Costochondritis
Medical Students Edition
Learning objectives: define costochondritis, describe its pathophysiology, perform a focused exam, outline evidence-based management, and list key differentials.
1. Definition
Costochondritis is a benign, self-limiting inflammatory process involving one or more costochondral or costosternal joints without associated swelling. It is distinguished from Tietze syndrome, which presents with painful swelling of a single costal cartilage.2. Epidemiology
- Accounts for 13–36 % of ED visits for chest wall pain.
- Peak age 20–40 years; F:M ≈ 3:1.
- Most commonly affects 2nd–5th costochondral junctions.
3. Anatomy Refresher
Ribs 1–7 articulate via hyaline cartilage to the sternum; ribs 8–10 form the anterior costochondral “false” ribs. Each joint is innervated by intercostal nerves (T2–T6).4. Etiology & Pathophysiology
- Repetitive microtrauma or overuse.
- Viral or post-infectious inflammation (rare).
- Associations: seronegative spondyloarthritis, RA, psoriatic arthritis.
5. Clinical Features
- Sharp, localized anterior chest pain reproduced by palpation or deep inspiration.
- No swelling, no systemic symptoms.
- Pain may radiate to the arm or back.
6. Focused Examination
- Inspection: no erythema, swelling, or deformity.
- Palpation: fingertip pressure over costochondral junctions elicits tenderness.
- Provocative: Crow’s sign (arm abduction increases pain).
7. Differential Diagnosis
| Condition | Red-flag clues |
|---|---|
| Acute MI | Crushing pain, diaphoresis, dyspnea, ↑ troponin |
| Pulmonary embolism | Pleuritic pain, hypoxia, D-dimer, CTPA |
| Tietze syndrome | Painful swelling of a single costal cartilage |
| Rib fracture | Trauma, crepitus on X-ray |
| Herpes zoster | Dermatomal vesicular rash |
8. Investigations
Costochondritis is clinical. Imaging (CXR, ultrasound, MRI) only if red flags or atypical features.9. Evidence-Based Management
- Education & reassurance (cornerstone).
- NSAIDs (e.g., ibuprofen 400 mg PO q8h × 7–10 days).
- Physical therapy: pectoral stretching, scapular stabilization.
- Intercostal nerve block (image-guided steroid/lidocaine) for refractory cases.
- Surgery (costochondrectomy) extremely rare.
10. Prognosis
- Most cases resolve within weeks to months.
- Recurrence ~10 %; counsel on activity modification.
- Return if pain becomes exertional or associated with red flags.
11. Exam Pearls
- Multiple tender joints + no swelling = costochondritis.
- Single swollen joint = Tietze syndrome.
- Reproducible tenderness on palpation is diagnostic.
- Imaging reserved for red flags.
- First-line: NSAIDs + reassurance + posture correction.
Sources: BMJ Best Practice 2024, UpToDate, American Family Physician, Cochrane Reviews.
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