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As a New Zealand manual physiotherapist and lecturer, I've added our standard recognised view of most costochondritis pain and inflammation at the sternocostal joints as overuse irritation driven by hypomobile costovertebral joints. Happy to justify.
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==Pathogenesis==
==Pathogenesis==
The pathogenesis underlying the development of costochondritis remains unclear. Proposed mechanisms of injury include [[neurogenic inflammation]], muscular imbalance, increased muscular pull on the rib,<ref name="Sik2009"/> mechanical dysfunction at the [[costotransverse joint]] of the rib,<ref name="Sik2009"/> or a derangement of the mechanical structure of the costochondral junction.<ref name="Ayloo2013"/>
The pathogenesis underlying the development of costochondritis remains unclear. Proposed mechanisms of injury include [[neurogenic inflammation]], muscular imbalance, increased muscular pull on the rib,<ref name="Sik2009"/> mechanical dysfunction at the [[costotransverse joint]] of the rib,<ref name="Sik2009"/> or a derangement of the mechanical structure of the costochondral junction.<ref name="Ayloo2013"/> A view from New Zealand manual [[Physical therapy|physiotherapy]] sees the pain and inflammation at the [[Sternocostal joints|costosternal joints]] on the breastbone as an overuse irritation consequent on hypomobility (lack of movement) of the [[costovertebral joints]] at the spinal ends of the same ribs.<ref name=":0">{{Cite journal|last=Ian Rabey|first=Martin|title=Costochondritis: Are the symptoms and signs due to neurogenic inflammation. Two cases that responded to manual therapy directed towards posterior spinal structures|url=http://linkinghub.elsevier.com/retrieve/pii/S1356689X07000276|journal=Manual Therapy|volume=13|issue=1|pages=82–86|doi=10.1016/j.math.2006.12.007}}</ref> <ref name=":1">{{Cite journal|last=Grindstaff|first=Terry L.|last2=Beazell|first2=James R.|last3=Saliba|first3=Ethan N.|last4=Ingersoll|first4=Christopher D.|date=2010-06-01|title=Treatment of a female collegiate rower with costochondritis: a case report|url=http://dx.doi.org/10.1179/106698110X12640740712653|journal=Journal of Manual & Manipulative Therapy|volume=18|issue=2|pages=64–68|doi=10.1179/106698110X12640740712653|issn=1066-9817}}</ref> This would account for such specific pain and inflammation localized to only some costosternal joints; a systemic origin does not.


==Differential diagnosis==
==Differential diagnosis==
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==Treatment==
==Treatment==
Costochondritis may be treated with physical therapy (including ultrasonic, [[Transcutaneous electrical nerve stimulation|TENS]], with or without nerve stimulation) or with medication. Treatment may involve the use of [[nonsteroidal anti-inflammatory drugs]] (NSAIDs) such as [[ibuprofen]] or other pain relief medications ([[analgesics]]) such as [[acetaminophen]].<ref name="Medline"/><ref name="Family"/> Severe cases of costochondritis may call for the use of [[opioid]] medications such as [[hydrocodone]] or [[oxycodone]], [[tricyclic antidepressant]] medications such as [[amitriptyline]] for pain from chronic costochondritis, or [[anti-epileptic drugs]] such as [[gabapentin]] may be used.<ref>{{cite web |url=http://www.mayoclinic.com/health/costochondritis/DS00626/DSECTION=treatments%2Dand%2Ddrugs |title=Treatments and drugs |year=2012 |work= |publisher=Mayo Clinic |accessdate=26 December 2012}}</ref> Oral or injected [[corticosteroid]]s may be used for cases of costochondritis unresponsive to treatment by NSAIDs; however, this treatment has not been the subject of study by rigorous [[randomized controlled trial]]s and its practice is currently based on clinical experience.<ref>{{cite journal |vauthors=Gandhi V, Costello J |title=Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: The use of corticosteroids in the management of costochondritis|journal=Emerg Med J |volume=29 |issue=8 |pages=686 |date=August 2012|pmid= 22787240|doi=10.1136/emermed-2012-201590.4 |type=Review}}</ref> Rest from stressful physical activity is often advised during the recovery period.<ref name="Family"/>
Costochondritis may be treated with physical therapy (including ultrasonic, [[Transcutaneous electrical nerve stimulation|TENS]], with or without nerve stimulation) or with medication. Treatment may involve the use of [[nonsteroidal anti-inflammatory drugs]] (NSAIDs) such as [[ibuprofen]] or other pain relief medications ([[analgesics]]) such as [[acetaminophen]].<ref name="Medline"/><ref name="Family"/> Severe cases of costochondritis may call for the use of [[opioid]] medications such as [[hydrocodone]] or [[oxycodone]], [[tricyclic antidepressant]] medications such as [[amitriptyline]] for pain from chronic costochondritis, or [[anti-epileptic drugs]] such as [[gabapentin]] may be used.<ref>{{cite web |url=http://www.mayoclinic.com/health/costochondritis/DS00626/DSECTION=treatments%2Dand%2Ddrugs |title=Treatments and drugs |year=2012 |work= |publisher=Mayo Clinic |accessdate=26 December 2012}}</ref> Oral or injected [[corticosteroid]]s may be used for cases of costochondritis unresponsive to treatment by NSAIDs; however, this treatment has not been the subject of study by rigorous [[randomized controlled trial]]s and its practice is currently based on clinical experience.<ref>{{cite journal |vauthors=Gandhi V, Costello J |title=Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: The use of corticosteroids in the management of costochondritis|journal=Emerg Med J |volume=29 |issue=8 |pages=686 |date=August 2012|pmid= 22787240|doi=10.1136/emermed-2012-201590.4 |type=Review}}</ref> In those cases where the pain and inflammation at the sternocostal joints on the breastbone is an overuse consequence of hypomobility of the costovertebral joints on the spine, manual physiotherapy treatment is directed at freeing these latter joints up, with good reported anecdotal and clinical results, though supported by limited research to date.<ref name=":0" /><ref name=":1" />  Rest from stressful physical activity is often advised during the recovery period.<sup>[4]</sup>


==Epidemiology==
==Epidemiology==
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* [http://patient.info/health/Costochondritis Benign Tender Chest Wall Pain of Costosternal Joints Inflammation at patient.info]
* [http://patient.info/health/Costochondritis Benign Tender Chest Wall Pain of Costosternal Joints Inflammation at patient.info]
* [http://www.medicinenet.com/costochondritis_and_tietze_syndrome/article.htm Costochondritis and Tietze Syndrome]
* [http://www.medicinenet.com/costochondritis_and_tietze_syndrome/article.htm Costochondritis and Tietze Syndrome]
* [https://www.youtube.com/watch?v=uvJbQFDeyOk New Zealand manual physiotherapy overview of costochondritis]


[[Category:Musculoskeletal disorders]]
[[Category:Musculoskeletal disorders]]

Revision as of 01:56, 4 October 2016

Costochondritis
SpecialtyRheumatology Edit this on Wikidata

Costochondritis, also known as chest wall pain, costosternal syndrome, or costosternal chondrodynia[1] is an acute[2] and often temporary inflammation of the costal cartilage, the structure that connects each rib to the sternum at the costosternal joint. The condition is a common cause of chest pain.[1][3][4] Though costochondritis often resolves on its own, it can be a recurring condition that has little or no signs of onset.[5]

Costochondritis symptoms can be similar to the chest pain associated with a heart attack.[6][7] Unexplained chest pain is considered a medical emergency until life-threatening cardiac issues can be ruled out.[4][7] Severe cases of costal cartilage inflammation that also involve painful swelling are sometimes referred to as Tietze's syndrome, a term sometimes used interchangeably with costochondritis. However, some physicians view costochondritis and Tietze's syndrome as separate disease states due to the absence of costal cartilage swelling in costochondritis.[2][8]

Treatment options are quite limited and usually involve a combination of rest, analgesics, or anti-inflammatory medications.[8] Cases with persistent discomfort may be managed with cortisone injections[6][8] or surgery may be indicated if the condition is severe. Individuals with costochondritis are typically instructed to avoid strenuous physical activity to prevent the onset of an attack.[9]

Signs and symptoms

Pain or tenderness to palpation usually occurs on the sides of the sternum, affects multiple ribs, and is often worsened with coughing, deep breathing, or physical activity.[2][10] On physical examination, a physician inspects and feels the patient for swollen or tender areas, and can often produce the pain of costochondritis by moving the patient's rib cage or arms.[2][4][8][11] A factor that may aid in the differentiation of costochondritis from Tietze syndrome is the location of the pain on the sternum. Costochondritis typically affects the third, fourth, and fifth costosternal joints in contrast to Tietze's syndrome, which usually affects the second or third costosternal joint.[8] Pain from costochondritis typically resolves within one year.[12]

Causes

In most cases of costochondritis, no cause is identified.[1][2][6] However, it may be the result of physical trauma (due to direct injury, strenuous lifting, or severe bouts of coughing), associated with scoliosis, ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, or a tumor (benign or cancerous).[13] Infection of the costosternal joint may cause costochondritis in rare cases. Most cases of infectious costochondritis are caused by Actinomyces, Staphylococcus aureus, Candida albicans, and Salmonella. In rare cases, Escherichia coli can be a cause of infectious costochondritis.[14] There is anecdotal evidence of costochondritic chest pain being associated with Vitamin D deficiency in some cases.[15] It also can be caused by Relapsing Polychrondritis

Pathogenesis

The pathogenesis underlying the development of costochondritis remains unclear. Proposed mechanisms of injury include neurogenic inflammation, muscular imbalance, increased muscular pull on the rib,[12] mechanical dysfunction at the costotransverse joint of the rib,[12] or a derangement of the mechanical structure of the costochondral junction.[7] A view from New Zealand manual physiotherapy sees the pain and inflammation at the costosternal joints on the breastbone as an overuse irritation consequent on hypomobility (lack of movement) of the costovertebral joints at the spinal ends of the same ribs.[16] [17] This would account for such specific pain and inflammation localized to only some costosternal joints; a systemic origin does not.

Differential diagnosis

Sternum with sternocostal joints and cartilage

Other causes of chest pain similar to that produced by costochondritis may include, but are not limited to the following:[7][18]

Treatment

Costochondritis may be treated with physical therapy (including ultrasonic, TENS, with or without nerve stimulation) or with medication. Treatment may involve the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or other pain relief medications (analgesics) such as acetaminophen.[3][4] Severe cases of costochondritis may call for the use of opioid medications such as hydrocodone or oxycodone, tricyclic antidepressant medications such as amitriptyline for pain from chronic costochondritis, or anti-epileptic drugs such as gabapentin may be used.[20] Oral or injected corticosteroids may be used for cases of costochondritis unresponsive to treatment by NSAIDs; however, this treatment has not been the subject of study by rigorous randomized controlled trials and its practice is currently based on clinical experience.[21] In those cases where the pain and inflammation at the sternocostal joints on the breastbone is an overuse consequence of hypomobility of the costovertebral joints on the spine, manual physiotherapy treatment is directed at freeing these latter joints up, with good reported anecdotal and clinical results, though supported by limited research to date.[16][17]  Rest from stressful physical activity is often advised during the recovery period.[4]

Epidemiology

Costochondritis is a common condition and is responsible for 30% of emergency room chest pain related visits. One-fifth of visits to the primary care physician are for musculoskeletal chest pain; of this 20% of primary care office visits, 13% is due to costochondritis.[7] Costochondritis cases are most often seen in people older than age 40 and occurs more often in women.[8]

See also

References

Template:Research help

  1. ^ a b c Mayo Clinic Staff (2012). "Costochondritis Definition". Mayo Clinic. Retrieved 26 December 2012.
  2. ^ a b c d e Jindal, A; Singhi, S (2011). "Acute chest pain". Indian journal of pediatrics. 78 (10): 1262–1267. doi:10.1007/s12098-011-0413-1. PMID 21541647.
  3. ^ a b U.S. National Library of Medicine (2010). "Costochondritis". National Institutes of Health. Retrieved 26 December 2012.
  4. ^ a b c d Proulx, AM; Zryd, TW (2009). "Costochondritis: diagnosis and treatment". American Family Physician. 80 (6): 617–620. PMID 19817327.
  5. ^ Stochkendahl, MJ; Christensen, HW (2010). "Chest pain in focal musculoskeletal disorders". The Medical clinics of North America. 94 (2): 259–273. doi:10.1016/j.mcna.2010.01.007. PMID 20380955.
  6. ^ a b c d e Ricker Polsdorfer, M.D. (2012). "Costochondritis". Keck Medical Center of USC. Retrieved 30 December 2012.
  7. ^ a b c d e Ayloo A, Cvengros T, Marella S (December 2013). "Evaluation and treatment of musculoskeletal chest pain". Prim Care (Review). 40 (4): 863–87. doi:10.1016/j.pop.2013.08.007. PMID 24209723.
  8. ^ a b c d e f g h Fauci, Anthony S.; Eugene Braunwald; Dennis L. Kasper; Stephen L. Hauser; Dan L. Longo; J. Larry Jameson; Joseph Loscalzo (2008). Chapter 330. Arthritis Associated with Systemic Disease, and Other Arthritides Harrison's principles of internal medicine (17th ed.). New York: McGraw-Hill. ISBN 978-0-07-147693-5.
  9. ^ Beers, Mark (2006). "Chapter 5". The Merck Manual of Diagnosis and Therapy (18th ed.). Merck Research Laboratories. ISBN 0-911910-18-2.
  10. ^ Mayo Clinic Staff (2012). "Costochondritis:Symptoms". Mayo Clinic. Retrieved 26 December 2012.
  11. ^ Mayo Clinic Staff (2012). "Costochondritis:Tests and diagnosis". Mayo Clinic. Retrieved 26 December 2012.
  12. ^ a b c Sik EC, Batt ME, Heslop LM (March–April 2009). "Atypical chest pain in athletes". Curr Sports Med Rep. 8 (2): 52–8. PMID 19280769.
  13. ^ Mayo Clinic Staff (2012). "Causes". Mayo Clinic. Retrieved 26 December 2012.
  14. ^ Sakran, W; Bisharat, N (2011). "Primary Chest Wall Abscess Caused by Escherichia coli Costochondritis". Am J Med Sci. 342 (3): 241–6. doi:10.1097/MAJ.0b013e31821bc1b0. PMID 21681074.
  15. ^ Shipton EA, Shipton EE (2015). "Vitamin D and Pain: Vitamin D and Its Role in the Aetiology and Maintenance of Chronic Pain States and Associated Comorbidities". Pain Research and Treatment (Review). 2015: 904967. doi:10.1155/2015/904967. PMC 4427945. PMID 26090221.{{cite journal}}: CS1 maint: unflagged free DOI (link) Citing Oh RC, Johnson JD (2012). "Chest pain and costochondritis associated with vitamin d deficiency: a report of two cases". Case Reports in Medicine. 2012: 375730. doi:10.1155/2012/375730. PMC 3384935. PMID 22761623.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  16. ^ a b Ian Rabey, Martin. "Costochondritis: Are the symptoms and signs due to neurogenic inflammation. Two cases that responded to manual therapy directed towards posterior spinal structures". Manual Therapy. 13 (1): 82–86. doi:10.1016/j.math.2006.12.007.
  17. ^ a b Grindstaff, Terry L.; Beazell, James R.; Saliba, Ethan N.; Ingersoll, Christopher D. (2010-06-01). "Treatment of a female collegiate rower with costochondritis: a case report". Journal of Manual & Manipulative Therapy. 18 (2): 64–68. doi:10.1179/106698110X12640740712653. ISSN 1066-9817.
  18. ^ "Costochondritis Diagnosis Differential". BMJ Publishing Group. 2012. Retrieved 26 December 2012.
  19. ^ Seferović PM, Ristić AD, Maksimović R, Simeunović DS, Milinković I, Seferović Mitrović JP, Kanjuh V, Pankuweit S, Maisch B (May 2013). "Pericardial syndromes: an update after the ESC guidelines 2004". Heart Fail Rev. (Review). 18 (3): 255–66. doi:10.1007/s10741-012-9335-x. PMID 22855353.
  20. ^ "Treatments and drugs". Mayo Clinic. 2012. Retrieved 26 December 2012.
  21. ^ Gandhi V, Costello J (August 2012). "Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: The use of corticosteroids in the management of costochondritis". Emerg Med J (Review). 29 (8): 686. doi:10.1136/emermed-2012-201590.4. PMID 22787240.
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