AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Chest pain is a common reason parents seek medical attention for their children. Annually, physicians evaluate approximately 650,000 cases of chest pain in patients aged 10-21 years, a number that may reflect overwhelming concern about chest pain as a manifestation of cardiac disease and cancer in older patients.

Costochondritis is a common cause of chest pain in children and adolescents. The condition is characterized as an inflammatory process of one or more of the costochondral cartilages that causes localized tenderness and pain of the anterior chest wall. Most cases of costochondritis are idiopathic. The remaining cases may result from costochondral irritation due to direct trauma, aggressive exercise that caused a strain, or a prior upper respiratory tract infection with cough that caused repeated stretching and strain at the costochondral junction.

Costochondritis is a relatively benign and usually self-limited condition. Patients are often evaluated initially in the emergency department (ED) or, with acute conditions, in their primary care physician's office.

The term Tietze syndrome implies swelling; costochondritis refers to pain alone.

Pathophysiology

The exact pathophysiology of cartilage and capsular involvement is unknown because costochondritis does not warrant surgical intervention or tissue biopsy. Theoretically, the cartilage involved in costochondritis is either inflamed or torn. Either condition presumably leads to inflammation with subsequent stimulation of pain receptors.

Frequency

United States

Several studies of chest pain in pediatric patients report costochondritis prevalences of 14-30%; a single study reported rates as high as 79%. The overall incidence rate is approximately 4% of children and adolescents.

Mortality/Morbidity

No reports have associated mortality with costochondritis, and no mortality is expected.

Race

A study indicates Hispanics may have an increased prevalence of costochondritis, but most studies do not mention race as a factor.

Sex

Studies of chest pain in children showed that females are diagnosed with costochondritis more often than males by a 2:1 ratio.

Age

No data support an association between age and costochondritis; the condition is well described in children of all ages, including infants.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The key to the diagnosis of costochondritis amid the differential diagnoses, which include cardiac and pulmonary disease, is a thorough history and physical examination.

Presenting characteristics of chest pain associated with costochondritis include the following:

• Onset - Typically insidious, occurring over several days or weeks; may be acute
• Nature - Sharp and stabbing
• Location - Anterior chest; pain usually unilateral, but may be bilateral
• Radiation - Chest, upper abdomen, or back
• Exacerbating factors - Coughing, sneezing, deep inspirations, movement of the upper torso and upper extremities
• Relieving factors - Rest, application of ice, or use of heat
• Preceding conditions - Upper respiratory tract infection or exercise (common in the preceding 3 months); musculoskeletal strain; trauma to chest wall

Physical

Vital signs should be assessed. Careful and complete pulmonary, cardiac, and abdominal examinations eliminate the possibility of an underlying disease process.

• Inspection focuses on symmetry of the chest wall. Asymmetry may indicate trauma as a cause of chest pain.
• Swelling is uncommon. Patients with Tietze syndrome, however, may have swelling over an upper costochondral junction.
• Ecchymosis would be expected only in trauma.
• Respiratory effort is normal.
• Palpation that reveals tenderness over the costochondral junction is diagnostic. The tenderness should be localized and is most common at the sternocostal cartilage of the second through the seventh ribs.
• Examination may be performed with firm, single-digit palpation of the area.
• Crepitus is uncommon and may indicate a fracture.
• Auscultation of the lungs, heart, and abdomen are normal.

Causes

Most cases of costochondritis are idiopathic. The remaining cases may be the result of costochondral irritation caused by the following:

• Direct trauma
• Aggressive exercise resulting in a strain (eg, repeated twisting of the upper torso, stretching-pulling activities of the upper extremities)¹
• Preceding upper respiratory tract infection with cough (which can cause repeated stretching and strain at the costochondral junction)

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Aneurysm
Gynecomastia
Muscle strain
Neurofibroma of an intercostal nerve
Psychogenic chest pain
Rib fracture
Slipping rib syndrome
Stress fracture

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Costochondritis has no confirmatory or diagnostic laboratory tests.

Imaging Studies

• Imaging studies are unnecessary to confirm a diagnosis of costochondritis.
• Chest radiography may exclude other possible causes of chest pain but offer no diagnostic value to costochondritis assessment. In the absence of confounding physical findings, the diagnostic yield of a chest radiograph is less than 2%.
• In the unusual circumstance that imaging is required, CT scanning is probably the best choice because it can demonstrate swelling of the costal cartilage. Ultrasonography may also demonstrate swelling but is less useful. Bone scanning may demonstrate uptake at the area of concern; however, increased uptake at costochondral junctions that do not produce symptoms may also be present, making this modality less useful.

Procedures

• Costochondral joint injection is indicated for patients with severe pain for whom oral analgesics are either ineffective or contraindicated. Costochondral joint injection may have a role in treating refractory cases of costochondritis. Using a 22-gauge needle, inject 2% lidocaine or a combination of corticosteroid and lidocaine. A total volume ranging from 1-3 mL may be injected depending on patient size.
• Contraindications include an uncooperative patient, known hypersensitivity to the injectant, unclear diagnosis, or unstable cardiopulmonary disease. Use caution in patients with a severe coagulopathy. Complications include bleeding, infection, and pneumothorax.
• Manipulation using a high velocity, low amplitude technique has been described to produce relief in costochondritis, but no larger studies have been done to confirm this.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Reassure patients diagnosed with costochondritis that the cause of their chest pain is neither cardiac nor malignant in origin.
• Treatment involves conservative local care with judicious use of nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics, as necessary. Cough suppressants may be beneficial if cough is an aggravating factor.
• Liberal use of ice is recommended for 20-minute intervals.
• Advise relative rest for the patient's upper extremities and avoidance of possible precipitating or exacerbating activities.

Consultations

Occasional refractory cases may require consultation with the following specialists:

• Primary care sports medicine physician
• Rheumatologist

Activity

• Activity restrictions include relative rest. Instruct the patient to avoid activities that exacerbate symptoms. Collision or contact sports may be limited until the patient can perform activity-specific movements without pain.
• Applying ice after activity usually helps alleviate a significant amount of pain or discomfort.
• Resumption of aggravating activities prior to resolution may cause relapse.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

NSAIDs provide analgesia for mild-to-moderate chest pain and may modulate the presumed inflammatory process. Purely analgesic drugs (eg, acetaminophen, tramadol hydrochloride) may suffice.

Drug Category: Nonsteroidal anti-inflammatory drugs

These provide analgesia and may play a role in controlling inflammation.

Drug Name	Naproxen (Aleve)
Description	Available as OTC preparation and in prescription form; OTC preparation has faster onset of action, though limited duration of action. Prescription form is available in both pill and elixir forms and has a convenient bid-dosing schedule.
Adult Dose	200-500 mg PO bid prn
Pediatric Dose	<2 years: Not established >2 years: 2.5-5 mg/kg PO q8-12h prn; not to exceed 20 mg/kg/d or 1 g/d
Contraindications	Documented hypersensitivity, known hypersensitivity to aspirin or other NSAIDs; active GI bleeding, active ulcer
Interactions	Avoid concomitant aspirin; may potentiate protein-bound drugs (eg, hydantoins, sulfonamides, sulfonylureas); monitor PO anticoagulants; may antagonize diuretics, beta-blockers, other antihypertensives; increased renal toxicity with ACE inhibitors; reduces methotrexate excretion; increases serum lithium levels
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Active peptic ulcer; history of GI disease; impaired renal or hepatic function; heart failure; edema; hypertension; monitor blood, hepatic, renal, and ocular function with long-term use; pregnancy category D at third trimester

Drug Category: Analgesics

These may be used to relieve mild-to-moderate pain.

Drug Name	Tramadol hydrochloride (Ultram)
Description	Inhibits ascending pain pathways, altering perception of and response to pain. Also inhibits reuptake of norepinephrine and serotonin.
Adult Dose	Gradually titrate upward over 3 d to 50-100 mg PO q4-6h; not to exceed 400 mg/d
Pediatric Dose	<16 years: Not recommended >16 years: Administer as in adults
Contraindications	Documented hypersensitivity; acute intoxication with alcohol; hypnotics, analgesics, opioids, or psychotropic drugs dependence
Interactions	Do not use concomitantly with MAOIs; may potentiate seizure risk with use of MAOIs, SSRIs, tricyclics, neuroleptics, and opioids; use caution when administering with other depressants; may potentiate digoxin activity; may be potentiated with concomitant use of CYP2D6 inhibitors (eg, quinidine, fluoxetine, paroxetine, amitriptyline)
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Initiate dose gradually to minimize nausea and vomiting; can cause dizziness, nausea, constipation, sweating, pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in liver disease, myxedema, hypothyroidism, hypoadrenalism; pregnancy, breastfeeding; seizure; development of tolerance or dependency with extended use

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Follow up as needed after initial diagnosis. Reevaluate patient if the nature, character, or severity of pain changes.
• For individuals who participate in athletics, follow up at 2 weeks or sooner and instruct patient to return to activity only with medical clearance.

Prognosis

• The overall prognosis of a patient with costochondritis is excellent; full recovery can be expected.
• Resolution occurs in several weeks or months and rarely lasts longer than 4-6 months. Relapse may occur if the patient returns to activity while still symptomatic.

Patient Education

• For excellent patient education resources, visit eMedicine's Lung and Airway Center and Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Costochondritis and Chest Pain.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider the broad list of chest pain causes may lead to missing the diagnosis of an underlying or concomitant disease process.
• Changes in the nature or character of the chest pain in costochondritis warrant a thorough interval history and physical examination to exclude a new diagnosis or disease process.

Special Concerns

• Changes in the biomechanics associated with pregnancy may contribute to the development of costochondritis. Pay particular attention to the lower costochondral cartilage.
• Acetaminophen and ice may be used for analgesia and treatment.
• Avoid NSAIDs, particularly in the third trimester.
• International Classification of Diseases, Ninth Revision (ICD-9) codes are "733.6 costochondritis" and "786.52 anterior chest wall pain." Current procedural terminology (CPT) billing code for a costochondral joint injection procedure is "20600 - arthrocentesis, injection; small joint."

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Nov 8, 2007