Approach
Costochondritis is a clinical diagnosis.
History
A history of repetitive upper-limb movement or prolonged coughing may be present in inflammatory costochondritis. The patient should be asked about recent intravenous drug use and recent surgical procedures when considering the possibility of infective costochondritis.
Pain that is usually gradual in onset, constant in nature, and exacerbated by deep inspiration and movement involving the chest wall is suggestive.
Examination
A key sign is the reproduction of the pain on palpation of the costochondral joints or movement involving the chest wall.
Tenderness may also occur on palpation of the adjacent muscles, ribs, and sternoclavicular joint. There is usually no chest-wall swelling. If chest-wall swelling is present in addition to costochondritis, this is known as Tietze's syndrome and inflammatory and infectious aetiologies will need to be ruled out.[8]
Investigations
If costochondritis is strongly suspected from the history and exam without suspicion of infectious or systemic inflammatory arthropathies, then patients should have either a therapeutic trial of an oral non-steroidal anti-inflammatory drug (NSAID) or a local injection of corticosteroid plus anesthetic into the affected sites. Oral NSAIDs are usually the preferred choice in the primary care setting as local injection is usually performed by a consultant (e.g., pain management, sports medicine, rehabilitation [physiatrist], rheumatologist, or orthopaedic surgeon). Knowledge of key anatomical landmarks and consideration of image guidance such as ultrasound should be considered to avoid inadvertent nerve and/or lung puncture. A beneficial response to these treatments confirms the diagnosis.
A failure to respond to the therapeutic trial of an NSAID or local injection, or clinical findings that put the patient at high risk of an alternate diagnosis (e.g., history of fever, malignancy, history of trauma or injury, and localised swelling and erythema), should prompt further investigations as indicated by the possible differential diagnosis.
Suspected infectious costochondritis
If an infectious cause of costochondritis is suspected from history and risk factors (e.g., intravenous drug use, and features of the history that might indicate an infectious cause [including fever, joint swelling, or involvement of the sternoclavicular joint]), further testing with wound and/or blood cultures, chest x-ray, and computed tomography (CT) or magnetic resonance imaging (MRI) should be performed. Note that this work-up is not necessary if an intravenous drug user has a benign presentation, without these clinical features, and responds well to NSAIDs.
Blood cultures are frequently positive for Staphylococcus species, especially in intravenous drug users. Imaging of septic costochondritis has not been studied adequately in comparison with a control group, but as with any bone or joint infection, typical findings from a CT or MRI include expanded and oedematous cartilage, bone oedema, and increased signal and contrast uptake. One small study of consecutive patients with Tietze's syndrome (presence of swelling in addition to costochondritis) found enlargement, thickening, and increased signals on T2/STIR/FAT-SAT sequences on affected cartilage, bone marrow oedema, and increased gadolinium uptake in a few cases.[15]
Bone scan with technetium is not a useful test for diagnosis, as it is not specific for costochondritis and may be positive in normal people.[16]
Use of this content is subject to our disclaimer