Costochondritis: An Easily Mistaken Condition

Costochondritis is a common type of inflammation that affects the cartilaginous region of the ribs. This costochondral junction, as it is also known, is fundamental to maintain the stability of the rib cage.

Although in most cases the origin is unknown, some causes that have been related to this pathology are thoracic traumas, exaggerated physical exertion, some viral or bacterial diseases, among others.

The main symptom is pain, which can range from mild to severe, in the entire rib cage – with special emphasis on the costochondral region. This is the real reason why it can be easily confused with any other disease affecting this region.

Some of the conditions most frequently confused with or mistaken for costochondritis include:

1. Arthritis

Arthritis is one of the most important inflammatory diseases in adulthood, characterized by affecting the hands and wrists more frequently, but can also affect other regions. 

The main symptom is pain, but it is also accompanied by a lot of stiffness. Unlike costochondritis, although arthritis affects the rib cage (which is rare), this joint inflammation is migratory and improves with movement. With costochondritis, the intensity of the pain is permanent.

2. Heart Attack

One condition most commonly confused with costochondritis is the heart attack. Although the prevailing symptom is the characteristic chest pain, with a heart condition we will have other signs that will guide us.

The pain with costochondritis increases with pressure, something that does not occur in a heart attack. Also, there are electrocardiographic and enzymatic changes that only occur when the heart is involved, so the differential diagnosis is simple.

3. Pericarditis

Pericarditis is an inflammation of the sac that lines the heart, the pericardium. It can be caused by a virus, heart surgery, or medications, though the cause is often unknown and improves only with symptomatic treatment. Although the main sign is pain, there may be direct changes in our heart (such as an increase in heart rate).

Pain in pericarditis responds to an analgesic position (where the patient finds total or partial absence of pain), also called a genupectoral position, where the weight of the body rests on the head and knees.

4. Pleuritis

Similar to pericarditis as previously explained, pleuritis is an inflammation of the lining of the lung, also called the pleura. Although the symptoms are similar, the affected region is different. 

While in costochondritis the pain comes almost exclusively from the costochondral region, in pleuritis the pain may encompass almost the entire rib cage depending on the course of the disease. 

5. GERD (Heartburn)

Gastroesophageal reflux also falls within the differential diagnoses of costochondritis. This is a common disease, especially in this modern world full of stress and bad eating habits.

Although one of its symptoms is pain, which is retrosternal and can increase with pressure on the abdomen, it should be noted that it is also accompanied by other symptoms that distinguish it from costochondritis, such as burning or retrosternal heartburn.

6. Cancer

Mediastinal tumors, as those that inhabit just behind the sternum and in front of the thoracic spine are known, can be easily confused with costochondritis, especially when the manifestations are mild. These include cancers such as DLBCL (Diffuse Large B-Cell Lymphoma) and PMBCL (Primary Mediastinal B-Cell Lymphoma). 

Cancer brings a lot of pain, but it also brings other symptoms such as weight loss, severe febrile episodes, swollen lymph nodes, night sweats, hoarse coughing, fevers, etc. The patient’s general condition is typically much worse in cancer than in costochondritis.

7. Acute Coronary Syndrome

Unlike a heart attack, coronary syndrome encompasses several heart diseases; however, the symptoms are quite like those of a conventional heart attack. Similarly, the pain in costochondritis worsens when we press just over the costochondral region, something that does not occur in acute coronary syndrome or heart attack. 

8. Fibromyalgia

Fibromyalgia is a disease that is becoming more recognized throughout the world. The main symptom is pain, which does not allow the patient to function normally in his or her life. 

The diagnosis is quite complicated and implies that at least 12 painful points are affected over the whole body. This is the primary reason it differs from costochondritis. For example, to diagnose fibromyalgia, the patient must feel pain in the arms, shoulders, legs, etc.

9. Painful Xiphoid Syndrome

Painful xiphoid is one of the least known pathologies of all those we have named so far. The xiphoid is a small bone at the end of the sternum and is the protagonist of this syndrome. The inflammation of this bone structure is usually due to traumas in that region and is manifested with pain that tends to be confused with other diseases. (1)

Although costochondritis is one of the possible differential diagnoses, the Xiphoid Syndrome is also easily confused with any cause of abdominal or chest pain. However, the main difference between our two contenders is the intensity of the pain according to location. For costochondritis, the pain will be around the entire sternum, while with xiphoid syndrome it will only be at the end or tip of the sternum. 

10. Relapsing Polychondritis

Relapsing Polychondritis is an condition that involves several systems and its fundamental mechanism is still unknown. Research has affirmed that certain changes in the immune system give rise to this disease.

The diagnosis is complicated and is based on the symptoms. Unlike the rest, costochondritis is part of the symptoms present in this disease, as well as the inflammation of many other cartilaginous regions of the body (ears, nose, larynx, etc.). For this reason, the patient with Relapsing Polychondritis would have several affected cartilage regions, as well as systemic lesions, and not only the thoracic region. (2)

11. Thoracic Herpes Zoster (Shingles)

Unlike common herpes simplex virus infections on the genitals or mouth, shingles are particularly special. This variant can affect the nerves of a specific region, causing neuritis, which can radiate through the entire path of the nerve.

Unlike costochondritis, in this disease vesicles on the skin that follow the path of the affected nerve will be present, and there will be a yellow-brown plaque over the entire route. Although they often affect the costochondral region, the affectation usually comes from the back or the lateral region of the rib cage.

12. Esophageal Perforation

Esophageal perforation is a serious complication arising from esophogeal trauma, such as the ingestion of caustics or when there are ulcers that have not been adequately treated. Even swallowing a fishbone could cause a perforation.

However, unlike costochondritis, esophageal perforation involves the development of fever, compromise of the general state, difficulty in swallowing, and a series of other symptoms that do not present in the inflammation of the costochondral cartilage, so the two can be easily differentiated typically. 

13. Pneumonia

Pneumonia is the most common lower respiratory infection in adults. Most of the time pneumonia is caused by viral agents, though it can also be caused by bacterial or fungal infections. 

Symptoms that stand out are dyspnea (difficulty breathing), mucous expectoration (green or yellowish), as well as fever and chest pain. These symptoms differ greatly from costochondritis, but some “hidden” cases of pneumonia may resemble it. Even so, the pain in pneumonia is all around the chest, and in costochondritis the pain is localized in the costochondral region.

14. Aortic Dissection

This often fatal condition is usually the result of degeneration of the walls of the aorta by trauma (such as an automobile accident) or serious chronic processes, such as uncontrolled high blood pressure. What happens is that one or two walls of the aorta tear, and blood begins to flow where it should not.

This causes extreme, debilitating pain (especially in the chest where much of the aorta is located) but an aortic dissection has specific characteristics. Unlike costochondritis, this pain will not increase with pressure in the costochondral region but will be more located to the left side of the chest.

15. Pulmonary Embolism 

When clots break off they may travel through the bloodstream and end up in the lungs, which will cause a pulmonary embolism. This is one of the most frequent postoperative complications, but can be prevented with proper care in a hospital. 

Although pain is a frequent symptom, the most important thing is the sudden dyspnea (difficulty breathing) and an evident change in color of the skin, which becomes more violet. The patient is critical and potentially close to death. Because of this, it is easily distinguishable from costochondritis.

Why is it Important to Screen for other Conditions?

As we can see, costochondritis is a disorder with a key general symptom of chest pain, but it can be easily differentiated from other conditions based on the type of pain it manifests or the symptoms that accompany it. 

The treatment of the above-mentioned diseases and conditions can be expensive, painful, and sometimes even unnecessary; patients can spend years following inadequate therapies, affecting their quality of life, while searching for the true diagnosis. 

Knowing costochondritis, how it manifests itself, and its diagnosis is important for improving the lives of those who suffer from this rather painful but treatable disorder. Improving our quality of life sometimes depends on our ability to discern, or that of those experts in charge of treating us. 

Have you been misdiagnosed with costochondritis, or was your costochondritis mistaken for another condition? Please feel free to leave a comment below.

Dr. Andres David

Dr. Andres David Velasquez MD is a graduate of the Universidad de Oriente, one of the top medical schools in Venezuela. Dr. Velasquez is part of the faculty at Hospital Universitario “Dr. Luis Razetti”. He enjoys playing music, as well as translation and medical writing.