|The costal cartilages|
Costochondritis, also known as chest wall pain, costosternal syndrome, or costosternal chondrodynia is an acute 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. Though costochondritis often resolves on its own, it can be a recurring condition that has little or no signs of onset.
Costochondritis symptoms can be similar to the chest pain associated with a heart attack. Chest pain is considered a medical emergency until life-threatening cardiac issues (such as an acute coronary syndrome) can be ruled out. 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.
Treatment options are quite limited and usually involve a combination of rest, analgesics, or anti-inflammatory medications. Cases with persistent discomfort may be managed with cortisone injections 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.
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. 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.
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. Pain from costochondritis typically resolves within one year.
In most cases of costochondritis, no cause is identified. 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).
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. There is anecdotal evidence of costochondritic chest pain being associated with Vitamin D deficiency in some cases, and multiple anecdotal reports that it could be associated with chest binding, as practiced by some members of the transgender community. Some case studies and a case series suggest that the pain and inflammation at the sternocostal joints are a consequence of hypomobility at the costovertebral and/or costotransverse joints. It also can be caused by relapsing polychondritis.
The pathogenesis underlying the development of costochondritis remains unclear. Proposed mechanisms of injury include neurogenic inflammation, muscular imbalance, increased muscular pull on the rib, mechanical dysfunction at the costotransverse joint of the rib, or a derangement of the mechanical structure of the costochondral junction. A commonly held view in New Zealand and Australian manual physiotherapy regards hypomobility at the costovertebral and costotransverse joints as the driver of compensatory excessive movement at the more structurally delicate sternocostal joints, leading to strain and localised inflammatory response. This mechanism is biologically plausible and would account for the extreme specificity of the symptoms at the sternocostal joints, which a systemic mechanism does not.
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. 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. 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. Rest from stressful physical activity is often advised during the recovery period.
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% are due to costochondritis. Costochondritis cases are most often seen in people older than age 40 and occur more often in women than in men.
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