Costochondritis is a common cause of chest pain in children and adolescents. The condition is characterized as an inflammatory process of 1 or more of the costochondral cartilages that causes localized tenderness and pain of the anterior chest wall. Most cases of costochondritis are idiopathic. The remaining cases may result from costochondral irritation due to direct trauma, aggressive exercise that caused a strain, or a prior upper respiratory tract infection with cough that caused repeated stretching and strain at the costochondral junction.

Costochondritis is a relatively benign and usually self-limited condition. Patients often are evaluated initially in the ED or, with acute conditions, in their primary care physician's office.

The term Tietze syndrome implies swelling; costochondritis refers to pain alone.

Pathophysiology: The exact pathophysiology of cartilage and capsular involvement is unknown because costochondritis does not warrant surgical intervention or tissue biopsy. Theoretically, the cartilage involved in costochondritis is either inflamed or torn. Either condition presumably leads to inflammation with subsequent stimulation of pain receptors.

Frequency:

• In the US: Several studies of chest pain in pediatric patients report costochondritis prevalences of 14-30%; a single study reported rates as high as 79%. The overall incidence rate is approximately 4% of children and adolescents.

Mortality/Morbidity: No reports have associated mortality with costochondritis, and no mortality is expected.

Race: A study indicates Hispanics may have a higher incidence of costochondritis, but most studies do not mention race as a factor.

Sex: Studies of chest pain in children found that females are diagnosed with costochondritis more often than males by a 2:1 ratio.

History: The key to the diagnosis of costochondritis amid the differential diagnoses, which include cardiac and pulmonary disease, is a thorough history and physical examination.

• Presenting characteristics of chest pain associated with costochondritis

• Onset - Typically insidious, occurring over several days or weeks, may be acute

• Nature - Sharp and stabbing

• Location - Anterior chest, pain usually unilateral, but may be bilateral

• Radiation - Chest, upper abdomen, or back

• Exacerbating factors - Coughing, sneezing, deep inspirations, movement of the upper torso and upper extremities

• Relieving factors - Rest, application of ice, or use of heat

• Preceding conditions - Upper respiratory tract infection or exercise (common in preceding 3 mo)

Physical: Vital signs should be assessed. Careful and complete pulmonary, cardiac, and abdominal examinations eliminate the possibility of an underlying disease process.

• Inspection focuses on symmetry of the chest wall. Asymmetry may indicate trauma as a cause of chest pain.

• Swelling is uncommon. Patients with Tietze syndrome, however, may have swelling over an upper costochondral junction.

• Ecchymosis would be expected only in trauma.

• Respiratory effort is normal.

• Palpation that reveals tenderness over the costochondral junction is diagnostic. The tenderness should be localized and is most common at the sternocostal cartilage of the second through the seventh ribs.

• Examination may be performed with firm, single-digit palpation of the area.

• Crepitus is uncommon and may indicate a fracture.

• Auscultation of the lungs, heart, and abdomen are normal.

Causes: Most cases of costochondritis are idiopathic. The remaining cases may be the result of costochondral irritation caused by the following:

• Direct trauma

• Aggressive exercise resulting in a strain (eg, repeated twisting of the upper torso, stretching-pulling activities of the upper extremities)

• Preceding upper respiratory tract infection with cough (which can cause repeated stretching and strain at the costochondral junction)

Lab Studies:

• Costochondritis has no confirmatory or diagnostic laboratory tests.

Imaging Studies:

• Imaging studies are unnecessary to confirm a diagnosis of costochondritis.

• Chest radiographs may exclude other possible causes of chest pain but offer no diagnostic value to costochondritis assessment. In the absence of confounding physical findings, the diagnostic yield of a chest radiograph is less than 2%.

• In the unusual circumstance that imaging is required, CT scanning probably is the best choice because it can demonstrate swelling of the costal cartilage. Ultrasound also may demonstrate swelling but is less useful. No formal studies of imaging for this condition have been reported.

Procedures:

• Costochondral joint injection is indicated for patients with severe pain for whom oral analgesics are either ineffective or contraindicated. Costochondral joint injection may have a role in treating refractory cases of costochondritis. Using a 22-gauge needle, inject 2% lidocaine or a combination of corticosteroid and lidocaine. A total volume ranging from 1-3 cc may be injected depending upon patient size.

• Contraindications include an uncooperative patient, known hypersensitivity to the injectant, unclear diagnosis, or unstable cardiopulmonary disease. Use caution in patients with a severe coagulopathy. Complications include bleeding, infection, and pneumothorax.

Medical Care:

• Reassure patients diagnosed with costochondritis that the cause of their chest pain is not cardiac disease or cancer.

   

• Treatment involves conservative local care with judicious use of nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics, as necessary. Cough suppressants may be beneficial if cough is an aggravating factor.

• Liberal use of ice is recommended for 20-minute intervals.

• Advise relative rest for the patient's upper extremities and avoidance of possible precipitating or exacerbating activities.

Consultations:

• Occasional refractory cases may require consultation with the following specialties:

• Primary care sports medicine

• Rheumatology

• Orthopedic surgery

Activity:

• Activity restrictions include relative rest. Instruct the patient to avoid activities that exacerbate symptoms. Collision or contact sports may be limited until the patient can perform activity-specific movements without pain.

• Applying ice after activity usually helps alleviate a significant amount of pain or discomfort.

• Resumption of aggravating activities prior to resolution may cause relapse.

NSAIDs provide analgesia for mild to moderate chest pain and may modulate the presumed inflammatory process. Purely analgesic drugs (eg, acetaminophen, tramadol hydrochloride) may suffice.
Drug Category: Nonsteroidal anti-inflammatory drugs -- Provide analgesia and may play a role in controlling inflammation.

Drug Category: Analgesics -- May be used to relieve mild to moderate pain.

Further Outpatient Care:

• Follow up as needed after initial diagnosis. Reevaluate patient if the nature, character, or severity of pain changes.

• For individuals who participate in athletics, follow up at 2 weeks or sooner and instruct patient to return to activity only with medical clearance.

Prognosis:

• The overall prognosis of a patient with costochondritis is excellent; full recovery can be expected.

• Resolution occurs in several weeks or months and rarely lasts longer than 4-6 months. Relapse may occur if the patient returns to activity while still symptomatic.