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Geriatric Considerations
Presents with multiple problems capable of causing chest pain, making a thorough history and physical exam imperative
Consider herpes zoster in elderly patients with nonspecific musculoskeletal chest pain.
DIFFERENTIAL DIAGNOSIS
- Cardiac
- Coronary artery disease (CAD)
- Cardiac contusion from trauma
- Aortic aneurysm
- Pericarditis
- Myocarditis
- Gastrointestinal
- Gastroesophageal reflux
- Peptic esophagitis
- Esophageal spasm
- Cholecystitis
- Musculoskeletal (4)
- Fibromyalgia
- Slipping rib syndrome
- Costovertebral arthritis
- Painful xiphoid syndrome
- Rib trauma
- Ankylosing spondylitis
- Precordial catch syndrome
- Psychogenic
- Anxiety disorder
- Panic attacks
- Hyperventilation
- Respiratory
- Asthma
- Pulmonary embolism
- Pneumonia
- Chronic cough
- Pneumothorax
- Other
- Domestic violence and abuse
- Herpes zoster
- Spinal tumor
- Metastatic cancer
- Substance abuse (cocaine)
DIAGNOSTIC TESTS & INTERPRETATION
- The diagnosis of costochondritis is primarily based on a thorough history and physical exam.
- Laboratory exams should be used to exclude other differential diagnosis.
- ESR is inconsistently elevated.
Initial Tests (lab, imaging)
No imaging is indicated for the diagnosis of costochondritis; chest x-ray and rib films are often normal.
Diagnostic Procedures/Other
- None indicated for the diagnosis of costochondritis.
- Consider ECG in patients age >35 years, those with history or risk of CAD (5)[C].
- Consider chest x-ray in patients with cardiopulmonary symptoms (5)[C].
- Consider spiral CT for pulmonary embolism and D-dimer if history or risk factors are present.
Test Interpretation
Costochondral joint inflammation
TREATMENT
Reassurance of benign nature of condition and potential for long, slow recovery from pain
GENERAL MEASURES
- Rest and heat (or ice massage, whichever makes the patient feel better) (6,7)[C]
- Stretching exercises
- Minimizing activities that provoke the symptoms (e.g., reducing the frequency or intensity of exercise or work activities) (6,7)[C]
MEDICATION
- Pain relief with NSAIDs (ibuprofen, naproxen, or diclofenac); acetaminophen or other analgesics may be considered in noninflammatory disorders (6,7)[C].
- Use of skeletal muscle relaxants may be beneficial if associated with muscle spasm.
ISSUES FOR REFERRAL
Consider referral to physical therapy or osteopathy. Refractory cases of costochondritis can be treated with local injections of combined lidocaine (Xylocaine)/corticosteroid into costochondral areas if severe; however, this is rarely necessary (8)[C].
COMPLEMENTARY & ALTERNATIVE MEDICINE
Limited data on use of manipulation or ice massage but may be safely tried if patient is interested.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Only indicated if differential diagnosis is unclear and cardiac or other more serious etiology of chest pain is being considered
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Follow up within 1 week if diagnosis is unclear or symptoms do not abate with conservative treatment.
PATIENT EDUCATION
- Educate the patient in regard to the self-limited (although potentially recurrent) nature of the illness.
- Instruct patient on proper physical activity regimens to avoid overuse syndromes.
- Stress importance of avoiding sudden, significant changes in activity.
PROGNOSIS
- Self-limited illness lasts for weeks to months but usually abates by 1 year, although sometimes chronic especially in adolescents.
- Often recurs
COMPLICATIONS
Incomplete attention to differential diagnosis or overly aggressive interventions to ensure a more life-threatening diagnosis is not missed.
REFERENCES
11 Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80(6):617-620.22 Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466-2469.33 Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract. 1994;38(4):345-352.44 Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013;40(4):863-887. doi: 10.1016/j.pop.2013.08.007.55 Miller CD, Lindsell CJ, Khandelwal S, et al. Is the initial diagnostic impression of "noncardiac chest pain" adequate to exclude cardiac disease? Ann Emerg Med. 2004;44(6):565-574.66 How J, Volz G, Doe S, et al. The causes of musculoskeletal chest pain in patients admitted to hospital with suspected myocardial infarction. Eur J Intern Med. 2005;16(6):432-436.77 Spalding L, Reay E, Kelly C. Cause and outcome of atypical chest pain in patients admitted to hospital. J R Soc Med. 2003;96(3):122-125.88 Aspegren D, Hyde T, Miller M. Conservative treatment of a female collegiate volleyball player with costochondritis. J Manipulative Physiol Ther. 2007;30(4):321-325.
ADDITIONAL READING
- Cayley WEJr. Diagnosing the cause of chest pain. Am Fam Physician. 2005;72(10):2012-2021.
- Freeston J, Karim Z, Lindsay K, et al. Can early diagnosis and management of costochondritis reduce acute chest pain admissions? J Rheumatol. 2004;31(11):2269-2271.
- Verdon F, Herzig L, Burnand B, et al. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly. 2008;138(23-24):340-347.
CODES
ICD10
M94.0 Chondrocostal junction syndrome [Tietze]
ICD9
733.6 Tietze's disease
SNOMED
- 64109004 Costalchondritis (disorder)
- 30128009 Tietze's disease
CLINICAL PEARLS
- A very common disorder, accounting for perhaps 30% of all cases of chest pain
- Diagnosis is based primarily on history and physical with lab and other testing done to exclude various differentials based on thorough history and risk factors.
- Educate the patient in regard to the self-limited (although potentially recurrent) nature of the illness. Instruct patient on proper physical activity regimens to avoid overuse syndromes.