungs.

Non-traditional (oriental) medicine considers disease as a manifestation of an imbalance in the three channels of the human body. Weakened immunity and diseases of the musculoskeletal system are the results of the disharmony of “Slime” and “Wind”. Thus, Eastern wisdom in interpreting the causes of myositis of the pectoral muscles complements the theory of traditional medicine.

What are the forms of thoracic myositis?

Today, there are two forms of myositis of the pectoral muscles – acute and chronic. The first is usually accompanied by severe pain in the chest area.

In the absence of proper treatment, the acute form flows into the chronic, then the pain dulls. The patient gets used to unpleasant sensations and does not pay attention to them. But at the same time, exacerbations steadily occur against the background of colds, changes in weather, or a long stay in an uncomfortable position.

Myositis can occur on the left side of the chest or on the right. In the first case, it can be confused with heart disease.

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Characteristic symptoms of chest myositis

The following symptoms of intercostal myositis are distinguished:

  • Pain. They can be exacerbated by changes in the weather, during intense movements, or after a long stay in one position. Over time, the pain may become more pronounced.
  • Puffiness. Swelling or puffiness is usually characteristic of purulent myositis. In addition, these symptoms may be accompanied by weakness, malaise, and fever. Also, at the site of inflammation, the skin may turn red.
  • Muscle tension. It slightly limits movement and reduces pain.

Sometimes the pain disappears and does not bother a person for several days, but then returns again, and often with double strength. This is most often due to bruising of the chest, hypothermia, or infections.

After a while, the affected muscles can become weaker, and then completely decrease in size, their atrophy develops.

In order to avoid serious complications, it is necessary to limit your activity during treatment. It is not recommended to drive for a long time, play sports, including light exercises and morning runs, it is forbidden to lift weights, engage in outdoor games. It is necessary to lead a sedentary lifestyle for the period of treatment. Also, recovery will slow down the abuse of alcoholic beverages and smoking. Such habits contribute to metabolic disorders, prolonged narrowing of blood vessels, and as a result, the disease will progress.

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