Can you tell me about costochondritis?
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Here is a thorough overview of costochondritis, drawn primarily from Harrison's Principles of Internal Medicine (22nd ed., 2025) and supplemented by other textbooks.
Costochondritis
What It Is
Costochondritis is inflammation of the costochondral or costosternal junctions - the cartilage that connects the ribs to the sternum. It produces localized anterior chest wall pain that can mimic cardiac or pulmonary disease, making it an important diagnosis to recognize (and to not over-diagnose).
The term is often used interchangeably with Tietze syndrome, but there is a meaningful clinical distinction:
| Feature | Tietze Syndrome | Costochondritis |
|---|---|---|
| Swelling | Present (visible/palpable) | Absent |
| Age of onset | Usually <40 years | Usually >40 years |
| Joints affected | Typically 2nd or 3rd costochondral joint (one joint) | 3rd, 4th, and 5th joints (often multiple) |
| Sex | Equal | More common in women |
Symptoms
- Anterior chest pain, which may be sudden or gradual in onset
- Pain that radiates to the arms or shoulders
- Pain worsened by sneezing, coughing, deep breathing, or twisting movements of the chest
- Tenderness reproducible on palpation of the affected costochondral joint(s)
The reproducibility of pain with chest wall palpation is the hallmark that distinguishes it from cardiac causes of chest pain. - Harrison's Principles of Internal Medicine 22E, p. 828
Diagnosis
Costochondritis is a clinical diagnosis - no specific test confirms it. Key points:
- Palpation of the costochondral joints reproduces or worsens the pain
- No imaging finding is diagnostic, though imaging may be used to exclude other causes
- Care should be taken not to over-diagnose it: many patients with acute chest pain syndromes will be tender to vigorous palpation of the costochondral joints even when costochondritis is not the true cause
Differential Diagnosis
Conditions that must be ruled out or considered include:
- Cardiac: angina, acute MI - always the priority exclusion
- Pulmonary-vascular: pulmonary embolism, pleuritis
- Inflammatory arthritis: rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and reactive arthritis can all involve costochondral joints, but are distinguished by other clinical features
- Chest wall trauma or rib fracture - reproducible with palpation, similar to costochondritis
- Herpes zoster (shingles) - can precede the rash
- Malignancy - rib or chest wall invasion can mimic Tietze syndrome
- Xiphoidalgia and the slipping rib syndrome (usually the 10th rib, pain below the rib cage reproducible by hooking the examiner's fingers under the rib)
- Osteomalacia - can cause rib pain with or without microfractures; check vitamin D levels
Murray & Nadel's Textbook of Respiratory Medicine notes that the best way to distinguish musculoskeletal chest pain from angina is reproduction of the pain with palpation or manipulation of the affected area, along with a history of recent trauma, infection, or coughing. - p. 1093
Treatment
Treatment is primarily symptomatic and the condition is usually self-limiting:
- NSAIDs / analgesics - first-line for pain relief and to reduce inflammation
- Local glucocorticoid injections - effective for refractory cases
- Heat or ice applied locally can provide symptomatic relief
- Activity modification - avoiding movements that aggravate the pain (heavy lifting, twisting)
- Frameworks for Internal Medicine notes that costochondritis, chest wall trauma, and rib fractures "typically respond well to NSAIDs"
There is no specific antibiotic or disease-modifying therapy. Most cases resolve over weeks to months.
Key Clinical Pearls
- Always exclude serious cardiac and pulmonary causes before settling on a costochondritis diagnosis, especially in patients with risk factors for heart disease
- Overly vigorous palpation can produce false-positive tenderness - be systematic and gentle
- In younger patients (<40) with a swollen costochondral joint, consider Tietze syndrome specifically
- In patients with very low vitamin D, rib pain can be from osteomalacia - worth checking
- Malignancy invading the chest wall can simulate this syndrome
No recent systematic reviews or meta-analyses specifically on costochondritis management were found in PubMed (2023-2026), reflecting that it remains primarily managed based on clinical guidelines and expert consensus rather than large trial data.
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