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Am Fam Physician. 2021;104(1):73-78

Patient information: See related handout on costochondritis.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Costochondritis is a common cause of chest pain. It most commonly occurs in adults between 40 and 50 years of age, with a slight predominance in women. Although musculoskeletal and other chest wall conditions are the most common etiology for chest pain presenting to primary care, an initial differential diagnosis should include cardiovascular, psychogenic, pulmonary, gastrointestinal, and miscellaneous or unknown sources (more to less common, respectively). Additionally, physicians should remain vigilant throughout the workup because a notable portion of patients with chest wall tenderness to palpation may also have acute myocardial infarction. After a musculoskeletal or chest wall source is determined, differential diagnosis includes costochondritis, muscle trauma (including postoperative) or overuse, arthritis, fibromyalgia, neoplasm, infection, herpes zoster, Tietze syndrome, painful xyphoid syndrome, and slipping rib syndrome. The diagnosis of costochondritis is largely based on history and a physical examination that demonstrates reproduction of pain through palpation of the parasternal region of the chest wall, performance of a crowing rooster maneuver, and/or a crossed-chest adduction maneuver. Although high-quality evidence is lacking, treatment options include local application of heat, oral or topical nonsteroidal anti-inflammatory drugs, lidocaine patches, capsaicin cream, physical therapy, and acupuncture. Most patients will have complete resolution of symptoms in a few weeks' time with conservative therapy. Recalcitrant cases may respond to corticosteroid injections.

Costochondritis is a commonly encountered condition in primary care that is characterized by chest wall pain from inflammation in the costochondral joints. It most commonly occurs in adults 40 to 50 years of age. This article reviews the best available patient-oriented evidence for costochondritis.

Epidemiology

  • The most common age for costochondritis is middle age (between 40 and 50 years of age) with a slight predominance in women (69%) vs. men (56%).13

  • Chest pain in adolescents presenting to an outpatient clinic is most often diagnosed with a musculoskeletal etiology (31%), with costochondritis being diagnosed 13% of the time.3,4

  • Approximately 1% to 3% of all ambulatory visits in the primary care setting are for chest pain.511 Of these, chest wall pain accounts for 20% to 50%.1,512 Costochondritis in particular accounts for 6% to 13%.6,10,11

  • In emergency departments, chest pain accounts for 9% to 10% of visits, with musculoskeletal causes accounting for 15% to 45% of noncardiac chest pain.1315

Diagnosis

DIFFERENTIAL DIAGNOSIS

  • The differential diagnosis for patients with chest pain is broad and must be carefully considered before settling on a diagnosis of costochondritis (Table 1).1,6,1628

  • Within the subset of musculoskeletal and other chest wall conditions, a number of diagnoses should be considered (Table 2).3,2937

DiagnosisClinical findingsLR+LR–
Acute myocardial infarction16 Chest pain radiates to both arms7.10.67
Third heart sound on auscultation3.20.88
Hypotension3.10.96
Acute thoracic aortic dissection17 Acute chest or back pain and a pulse differential in the upper extremities5.3NA
Chest wall pain1 At least two of the following findings: localized muscle tension, stinging pain, pain reproducible by palpation, absence of cough3.00.47
Gastroesophageal reflux disease18,19 Burning retrosternal pain, acid regurgitation, sour or bitter taste in the mouth; one-week trial of high-dose proton pump inhibitor relieves symptoms3.10.30
Heart failure20 Pulmonary edema on chest radiography11.00.48
Clinical impression/judgment9.90.65
History of heart failure5.80.45
History of acute myocardial infarction3.10.69
Panic disorder/anxiety state21 Ask a single question: In the past four weeks, have you had an anxiety attack (suddenly feeling fear or panic)?4.20.09
Pericarditis22,23 Clinical triad of pleuritic chest pain (increases with inspiration or when reclining and lessens by leaning forward), pericardial friction rub, and electrocardiographic changes (PR-interval depression, diffuse ST-segment elevation with concave downward appearance, and lack of T-wave inversion)NANA
Pneumonia24,25,28 Egophony (E to A change due to increased resonance and higher pitch of spoken words when auscultated over areas of lung consolidation)8.60.96
Clinical impression7.70.54
Dullness to percussion4.30.79
Fever2.10.71
Pulmonary embolism26,27 High pretest probability based on Wells criteria6.81.80
Moderate pretest probability based on Wells criteria1.3*0.70
Low pretest probability based on Wells criteria0.17.60
ConditionDiagnostic considerationsTreatment principles
Arthritis of sternoclavicular, sternomanubrial, or shoulder jointsTenderness to palpation of specific joints of the sternum; evidence of joint sclerosis visible on radiographyAnalgesics, intra-articular corticosteroid injections, physiotherapy 29,30
CostochondritisTenderness to palpation of costochondral junctions; reproduces patient's pain; usually multiple sites on same side of chest31 Simple analgesics; heat or ice; rarely, local anesthetic injections or corticosteroid injections29,30
Destruction of costal cartilage by infections or neoplasmBacterial or fungal infections or metastatic neoplasms to costal cartilages; infections occur postsurgery or in intravenous drug users; chest computed tomography imaging useful to show alteration or destruction of cartilage and extension of masses to chest wallAntibiotics or antifungal drugs; surgical resection of affected costal cartilage; treatment of neoplasm based on tissue type32,33
FibromyalgiaSymmetric tender points at second costochondral junctions, with characteristic tender points in the neck, back, hip, and extremities and widespread pain29,31 Graded exercise is beneficial; cyclobenzaprine (Flexeril), antidepressants, and pregabalin (Lyrica) may be beneficial34
Herpes zoster of thoraxClusters of vesicles on red bases that follow one or two dermatomes and do not cross the midline; usually preceded by a prodrome of pain; postherpetic neuralgia is potential complication that is more common in older patients35 Oral antiviral agents (e.g., acyclovir, famciclovir [Famvir], valacyclovir [Valtrex]); analgesics as needed for pain; may require narcotics or topical lidocaine patches to control pain35
Painful xiphoid syndromeTenderness at sternoxiphoid joint or over xiphoid process with palpation36 Usually self-limited unless associated with congenital deformity of xiphoid; analgesics; rarely, corticosteroid injections36
Slipping rib syndromeTenderness and hypermobility of anterior ends of lower costal cartilages causing pain at lower anterior chest wall or upper abdomen; diagnosis by “hooking maneuver”: curving fingers under costal margin and gently pulling anteriorly—a “click” and movement is felt that reproduces patient's pain31,37 Rest, physiotherapy, intercostal nerve blocks; if chronic and severe, surgical removal of hypermobile cartilage segment31
Tietze syndromeSingle tender and swollen, but nonsuppurative, costochondral junction, usually in costochondral junction of ribs two and three31,37 Simple analgesics; usually self-limiting; rarely, corticosteroid injections29,31
Traumatic muscle pain and overuse myalgiaHistory of trauma to chest or recent new onset of strenuous exercise to upper body (e.g., rowing); may be bilateral and affecting multiple costochondral areas; muscle groups may also be tender to palpation31 Simple analgesics; refrain from doing or reduce intensity of strenuous activities that provoke pain29,31

SIGNS AND SYMPTOMS

  • The typical presentation of costochondritis is bilateral parasternal chest wall pain exacerbated by deep breaths, coughing, and stretching.

  • The upper (predominantly second through fifth) costochondral and/or costosternal junctions are most commonly involved.2,3,31,38

  • The areas of tenderness are not generally accompanied by heat, erythema, or localized swelling.2,3,31,38,39

  • Tietze syndrome presents similarly to costochondritis but includes visible edema at the involved joint(s), typically is unilateral involving the second rib, and is often incited by infection or trauma.3,31,40

  • Pain reproduced by the following maneuvers has classically proven helpful: direct palpation to the involved costosternal or costochondral junction; the crowing rooster maneuver (patient neck extension simultaneously accompanied by the physician placing posterior and superior traction on the patient's arms from behind [Figure 1; also see a video describing the crowing rooster maneuver); and crossed-chest adduction of the ipsilateral arm combined with neck rotation toward the ipsilateral shoulder41 (Figure 2; also see a video describing the crossed-chest adduction maneuver).

  • A study of primary care patients with chest pain found that pain reproducible by palpation, no history of coronary heart disease, pain that is neither retrosternal nor oppressive, the physician not being concerned about the cause of chest pain, pain being well-localized by history or physical examination, and stabbing pain were all independent predictors of chest wall syndrome as the cause of chest pain (Table 3).42

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