Costochondritis, Costosternal Syndrome, Parasternal Chondrodynia, Anterior Chest Wall Syndrome

  • Definitions
  1. Costochondritis
    1. Chest Wall Pain due to costochondral joint inflammation
  • Epidemiology
  1. Peak Incidence age 40 to 50 years old
  2. Slightly more common in women
  • Pathophysiology
  1. Chronic inflammation affecting the costochondral joints
  2. Idiopathic
  • Symptoms
  1. Bilateral, parasternam Chest Wall Pain accentuated by respiratory movements (e.g. deep breathing, cough)
  2. Localized pain to the costochondral margin at ribs 2 to 5
  3. Affects more than one costochondral margin in most patients
  • Signs
  1. NO swelling, erythema, warmth at costochondral margins (inflammatory changes absent)
  2. Costochondral margin tenderness
    1. Precaution: Many patients with Acute Coronary Syndrome also have Chest Wall Tenderness
  3. Palpation reproduces Chest Pain
  4. Crowing Rooster Maneuver
    1. Patient extends neck AND
      1. Places hands behind their head or
      2. Places hands, palms out, in front of chest, with flexed elbows and abducted Shoulders
    2. Provider pulls patients arms posteriorly and superiorly behind them
  5. Crossed Chest Adduction
    1. Ipsilateral arm adducted across chest AND
    2. Neck rotated toward ipsilateral Shoulder
  • Differential Diagnosis
  1. See Chest Wall Pain
  2. See Chest Pain
  3. See Pleuritic Chest Pain
  4. Tietze Syndrome
    1. Local edema of involved joint
    2. Common unilaterally at second rib margin
    3. Provoked by infection or Trauma
  • Evaluation
  1. See Chest Pain
  2. Evaluate Costochondritis as a diagnosis of exclusion
    1. Delayed Costochondritis diagnosis is not associated with significant adverse effects
    2. Missed coronary syndrome, Pulmonary Embolism, Aortic Dissection risks death
      1. At minimum, obtain a throrough Chest Pain history and exam, and at least an EKG in most patients
    3. No lab test or imaging test is definitive for Costochondritis
      1. Testing is intended to exclude other, more serious Chest Pain Causes
  • Imaging
  1. See Chest Pain for non-musculoskeletal indications
  2. XRay Indications
    1. Respiratory symptoms (e.g. Shortness of Breath, cough)
  3. CT Chest Indications
    1. Neoplasm or infection-associated local destruction suspected
  4. Gallium Scanning Indications
    1. Infection suspected
  • Management
  1. Avoid provocative activities
  2. Local measures
    1. NSAIDs
    2. Local heat or ice to the area
    3. Lidocaine 4% patch on for 12 of every 24 hours
    4. Diclofenac Gel applied to affected area
  3. Other measures that may have benefit
    1. Acupuncture
    2. Physical Therapy
      1. Small benefit with physical therapist directed targeted Stretching Program
      2. Rovetta (2009) G Ital Med Lav Ergon 31(2): 169-71 [PubMed]
  • Prognosis
  1. Conservative management (rest, NSAIDs)
    1. Resolution within 3 weeks in 91% of patients, and a 4% recurrence rate after 2 years
    2. Boran (2017) World J Pharm Res 6(8): 76-85 [PubMed]