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costochondritis (Tietze syndrome)
Chronic inflammation affecting the costochondral joints.
Etiology: unknown
Clinical manifestations:
1) chest pain, accentuated by respiration, sneezing, coughing, twisting or reaching overhead
2) onset of pain may be sudden or gradual in onset
3) possible radiation of pain to arms, shoulders or entire chest
4) tenderness & swelling at costochrondral joints, especially 2nd & 3rd ribs
5) erythema of overlying skin may be present
6) absence of visible swelling or crepitus
7) most commonly involves left anterior chest wall
Laboratory: of little value
Radiology:
1) chest x-ray to rule out other diseases
2) bone scan if infectious etiology suspected or history of intravenous drug abuse
3) echocardiogram
Differential diagnosis:
1) ankylosing spondylitis
2) bone metastases
3) contusion
4) cardiac angina (may coexist with costochondritis)
5) costal cartilage separation
6) Herpes zoster
7) infection
8) lipoma
9) muscle spasm
10) neoplasm
11) rib fracture
12) Reiter's syndrome
13) rheumatoid arthritis
14) septic arthritis
15) slipping rib syndrome
16) sternalgia
17) xiphoidalgia
Management:
1) pharmacologic agents
a) non-steroidal anti-inflammatory drugs (NSAIDs)
- naproxen 500 mg PO BID with meals
- etodolac 300 mg PO TID with meals
b) acetaminophen
c) salicylates
d) joint injection with corticosteroid/anesthetic
- 20 mg methylprednisolone acetate (DepoMedrol)
- 1-2 mL of 1% lidocaine
2) physical modalities
a) local heat
b) refrain from aggravating activities
c) stretching exercises, especially pectoralis major continued for at least 3 weeks after improvement of symptoms
3) surgical resection of involved cartilages in severe or refractory cases
4) patient education
a) generally self-limited with improvement within 3-6 months
b) occasionally symptoms may last months or recur
c) smoking cessation
5) be aware that costochondritis may coexist with other disorders, especially coronary artery disease
General
cartilage disease
joint disease; articular disease; arthropathy
syndrome
References
- DeGowin & DeGowin's Diagnostic Examination, 6th edition,
RL DeGowin (ed), McGraw Hill, NY 1994, pg 876
- Saunders Manual of Medical Practice, Rakel (ed),
WB Saunders, Philadelphia, 1996, pg 785-86
- Medical Knowledge Self Assessment Program (MKSAP) 16,
American College of Physicians, Philadelphia 2012