Costochondritis: A Comprehensive Review

Costochondritis is a common inflammatory condition affecting the costochondral or chondrosternal joints, characterized by localized chest pain that can be severe and debilitating. This condition often presents a diagnostic challenge for clinicians due to its symptom similarity with cardiac conditions. Understanding costochondritis is crucial for physiotherapists and other healthcare practitioners to ensure appropriate management and patient education. This review examines the current evidence on the aetiology, pathophysiology, clinical presentation, assessment techniques, and management strategies for costochondritis.

Aetiology

Costochondritis involves inflammation of the costochondral or chondrosternal joints, which connect the ribs to the sternum. While the exact cause often remains undetermined in many cases, several factors have been identified as potential contributors to its development:

Inflammatory Causes

Primary costochondritis typically arises from non-infectious inflammatory processes affecting the costochondral junctions. This inflammation can occur spontaneously or following physical strain to the chest wall2.

Infectious Causes

Though less common, infectious costochondritis can occur through direct invasion of pathogens. Salmonella costochondritis, while rare, has been documented in patients with compromised cellular immunity4. These patients typically present with swelling and erythematous changes in the affected area, with or without pain. In more severe cases, this can progress to chest wall abscess formation.

Case reports have also identified methicillin-sensitive Staphylococcus aureus (MSSA) as a causative organism for costochondritis and chest wall abscess, particularly in immunocompromised patients such as those receiving immunosuppressive treatments like tocilizumab and methylprednisolone13.

Mechanical Factors

Mechanical stress on the costal cartilages can trigger costochondritis. Activities involving repetitive upper body movements, poor posture, or direct trauma to the chest wall may contribute to the development of this condition. Occupational factors, particularly in office workers with prolonged static postures, have been identified as potential risk factors3.

Other Contributing Factors

Certain conditions like fibromyalgia and other systemic inflammatory disorders may predispose individuals to developing costochondritis. Additionally, upper respiratory infections might precede the onset of symptoms in some patients, suggesting a potential post-infectious inflammatory response.

Pathophysiology

The pathophysiological mechanisms underlying costochondritis involve inflammation at the junction between the costal cartilage and the sternum or ribs. This inflammation can affect the cartilage, surrounding soft tissues, and the perichondrium (the connective tissue covering the cartilage).

The inflammatory process typically involves:

1. Initial irritation or microtrauma to the costochondral or chondrosternal junctions

2. Release of inflammatory mediators causing local tissue swelling

3. Sensitization of nociceptors in the affected region

4. Persistent inflammation leading to pain and functional limitations

In Cyriax syndrome, a related condition, irritation of the intercostal nerves occurs due to incomplete dislocation of the costal cartilage of the ribs, resulting in lower chest or upper abdominal pain15. This mechanical disruption illustrates the interplay between structural abnormalities and neural sensitization in the pathogenesis of costochondritis.

In infectious cases, direct invasion of pathogens into the costochondral region triggers an inflammatory response with potential abscess formation. The resulting inflammation can cause significant tissue damage if left untreated, particularly in immunocompromised hosts413.

Clinical Signs

Costochondritis presents with a characteristic set of clinical features that help differentiate it from other causes of chest pain:

Pain Characteristics

The primary symptom is anterior chest pain associated with painful tender costochondral joints on palpation. This pain mainly affects the 2nd to 5th costochondral junctions and can be either unilateral or bilateral2. The pain is often described as sharp, stabbing, or pressure-like, and may radiate to the back or abdomen.

Severity and Pattern

The pain can vary in intensity from mild discomfort to severe debilitating pain. It frequently worsens with certain movements, deep breathing, coughing, or physical activity. Notable characteristics include:

• Often severe and nocturnal

• Can be of sudden onset

• May be associated with shock, nausea, and dyspnoea in severe cases, causing patients to seek emergency care2

• Typically exacerbated by activities that stress the chest wall

Associated Features

Unlike cardiac chest pain, costochondritis is not typically associated with shortness of breath, diaphoresis, or radiation to the jaw or left arm. However, anxiety related to chest pain may cause secondary symptoms like hyperventilation or tachycardia, which can confound the clinical picture.

Assessment

Accurate assessment of costochondritis is crucial for appropriate management and to rule out more serious conditions:

History Taking

A detailed history should explore:

• Pain characteristics (location, severity, duration, aggravating/relieving factors)

• Previous episodes of similar pain

• Recent activities that might have strained the chest wall

• History of respiratory infections

• Systemic symptoms that might indicate alternative diagnoses

Physical Examination

The physical examination should include:

• Inspection for visible swelling or redness over the affected area

• Palpation of the costochondral junctions to reproduce the pain (a key diagnostic finding)

• Assessment of chest wall movements and their effect on pain

• Examination of the thoracic spine and shoulder for potential referred pain

• Testing for hypermobility, which may be associated with costochondritis in some patients

Differential Diagnosis

It’s essential to rule out serious conditions that may present with similar symptoms:

• Cardiac conditions (acute coronary syndrome, pericarditis)

• Pulmonary conditions (pulmonary embolism, pneumonia)

• Gastrointestinal disorders (reflux, esophageal spasm)

• Other musculoskeletal conditions (thoracic outlet syndrome, cervical radiculopathy)

Diagnostic Imaging

Imaging is primarily used to exclude other pathologies rather than confirm costochondritis:

• Chest X-rays are usually normal in costochondritis15 but help rule out other causes

• Advanced imaging (CT or MRI) may be warranted in cases of suspected infection or if symptoms persist despite treatment

• In cases of infectious costochondritis, imaging can help identify abscess formation requiring surgical intervention413

Physiotherapy Management

Physical therapy interventions can be effective in managing costochondritis:

Manual Therapy

Manual therapy techniques have shown promise in treating chronic costochondritis. A case report demonstrated positive outcomes using manual therapy approaches for a male office worker with chronic symptoms3. Techniques may include:

• Soft tissue mobilization of the intercostal muscles and surrounding structures

• Joint mobilization of the costovertebral and costotransverse joints

• Gentle stretching of the chest wall musculature

• Postural correction and ergonomic advice

Exercise Therapy

Exercise therapy forms an important component of management:

• Gradual introduction of mobility exercises for the thoracic spine and ribcage

• Strengthening of postural muscles to reduce stress on the costochondral junctions

• Breathing exercises to maintain normal thoracic mobility while managing pain

• Progressive return to functional activities with modifications as needed

Acupuncture

Several studies have demonstrated the benefits of acupuncture for costochondritis:

• A retrospective chart review of three adolescent patients showed satisfactory symptomatic reduction following acupuncture treatment1

• A case series of eight patients indicated positive responses to acupuncture, where treatments included local tender/trigger points and distal Chinese acupuncture points2

• Treatment protocols typically involve weekly sessions with 0.25×25mm and 0.25×30mm needles with silicon tips and guide tubes to prevent painful insertion

• Adjunctive treatments like infrared lamp therapy and electro-acupuncture may be incorporated for enhanced effects2

Education and Self-Management

Patient education is crucial and should include:

• Explanation of the condition and its typically benign nature

• Activity modification to avoid aggravating movements

• Posture advice, particularly for office workers

• Home exercise program to maintain gains from therapy

Medication Management

Pharmacological interventions are often necessary to manage pain and inflammation:

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs remain the first-line treatment for uncomplicated costochondritis14. These medications help reduce both pain and inflammation at the costochondral junction and may include:

• Ibuprofen

• Naproxen

• Diclofenac

• COX-2 selective inhibitors for patients with gastrointestinal concerns

Analgesics

When NSAIDs are contraindicated or insufficient:

• Acetaminophen (paracetamol) can provide pain relief without anti-inflammatory effects

• Topical analgesics may offer localized relief with minimal systemic effects

• In severe cases, short-term opioid analgesics might be considered, though this is generally avoided due to their side effect profile and potential for dependency

Local Injections

For persistent or severe cases:

• Local anesthetic injections (e.g., 1% lidocaine) can provide temporary relief and diagnostic information15

• Corticosteroid injections into the affected costochondral junctions may be considered for refractory cases

• Proper technique under imaging guidance may improve outcomes and reduce complications

Antibiotics

In cases of infectious costochondritis:

• Appropriate antibiotics based on culture results are essential

• Treatment duration is typically extended (weeks to months)

• Surgical debridement may be necessary for abscess formation4

• Follow-up imaging is important to ensure resolution of the infection13

Conclusion

Costochondritis, while often benign and self-limiting, can cause significant pain and functional limitations. A multidisciplinary approach involving proper assessment, physiotherapy interventions, and appropriate medication management offers the best outcomes for patients. For physiotherapists, understanding the condition’s aetiology, presentation, and management strategies is essential for effective treatment planning and patient education.

Early recognition, appropriate intervention, and patient education about the typically benign nature of the condition can help reduce anxiety and improve outcomes. For refractory cases, an integrated approach combining manual therapy, exercise, acupuncture, and judicious use of medications appears to provide the most comprehensive management strategy.