Diagnosing Costochondritis

Costochondritis is typically diagnosed by ruling out other conditions, and there is no specific laboratory or imaging test that can diagnose the condition. We’ll talk about the process for diagnosing costochondritis in this article, including typical symptoms and characteristics of the condition, other conditions that should be ruled out, as well as what tests or imaging may be performed. First we should make clear – what is costochondritis and what are its primary characteristics?

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Costochondritis is a chronic inflammatory condition that involves the costal cartilages and their sternal joints at the anterior chest wall. Although the condition is self-limiting, the pain and breathing difficulties brought on by it cause significant discomfort and interfere with daily life activities for many people. The treatment is mainly focused on pain relief and the disease usually lasts for several weeks, though some have reported long-lasting and recurring symptoms.

Characteristics

The rib cage is made up of bones that join with the sternum (breast bone) anteriorly with the help of the costal cartilage. The presence of this cartilage allows space for breathing movements to occur. 

Inflammation of the costal cartilage results in pain that usually worsens with breathing, coughing, sneezing, or during physical activity. The pain originates at the sides of the sternum, radiates to the whole chest wall, and is usually described by patients as dull or aching. The pain is often exacerbated by certain body positions such as lying down. Swelling associated with chest pain is not a feature of costochondritis and should warrant a different diagnosis (e.g. Tietze Syndrome).

Causes

The cause of costochondritis is usually not apparent, but it can occasionally be attributed to: 

• Trauma or injury from a direct blow on the chest
• Joint conditions such as rheumatoid arthritis, ankylosing spondylolysis, etc.
• Septic arthritis of costosternal joints by S. Aureus or infection by viruses, fungi, and other bacteria e.g. Mycobacterium tuberculosis, Aspergillus fumigatus. 
• Benign and malignant tumors of costal cartilages can first present as costochondritis. Metastatic cancers from other sites of the body, especially breast cancer, thyroid, and lungs can lodge in the anterior chest wall to cause costochondritis.   

Diagnosis

Costochondritis is a diagnosis of exclusion and requires no specific tests for diagnosis. The disease can be satisfactorily diagnosed through a relevant history and examination. The investigations are usually carried out to rule out other causes of chest pain that, if ignored, can lead to life-threatening complications. 

The pain of costochondritis is very characteristic as already described and is the most common clue. On examination, the pain can be elicited by light palpation and can be localized to lateral sides of the sternum. The examination should check for any lumps or swelling. Redness and increase in temperature at costochondral junctions compared to surrounding areas are symptoms pointing to costochondritis. There is a decrease in thoracic movements of respiration and an increase in the use of abdominal muscles in moderate to severe cases.

Cardiac pain is also reproducible with light palpation and should be kept in mind. The diagnosis of costochondritis is highly unlikely if you have:

• History of fever not responding to over-the-counter medications.
• Signs of infection such as painful spot, swelling, and discharging pus.
• Persistent chest pain radiating to the left arm and lower jaw
• Constant pain not related to posture, chest pain, or breathing.
• Productive cough, sweating, nausea & vomiting.

Patients experiencing these symptoms are more likely to have chest pain caused by another condition. 

Tests and exams for costochondritis include 

• Complete blood count (CBC) to check for an underlying infection
• Blood cultures in case an infection is suspected
• Cardiac enzymes and biomarkers to rule out acute coronary syndrome
• ECG for ischemic heart changes of infectious causes of chest pain
• Chest X-ray to rule out any lung pathology
• CT-scan & MRI are more advanced diagnostic tests and are only indicated in cases of primary or metastatic malignancies.

Differential diagnosis

Costochondritis may be confused with the more rare Tietze’s syndrome, owing to its resemblance in clinical presentation. While the two conditions seem similar, there are key differences in their characteristics.

You can read more here about other conditions that may be confused for costochondritis.

Life-Threatening Conditions

These other deadly causes of chest pain should also be kept in mind when diagnosing costochondritis. These include:

• Acute coronary syndrome: presents concurrently with sweating, palpitations, pain radiating to arm and jaw, and sometimes with syncope
• Pulmonary Embolism: sudden onset chest pain with shortness of breath, tachycardia and decreased peripheral perfusion
• Aortic dissection: sharp pain radiating to back
• Pneumonia: usually presents with productive cough and moderate to high-grade fever
• Esophageal injury: has an element of dysphagia and shock, along with severe central chest pain
• Pneumothorax: sudden unilateral chest pain associated with shortness of breath and, occasionally, with shock

You can read more here about other conditions that cause chest pain. 

Treatment

After diagnosis, costochondritis treatment is typically focused on patient education and reassurance for the patient that the life-threatening causes of chest pain have been ruled out. Usually, only symptomatic treatment is required. 

Over-the-counter pain relief medications and avoiding strenuous physical activities are the mainstays of treatment. Physicians may prescribe stronger, narcotic medications if the pain is severe and unbearable. Physical therapy may also be prescribed. Home remedies are also effective in improving pain symptoms, such as gentle chest stretches or yoga to improve mobility, diet changes, and applying hot/cold compresses to the area.

Surgical interventions and nerve blocks are last resorts and are rarely needed in cases of costochondritis not responding to medical management. 

Book an appointment with your doctor if you are experiencing chest pain, prompt diagnosis of chest pain helps avoid complications and improves clinical outcomes. 

Have you been diagnosed with costochondritis? What led to your diagnosis? Feel free to leave a comment below.

Dr. Anique Ali

Dr. Anique Ali is a doctor at Nishtar Medical University, one of the oldest and most famous medical institutions in Pakistan. Dr. Ali uses his knowledge and experience to find ways to share medical information in interesting and engaging ways for his readers and enjoys writing, bioinformatics, and traveling in his spare time.