What Triggers Costochondritis?

Costochondritis is pain and inflammation of the ribs that join the costal cartilage.

Costochondritis is inflammation of the junctions where the upper ribs join the costal cartilage that attaches them to the breastbone (sternum). Costochondritis causes localized chest wall pain and tenderness that can be reproduced by pushing on the involved cartilage in the front of the rib cage.

• Costochondritis is a relatively harmless musculoskeletal chest pain and usually resolves without treatment.
• The cause is usually unknown.
• Costochondritis affects females more often than males (70% versus 30%).
• Costochondritis is a common cause of chest pain in children and adolescents. It accounts for 10%-30% of all chest pain in children. Annually, doctors evaluate about 650,000 cases of chest pain in young people 10-21 years of age. The peak age for the condition is 12-14 years of age.
• Overall, costochondritis is one of the most common causes of musculoskeletal chest pain.
• While chest pain can represent heart disease and heart attack, inflammation around the heart (pericarditis), or lungs (pleuritis), costochondritis is also considered as a possible diagnosis in adults with chest pain.
• Tietze syndrome, or Tietze's disease, is also a cause of localized musculoskeletal chest pain. Tietze syndrome is distinguished from the more common costochondritis.
  • As opposed to costochondritis in which there is no swelling, Tietze disease is accompanied by a localized swelling at the painful area (the junction of the ribs and breastbone).

Costochondritis is an inflammatory process. Nevertheless, it usually has no definite cause. Repeated minor trauma to the chest wall or viral respiratory infections can cause costochondritis. Occasionally, costochondritis as a result of bacterial infections can occur in people who use recreational IV drugs or who have had surgery on their upper chest. Costochondritis can also be a feature of relapsing polychondritis, reactive arthritis, fibromyalgia, and injury.

Different types of infectious diseases can cause costochondritis, although this is uncommon.

• Viral: Costochondritis commonly occurs with viral respiratory infections because of the inflammation of costochondral junctions from the viral infection itself or from the strain of coughing.
• Bacterial: Costochondritis may occur after surgery and be caused by bacterial infections.
• Fungal: Fungal infections are rare causes of costochondritis.

Costochondritis can also occur with certain forms of arthritis, such as ankylosing spondylitis and psoriatic arthritis, and is sometimes associated with breastbone pain (sternum pain) in these conditions. Costochondritis can occur in people with fibromyalgia.

• The reproducible tenderness when pressing on the rib joints (costochondral joints) is a characteristic feature of costochondritis. Without tenderness, a diagnosis of costochondritis is unlikely.
• Chest pain associated with costochondritis can be preceded or aggravated by exercises, minor injury, or an upper respiratory infection.
• Costochondritis pain usually will be sharp and located on the front chest wall. It may radiate from the chest area to the back or abdomen to cause back pain or belly pain.
• The most common sites of pain are the fourth, fifth, and sixth ribs. This pain increases when moving the trunk or when deep breathing and, therefore, may cause breathing problems. Conversely, it decreases as any movement stops or with quiet breathing.
  • Costochondritis can be misdiagnosed or accompanied by anxiety about having chest pain.
  • When costochondritis occurs as a result of infection after an operation (surgery), there can be inflammation with redness, swelling, or pus discharge at the site of the procedure.

Call a medical professional for any of the following symptoms:

• Trouble breathing
• High fever
• Signs of infection such as redness, pus, and increased swelling at the rib joints
• Continuing or worsening pain despite medication with over-the-counter (OTC) anti-inflammatory medications

Go to a hospital's emergency department when experiencing difficulty breathing or any of the following symptoms occur. These symptoms are generally not from costochondritis:

• High fever not responding to fever-reducing medicines such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin)
• 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 unsure what is causing the condition, always go to the emergency department.

Costochondritis is diagnosed using a history and physical exam rather than by specific laboratory or imaging tests. Tests are sometimes used to rule out other conditions that can have similar symptoms but are more dangerous, such as heart disease.

• The doctor will try to reproduce tenderness over the affected ribs. There is usually no significant visible swelling.
• Blood work and a chest X-ray are usually not helpful in diagnosing costochondritis, but these may be used to rule out other causes of chest pain. However, after sternum surgery, or for people at risk for heart disease, doctors will be more likely to do tests if there is chest pain and possible costochondritis to be certain there is no infection or other serious medical problems.
  • They will look for signs of infection such as redness, swelling, pus, and drainage at the site of surgery.
  • A more sophisticated imaging study of the chest, a gallium scan, can be used to check for infection. It will show increased uptake of the radioactive material gallium in an area of infection.
  • In situations of possible infection, the white blood cell count may be elevated.
  • A chest X-ray is obtained if pneumonia is a suspected cause of chest pain.
  • ECG and other tests will be done if a heart problem is considered.

• Treatment of typical costochondritis often involves conservative measures, such as local heat or ice applications for symptom relief.
• Medicines to reduce inflammation, such as ibuprofen (Advil, Motrin) or naproxen (Aleve), can be helpful. These anti-inflammatory drugs should be taken with food and not taken by people with stomach problems, ulcers, kidney disease, or bleeding disorders.
• Avoid unnecessary exercise or activities that make the symptoms worse. Avoid contact sports until there is improvement in symptoms, and then return to normal activities only as tolerated.

• Costochondritis can resolve with nonsteroidal anti-inflammatory medications such as ibuprofen (Advil or Motrin) and naproxen (Aleve).
• Costochondritis can be treated with a local anesthetic and steroid injection (such as methylprednisolone [Depo-Medrol] or betamethasone [Celestone]) into the area that is tender if normal activities become very painful and the pain does not respond to other medications.
• Infectious (bacterial or fungal) costochondritis (rare) is treated with antibiotics.

Physical therapy is sometimes used in more severe cases of costochondritis. Infectious costochondritis requires close follow-up to prevent spread or recurrence of the infection.

Physicians who treat costochondritis include

• general-medicine doctors, including primary care physicians,
• family practitioners, internists, as well as orthopedists,
• rheumatologists, and
• physiatrists.
• Ancillary health care professionals who can be involved in the treatment of costochondritis include physical therapists and massage therapists.

Because inflammatory costochondritis has no definite cause, there is no real way to prevent it.

• Noninfectious costochondritis will go away on its own, with or without anti-inflammatory treatments. Most people will recover fully.
• Infectious costochondritis responds well to intravenous (IV) antibiotics and surgical repair.