Costochondritis. A prospective analysis in an emergency department setting

Musculoskeletal chest pain prevalence in emergency department presentations: A retrospective case notes review

OBJECTIVE

Musculoskeletal (MSK) causes of chest pain are considered common in emergency care, yet management is limited, reported outcomes are poor and prevalence data in New Zealand are lacking. The present study aims to estimate the prevalence of MSK chest pain in New Zealand EDs and describe the characteristics of MSK chest pain cases.

METHODS

A retrospective chart review was conducted based on de-identified clinical notes extracted from four hospitals within the South Island of New Zealand from 3 months spanning 1 March to 31 May 2021. Individual cases were categorised to the single best-fitting cause of chest pain using systems-based categorisation, based primarily on the doctors' documented final impression.

RESULTS

A total of 1344 cases were categorised in the present study. MSK chest pain had a prevalence of 15% (range 11-31%) of chest pain presentations across all study sites. This represented the second most common system responsible for chest pain, after the cardiovascular system. The mean age of MSK chest pain cases was 46.9 (standard deviation [SD] 19.1) years, compared to 55.5 (SD 19.7) years in all cases. Age and gender-specific data, data from rural hospitals and MSK sub-type data are presented.

CONCLUSIONS

These data provide a conservative estimate of MSK chest pain prevalence in EDs within the South Island of New Zealand. The findings highlight MSK chest pain as common in emergency care, providing a basis and justification for further research to improve management and outcomes for people with MSK chest pain.

Local treatment of pain in Tietze syndrome: A single-center experience

Background

In this study, we present our experiences with local injections of triamcinolone and prilocaine in patients diagnosed with Tietze syndrome.

Methods

Between January 2016 and January 2019, a total of 28 patients (12 males, 16 females; median age: 33 years; range, 21 to 51 years) who were diagnosed with TS in our clinic were retrospectively analyzed. Triamcinolone hexacetonide and prilocaine hydrochloride were injected into painful joints. At first week, pain sensation of the patients was recorded using the Pain Rating Scale developed by the British Pain Society. Pain was also assessed at one, two, and three weeks after injections qualitatively and based on physical examination.

Results

At one week, the pain severity before the local injection treatment was above average the pain-related discomfort rates, and the response was quite favorable after the treatment (p=0.005 and p=0.001, respectively). A statistically significant rating was observed for treatment response and success (p=0.003). Totally 75% of the patients experienced more than 70% reduction in pain level after the injection.

Conclusion

Our treatment approach involving injection of a mixture of steroid and a local anesthetic provides a rapid relief from pain, irrespective of age, sex, or employment status in patients diagnosed with Tietze syndrome.

Atypical Costochondritis: Complete Resolution of Symptoms After Rib Manipulation and Soft Tissue Mobilization

Costochondritis is a self-limiting, poorly described, and benign condition that usually manifests as non-cardiac chest pain. The symptoms usually tend to resolve in a couple of weeks. Serious causes of chest pain should be ruled out prior to diagnosing costochondritis, as it is often a diagnosis of exclusion. Costochondritis that does not self-resolve is referred to as atypical costochondritis and is associated with high medical expenses and psychological burden on the patient.

In this report, we discuss the case of a 37-year-old healthy male patient who presented with a two-year history of intermittent pain along the right anterolateral rib cage without any history of trauma. After extensive diagnostic work-up by Cardiology and Gastroenterology, Physical Medicine and Rehabilitation (PM&R) got involved. The initial diagnosis of chest pain evolved into atypical costochondritis given the time course, physical examination findings of focal tenderness, along with normal laboratory values, electrocardiogram, and imaging studies. A multimodal approach was adopted for the treatment of this patient, including manipulative therapy to determine if regional interdependence was present, followed by instrument-assisted soft tissue mobilization (IASTM) and stretching to address the potential myofascial pain generators. After three appointments, there was complete resolution of morning pain and there was no pain upon examination.

This case highlights how osteopathic manipulation techniques (OMT) can be useful in the treatment of rib dysfunction, especially in atypical costochondritis. Further studies are required to expand our knowledge of costochondritis and physical therapy (PT) techniques, which would allow for early identification and effective treatment of the condition.

The role of the three phase bone scintigraphy in the management of the patients with costochondral pain

AIM

The bone scintigraphy is indicated in patients with costochondral pain in order to identify the organic etiology. We aimed to investigate the local and projecting pain, or incidental findings in the three phase bone scintigraphy of the patients referred for costochondral pain.

METHODS

We included 50 patients (36F, 24M; mean: 41±18 years-old) referred to our department for three phase bone scintigraphy for costochondral pain between January 2009-July 2012.

RESULTS

Among the 50 patients 22 had normal scintigraphy. An increased activity accumulation in the sternoclavicular joint was observed in 12 patients (right in 4, left in 4 and bilateral in 4) only in late phase and in 9 patients (right in 2, left in 1 and bilateral in 6) with increased vascularity. Among projecting pain causes, activity was present on sternum in 4 patients, on humerus in 2 patients and on the first costae in 2 patients. For the characterization of inflammatory pathology, the three phase bone scintigraphy showed sensitivity, specificity, accuracy, positive and negative predictive values of 43%, 94%, 78%, 77% and 78% respectively.

CONCLUSION

Bone scintigraphy is an effective diagnostic method for the identification of local or projecting pain, and additionally unexpected incidental pathologies ssociated with costochondral pain. However regarding the characterization of inflammatory process false negatives should be considered.

CONFLICT OF INTEREST

None declared.

Treatment of a female collegiate rower with costochondritis: a case report

Rib injuries are common in collegiate rowing. The purpose of this case report is to provide insight into examination, evaluation, and treatment of persistent costochondritis in an elite athlete as well as propose an explanation for chronic dysfunction. The case involved a 21 year old female collegiate rower with multiple episodes of costochondritis over a 1-year period of time. Symptoms were localized to the left third costosternal junction and bilaterally at the fourth costosternal junction with moderate swelling. Initial interventions were directed at the costosternal joint, but only mild, temporary relief of symptoms was attained. Reexamination findings included hypomobility of the upper thoracic spine, costovertebral joints, and lateral ribs. Interventions included postural exercises and manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility. Over a 3-week time period pain experienced throughout the day had subsided (visual analog scale - VAS 0/10). She was able to resume running and elliptical aerobic training with minimal discomfort (VAS 2/10) and began to reintegrate into collegiate rowing. Examination of the lateral ribs, cervical and thoracic spine should be part of the comprehensive evaluation of costochondritis. Addressing posterior hypomobility may have allowed for a more thorough recovery in this case study.

Chest pain in focal musculoskeletal disorders

The musculoskeletal system is a recognized source of chest pain. However, despite the apparently benign origin, patients with musculoskeletal chest pain remain under-diagnosed, untreated, and potentially continuously disabled in terms of anxiety, depression, and activities of daily living. Several overlapping conditions and syndromes of focal disorders, including Tietze syndrome, costochondritis, chest wall syndrome, muscle tenderness, slipping rib, cervical angina, and segmental dysfunction of the cervical and thoracic spine, have been reported to cause pain. For most of these syndromes, evidence arises mainly from case stories and empiric knowledge. For segmental dysfunction, clinical features of musculoskeletal chest pain have been characterized in a few clinical trials. This article summarizes the most commonly encountered syndromes of focal musculoskeletal disorders in clinical practice.

Evaluation of chest pain in the pediatric patient

Chest pain is common in children seen in emergency departments, ambulatory clinics, and cardiology clinics. Although most children have a benign cause of their pain, some have serious and life-threatening conditions. The symptom must be carefully evaluated before reassurance and supportive care are offered. Because serious causes of chest pain are uncommon and not many prospective studies are available, it is difficult to develop evidence-based guidelines for evaluation. The clinician evaluating a child with chest pain should keep in mind the broad differential diagnosis and pursue further investigation when the history and physical examination suggest the possibility of serious causes.

Musculoskeletal problems of the chest wall in athletes

Chest pain in the athlete has a wide differential diagnosis. Pain may originate from structures within the thorax, such as the heart, lungs or oesophagus. However, musculoskeletal causes of chest pain must be considered. The aim of this review is to help the clinician to diagnose chest wall pain in athletes by identifying the possible causes, as reported in the literature. Musculoskeletal problems of the chest wall can occur in the ribs, sternum, articulations or myofascial structures. The cause is usually evident in the case of direct trauma. Additionally, athletes' bodies may be subjected to sudden large indirect forces or overuse, and stress fractures of the ribs caused by sporting activity have been extensively reported. These have been associated with golf, rowing and baseball pitching in particular. Stress fractures of the sternum reported in wrestlers cause pain and tenderness of the sternum, as expected. Diagnosis is by bone scan and limitation of activity usually allows healing to occur. The slipping rib syndrome causes intermittent costal margin pain related to posture or movement, and may be diagnosed by the 'hooking manoeuvre', which reproduces pain and sometimes a click. If reassurance and postural advice fail, good results are possible with resection of the mobile rib. The painful xiphoid syndrome is a rare condition that causes pain and tenderness of the xiphoid and is self-limiting. Costochondritis is a self-limiting condition of unknown aetiology that typically presents with pain around the second to fifth costochondral joints. It can be differentiated from Tietze's syndrome in which there is swelling and pain of the articulation. Both conditions eventually settle spontaneously although a corticosteroid injection may be useful in particularly troublesome cases. The intercostal muscles may be injured causing tenderness between the ribs. Other conditions that should be considered include epidemic myalgia, precordial catch syndrome and referred pain from the thoracic spine.