5.03 Costochondritis

agk’s Library of Common Simple Emergencies

Presentation

The patient’s age is usually in the mid-teens through the thirties, and he complains of a day or more of steady aching with intermittant stabbing chest pain, perhaps following a period of frequent coughing or unusual physical stress, localized to the left or right of the sternum, without radiation, but worse with taking a breath, changing position or moving the arm overhead. He may be concerned about the possibility of a heart attack (though he may not voice his fear) but there is no associated nausea, vomiting, diaphoresis, or dyspnea. The mid anterior costal cartilages (connecting ribs to sternum) are diffusely tender to palpation, without swelling or erythema, exactly matching the patient's complaint. The rest of the physical examination is normal, along with normal vital signs and pulse oximetry.

What to do:

• Perform a thorough history and physical examination. Give special attention to the character of the pain (onset, severity, quality, radiation, duration, relationship to movement), associated symptoms (shortness of breath, nausea, vomiting, diaphoresis, cough), and past history of pre-existing cardiac risk factors (family history of coronary artery disease, smoking, hypertension, diabetes mellitus, elevated cholesterol, cocaine use, age >33 for men and >40 for women). Read the nurse’s note for critical details the patient has not repeated to you. Look for pleural or pericardial rubs and arrythmias and obtain a cardiogram and chest x ray when there is any suspicion of a cardiac or pulmonary disorder. The presence of costochondritis does not exclude the possibility of myocardial infarction, pericarditis, pulmonary embolus pneumothorax, pneumonia, or pleural effusion.
• If there is any suggestion of cardiac or pulmonary disease, complaints of chest tightness or pressure, or significant cardiac risk factors, obtain apropriate consultation to consider admission and further diagnostic evaluation.
• If there is no evidence of other disease, prescribe anti-inflammatory analgesics, have the patient apply heat for comfort, explain the condition and the lack of other disease, and direct the patient to seek followup with instructions to return for any fever, shortness of breath, diaphoresis, change in character of pain, or radiation to arm, shoulder or jaw.

What not to do:

• Do not rule out myocardial infarction especially in the middle aged and elderly patient, simply because there is tenderness over the costal cartilage, which could represent a coincidental finding, skin hypesthesia or contiguous inflammation secondary to the infarct.

Discussion

This local inflammatory process is probably related to minor trauma, and would not be brought to medical attention so often if it did not resemble the pain of a heart attack. Careful reassurance of the patient is therefore most important. This disorder is self-limited, but there may be remissions and exacerbations: the pain usually resolves in weeks to months. Tietze’s syndrome is a rare variant that is generally less diffuse and associated with local swelling. When exquisite tenderness localizes over the xyphoid cartilage this represents a xyphoiditis or xyphoidalgia and can often be treated immediately with an injection of DepoMedrol 40mg along with 5cc of 1% Xylocaine and a course of nonsteroidal anti-inflammatories as above. Injection of the xyphoid cartilage is similar to that of other trigger points: use a fine needle and fan out around the point of maximum tenderness. While injecting the xyphoid, you must use some caution to avoid causing a pneumothorax or injecting the myocardium.

References:

• Disla E, Rhim HR, Reddy A et al: Costochondritis: a prospective analysis in an ED setting. Arch Intern Med 1994;154:2466-2469.

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