There are few patient complaints that can capture the undivided attention of the medical community as quickly as, “I’ve got chest pain,” especially when uttered in an emergency room setting. Acute central chest pain accounts for nearly 30% of emergency medical hospital admissions.¹ While it’s important to consider and exclude the serious causes of chest pain — ischemic heart disease, pulmonary embolism and aortic dissection, to name but a few — all that glitters is not gold. Fewer than 20% of chest pain presentations in primary care settings are related to life-threatening conditions.² And once a serious cause, like acute coronary syndrome, is judged unlikely, patients are often dismissed with no further diagnostic efforts.

Undiagnosed chest pain, whatever the etiology, can result in ongoing patient anxiety and lead to repeat medical assessments and extensive medical costs. Since non-cardiac chest pain is estimated to affect one in four adults during their lifetime, the potential long-term medical expenditures are enormous. It’s therefore important to diagnose all causes of chest discomfort, and provide patients with appropriate reassurance, without breaking the healthcare bank in the process.

Costochondritis is a prime example of a benign chest pain condition, diagnosed in as many as 30% of the patients who present to the hospital emergency room with chest pain.³ But costochondritis is still often mistaken for angina pectoris or another serious condition, resulting in unnecessary investigations and hospital admissions.

What is costochondritis?

Costochondritis is an inflammatory disorder of uncertain etiology. It most often involves the second and third costochondral joints, which lie just lateral to the superior portion of the sternum. The pain produced by the inflammation is superficial in nature and often described as “sharp” in quality, commonly intensified by coughing, deep breathing, and chest movement. By contrast to Tietze’s syndrome, which is defined as acute non-suppurative swelling of the costosternal junctions (as first described by German surgeon Alexander Tietze in 1921), costochondritis doesn’t cause swelling and tends to be chronic and recurring in its course. The characteristic discomfort of costochondritis can usually be reproduced by palpation over the costochondral junctions. While localized reproducible discomfort is the key diagnostic feature of costochondritis, chest wall tenderness has also been noted in patients presenting with ischemic heart disease, underscoring the necessity to exclude more serious causes of chest pain.⁴

Red flags

The differential diagnosis of chest pain can pragmatically be separated into conditions that are life-threatening and those that are not. A number of clinical red flags can alert physicians to the presence of a serious chest pain presentation. These include the symptoms of nausea, emesis, diaphoresis, dyspnea, or syncope, and the signs of fever, hemodynamic instability or pulmonary edema. Patients with any of these concerning features require immediate workup in an acute care setting to define the etiology of their symptoms precisely. The clinical context of the chest pain complaint is also an important diagnostic determinant, such as the age and gender of the patient, as well as their cardiovascular risk factor profile, including hypertension, diabetes mellitus, smoking, dyslipidemia and documented vascular disease. In the absence of concerning clinical features or cardiovascular risk factors, less serious causes of chest pain can be readily entertained, including musculoskeletal disorders such as costochondritis.

Pain in the chest may be the presenting feature of a diverse number of musculoskeletal chest wall conditions. These include blunt trauma and overuse myalgia, as well as hematologic, infectious and rheumatologic processes like rheumatoid, psoriatic and osteoarthritis, as well as ankylosing spondylitis, septic arthritis, and crystal arthropathies. But far and away, costochondritis tops the list, and is worth considering early on in the diagnostic assessment. The diagnosis of costochondritis is one of exclusion, to be sure, but this doesn’t mean that the diagnosis depends upon a battery of blood tests being ordered and a body MRI scan.

There’s the rub

Costochondritis is a clinical diagnosis. This means that in the appropriate clinical context, the diagnosis of costochondritis can usually be confirmed by clinical examination alone, the key to which is reproducing the patient’s pain by palpation over the costochondral junctions. The characteristic discomfort of costochondritis can usually be reproduced by palpating through the pectoralis major muscle and pressing over the involved costal cartilage using a firm, back and forth, rubbing motion. There is a need for doctors to consider costochondritis in patients presenting with acute chest pain, particularly if the symptoms are recurrent. Patient reassurance and the provision of an effective treatment regimen, such as anti-inflammatory therapy, have been shown to improve patient care and reduce healthcare expenditure.⁵ It’s not enough to just identify the life-threatening needles that can cause chest pain; we must also effectively sift through the haystack of benign causes, and identify treatable conditions like costochondritis.

References

1. BMJ 2002;325:588-91.
2. Aliment Pharmocol Ther 2003;17(9):1115-24.
3. Arch Intern Med 1994 Nov 14;154(21):2466-9.
4. Am Heart J 1963;66:296-300.
5. J Rheumatol 2004;31(11):2269-71.