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5.03 Costochondritis


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:

What not to do:

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:


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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Craig Feied, MD
Mark Smith, MD
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