Costochondritis

Costochondritis is a common benign cause of chest wall pain from inflammation or irritation of the costochondral and sternocostal joints, without swelling.

• Accounts for 10 to 30% of chest pain in emergency and primary care.

• Often affects the 2nd to 5th costochondral junctions, multiple sites, more commonly in women over 40.

• Causes: overuse, repetitive strain, coughing, trauma, viral infection, rheumatic disease (spondyloarthritis, fibromyalgia).

• Self-limiting over weeks to months; recurrent in some.

• Sharp, aching or pressure-like anterior chest pain, reproduced by palpation of affected costochondral junctions, worse with movement, deep inspiration, coughing, lying on the side.

• No swelling (distinguishes from Tietze syndrome), no fever.

• Multiple sites, usually unilateral.

• Normal cardiorespiratory examination.

• Diagnosis of exclusion after assessing for life threatening causes: ECG, troponin if risk factors, chest radiograph, D-dimer when indicated, based on clinical risk.

• Reproducible tenderness on palpation (positive crowing rooster and horizontal arm traction manoeuvres).

• Imaging is rarely required; ultrasound or MRI if suspicion of infection or inflammation.

• Consider fibromyalgia, spondyloarthritis (inflammatory back pain, HLA-B27) if persistent.

• Reassurance regarding benign nature.

• Analgesia: paracetamol 1 g four times daily, NSAIDs (ibuprofen 400 mg three times daily with food for 1 to 2 weeks, naproxen 500 mg twice daily), topical NSAIDs.

• Heat packs, gentle stretching, posture correction, avoiding triggering activities.

• Local injection of corticosteroid and lidocaine for persistent pain (triamcinolone 20 mg with lidocaine 1% 2 mL).

• Physiotherapy and TENS.

• Low dose amitriptyline 10 to 25 mg at night or gabapentin 300 mg for chronic pain.

• Review if pain persists over 6 weeks to look for alternative diagnoses.