Costochondritis

Definition & Distinction from Tietze Syndrome

Clinical Features

• Anterior chest pain — may be sudden or gradual in onset
• Pain can radiate to the arms or shoulders
• Aggravated by:
  • Sneezing, coughing
  • Deep inspiration
  • Twisting motions of the chest
• Point tenderness on palpation of the affected costochondral joints — a key clinical sign
• Can superficially mimic cardiac or pulmonary-vascular causes of chest pain

Differential Diagnosis

• Cardiac: Myocardial infarction, angina (costochondritis can mimic these closely)
• Pulmonary/vascular: Pulmonary embolism, pleuritis
• Inflammatory arthritis: Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, reactive arthritis — distinguished by other systemic features
• Malignancy: Rib/chest wall invasion by tumor
• Thoracic herpes zoster: Can produce similar chest wall pain
• Osteomalacia: Rib pain ± microfractures; check vitamin D levels
• Xiphoidalgia
• Slipping rib syndrome: Involves the 10th or lower ribs; pain below the rib cage reproducible by hooking fingers under the rib and applying caudal traction
• Mastalgia (in women): Extramammary causes of breast/chest pain include costochondritis

Diagnosis

• Localized tenderness on palpation of the costochondral joints
• Reproduction of pain with chest movement
• Exclusion of life-threatening causes of chest pain

⚠️ Care should be taken not to over-diagnose costochondritis in acute chest pain — many patients are tender to vigorous palpation of the costochondral joints even without this condition.

Treatment

• Analgesics (NSAIDs are first-line)
• Anti-inflammatory drugs
• Local glucocorticoid injections — for refractory cases
• The condition is generally self-limiting

Costochondritis in a 33-Year-Old Male

Age/Sex Context

• Tietze syndrome typically affects patients under 40, with equal sex distribution
• Classic costochondritis tends to occur in women >40
• At age 33, the presentation may include visible or palpable swelling at the affected joint — distinguishing it as Tietze syndrome

Presentation to Expect

• Anterior chest pain, usually at the 2nd or 3rd costochondral joint (Tietze) or 3rd–5th (costochondritis)
• Pain may radiate to the shoulder or arm — can be mistaken for cardiac pain
• Worsened by deep breathing, coughing, sneezing, twisting
• Point tenderness on palpation — the most important clinical finding
• May follow an upper respiratory tract infection or physical exertion

Critical Priority: Rule Out Life-Threatening Causes First

Spontaneous pneumothorax specifically affects tall, thin young men and presents with acute dyspnea and pleuritic chest pain — always consider this in a young male before labeling pain as costochondritis.

Diagnosis

• ECG — rule out ischemia/pericarditis
• Troponin — rule out ACS (if presentation warrants)
• CXR — rule out pneumothorax, pneumonia
• D-dimer / CT-PA — if PE suspected
• Physical exam: firm pressure on the costochondral joint reproducing the pain is key

⚠️ Do not over-diagnose: many patients are tender to vigorous palpation of costochondral joints even without true costochondritis. Be cautious in any patient with acute chest pain and cardiac risk factors.

Treatment

1. NSAIDs (e.g., ibuprofen 400–600 mg TID with food) — first-line
2. Rest and activity modification — avoid aggravating movements
3. Topical diclofenac — useful adjunct with fewer systemic effects
4. Local corticosteroid injection — for refractory or severe cases
5. Reassurance — the condition is benign and self-limiting; most cases resolve within weeks to months