Costochondritis: Symptoms & Treatment

Costochondritis is an inflammation of the junctions where the upper ribs join with the cartilage that holds them to the breastbone or sternum. It is, in fact, an inflammation of the connective tissue between the breastbone and the ribs.

What exactly is cartilage? Cartilage is a tough rubbery tissue that lines and cushions the surfaces of joints. Although most people think that every pain in the chest is linked to myocardial ischemia or infarction, this condition also causes localized chest pain that you can reproduce by pushing on the cartilage in the front of your ribcage. [1]

The pain may be more noticeable in sitting or reclining positions, and stress is known to aggravate it. The fact is that costochondritis is a relatively harmless condition and usually goes away without treatment. It is never accompanied by swelling. The inflammation can involve cartilage areas on both sides of the sternum, but it is usually located on only one side. It is a very similar condition to a disease called Tietze's syndrome, with only one difference — Tietze's includes swelling. The discomfort of costochondritis often lasts a few days and then subsides. [2]

Incidence of Costochondritis

Costochondritis is a common cause of chest pain in children and adolescents. In fact, it accounts for 10-30% of all chest pain in children. Doctors evaluate that there are about 650,000 cases of chest pain in young people aged 10-21 years annually. The peak age for the condition is 12-14 years.

Symptoms of Costochondritis

Costochondritis is a specific condition which is characterized by pain and tenderness in the places where ribs attach to the breastbone. In most cases, the pain is sharp, though it can also feel like a dull, gnawing pain. Any of the 7 costo-chondral junctions may be affected, and more than 1 site is affected in 90% of cases. Pain associated with costochondritis occurs more often on the left side of your breastbone, though it can occur on either side of your chest. [2]

Pain may radiate to the back or abdomen. The most common sites of pain are the fourth, fifth, and sixth ribs and the pain increases as you move your trunk or take deep breaths. Conversely, your pain decreases as your movement stops or on quiet breathing.

Other signs and symptoms of costochondritis may include:

• Pain when taking deep breaths
• Pain when coughing
• Difficulty breathing
• The reproducible tenderness you feel when you press on the rib joints is a constant feature of costochondritis. Without this tenderness, a diagnosis of costochondritis is unlikely.

When called Tietze's syndrome, the pain is accompanied by redness and/or swelling in the most tender areas. When associated with an autoimmune disease such as PBC, it may linger for years or a lifetime.

Possible causes of costochondritis

The fact is that the cause of costochondritis is classified as 'idiopathic', which means that there is no identifiable cause for the condition, in most cases. 

Traumatic injury

The most common cause of costochondritis that can be attributed to a source is costochondritis as the result of a traumatic injury. For example, car accidents in which the driver strikes the steering wheel with his chest. Repetitive minor trauma has also been proposed as a common cause of costochondritis. [3]

Viral infections

Viral infections, mainly upper respiratory infections, have also been identified as a cause of costochondritis. 

Bacterial infections

This happens mostly to people who use IV drugs or who have had surgery to their upper chest. After a surgery, the cartilage can become more prone to infection, because of the reduced blood flow in the region that has been operated on.

Fungal infections

Fungal infections are rare causes of costochondritis.

Fibromyalgia

The fact is that recurring costochondritis could be a symptom of fibromyalgia. People with fibromyalgia often have several tender spots. The upper part of the breastbone is a common tender spot.

Pain from other areas of your body

Many people are not aware that pain signals can sometimes be misinterpreted by the brain, causing pain in places far away from the place where the problem occurs. The doctor might call this a "referred pain." Pain in your chest can sometimes be caused by problems with the bones in your spine compressing the nerves.

Vitamin D Deficiency

Research indicates that chest pain and costochondritis are associated with vitamin D deficiency. [4]

Differential Diagnosis

There is only one condition that could be wrongly interpreted as a costochondritis and it is a heart attack or myocardial ischemia. That’s why there are some useful tricks that every patient should know about telling the difference between these two conditions! [5]

• The pain of a heart attack is often more widespread, while costochondritis pain is focused on a small area.
• Heart attack pain usually feels as though it's coming from under your breastbone, while costochondritis pain seems to come from the breastbone itself.
• Heart attack pain may worsen with physical activity or stress, while the pain of costochondritis remains constant.

The fact is that patients should not waste time because every chest pain is an emergency.

Other problems to be considered:

• Pericarditis
• Pleurodynia
• Polychondritis
• Fibromyalgia

As we already mentioned, Tietze’s syndrome is also very similar to costochondritis. However, it exhibits swellings at the rib-cartilage junction and costochondritis has no noticeable swelling. Neither condition involves pus or abscess formation.

Tietze’s syndrome usually affects the junctions at the second and third ribs and the swelling may last for several months. The syndrome can develop as a complication of surgery on your sternum months to years after the operation.

When to Seek Medical Help?

If a person feels some of the following symptoms, he or she should definitely seek help:

• Trouble breathing
• High fever
• Signs of infection such as redness, pus, and increased swelling at the rib joints
• Continuing or worsening pain despite medication

The following symptoms are generally not associated with costochondritis:

• High fever not responding to fever-reducers such as acetaminophen (Tylenol) or ibuprofen (Advil)
• Signs of infection at the tender spot such as pus, redness, increased pain, and swelling
• Persistent chest pain of any type associated with nausea, sweating, left arm pain, or any generalized chest pain that is not well localized

These symptoms can be signs of a heart attack. If you are not sure about your condition, go to the emergency department.

Diagnosis of Costochondritis

Physical examination

Your doctor should first conduct a physical exam to diagnose costochondritis. He should ask the patient to describe the pain and what influences it or triggers it. The pain of costochondritis can be very similar to the pain associated with heart disease, lung disease, gastrointestinal problems, and osteoarthritis. The doctor will also palpate along the breastbone for areas of tenderness or swelling.

Radiological imaging

Costochondritis generally can't be seen on chest X-rays or other imaging tests used to see inside your body but your doctor may order these tests or others to rule out other conditions.

Lab Studies

No specific studies exist for costochondritis. The clinical scenario and the most likely differential diagnoses should guide lab orders.

Treatment of costochondritis

Medications

Non-steroidal anti-inflammatory medications

Costochondritis responds well to non-steroidal anti-inflammatory medications such as ibuprofen (Advil or Motrin) and naproxen (Aleve).

Steroid medications 

The patient may also be given a local anesthetic and steroid injection in the area that is tender, if normal activities become very painful and the pain does not respond to medications.

Antibiotics

Infectious costochondritis should be treated initially with IV antibiotics. The antibiotic therapy should be administered either by mouth or IV for another 2-3 weeks for the complete recovery.

Antidepressants

Antidepressants, specifically a category of medicines called tricyclic antidepressants, should be given if the pain is making it difficult to sleep at night.

Muscle relaxants

It is proven that muscle relaxants can also help ease the pain.

Surgery

Surgical removal of the sore cartilage may be required if there is no response to medical therapy. A doctor should refer a patient to a surgeon for a consultation should this option be considered necessary.

Self-Care Tips

For many patients, it can be frustrating to know that there's little that a doctor can do to treat their costochondritis related pain. To help relieve the pain caused by costochondritis, a patient should try to [3]:

• Rest more and avoid activities that make pain worse.
• Exercise more. Although it may seem contradictory to rest, it is proven that gentle exercises, such as walking or swimming, can improve your mood and keep your body healthy.  
• Usage of a heating pad. A heating pad should be applied to the painful area several times a day.

Prognosis and Prevention

The prognosis for patients with costochondritis is excellent. After 1 year, about half of the patients may still have some discomfort while approximately one third report tenderness with palpation. Since inflammatory costochondritis has no definite cause, there is no good way to prevent it.