Non-Cardiac Chest Wall Pain: Costochondritis

After cardio-vascular disease has excluded from the differential diagnosis of the patient presenting with chest pain, fibromuscular and skeletal etiologies of chest pain can be considered. Costochondritis is one of the most common problems that cause chest wall pain, in the primary care setting

While it is very satisfying to demonstrate the absence of life-threatening vascular occlusions, the patient will remain unsatisfied if the pain persists and the diagnosis is missed.  Prior to hospitalization and catheterization, many unnecessary hospital admissions result from the failure to consider these common non-life threatening causes of chest pain.

In our well recognized spare time, it pays tremendous dividends for the practitioner to re-examine the anatomy of the skeletal chest wall.  This anatomic review reveals a complicated matrix of joints, some are bone to bone, others are bone to cartilage, and some are cartilage to cartilage.   Each of these joints can be jammed, jolted or otherwise damaged with physical activity, coughing or external trauma.  Review of the anatomy demonstrates the predominance of bone-cartilage joints in the anterior thorax, in the area surrounding the heart. Cartilage-cartilage joints form the inferior costal margin, over the viscera.  Injured with forced extension of the arm, these joints can be injured with blunt trauma to the chest, they are vulnerable with motor-vehicle mishaps, and they are vulnerable to injuries sustained with lifting, slips, and falls.

The joints of the rib cage are innervated by branches of the anterior cutaneous branches of the Intercostal Nerves, the lateral cutaneous branches of the Intercostal Nerves as well as through autonomic nerves that accompany the many vascular elements within the area.

Careful physical examination will nearly always demonstrate which of these joints in the anterior chest wall has become damaged or dysfunctional, resulting in the complaint of chest pain.

Symptoms of inflammation of the costochondral joints include pain in the anterior chest and arm, aching under the breast, feeling ‘as if it were a heart attack.’ This pain is autonomically modulated.  The stabbing, intermittent, knife-like pain is usually somatically modulated.  It is common for the patient to be unable to assist in the precise location of the pathology.

The precise symptoms will differ significantly due to the factors that impart physical stress or move the joint, and the symptoms are different due to the peculiar innervation of these joints.   When these joints are damaged, they become inflamed, as expected in any joint present in the body.  When damaged, the resulting pain is modulated partly through the Intercostal Nerves, but also through the Autonomic Nervous System, resulting in referred pain patterns that can be similar or identical to cardiogenic pathology. This is the obvious clinical challenge.  Because the innervation of these joints is largely autonomic in nature, symptoms are most often vague, dull and aching in nature. 

More and more common in clinical practice women are presenting with self-inflicted Costochondritis. Unwise clothing options can damage these delicate joints, as well as damage the nerve fibers that innervate the joints.  Under-wire bras are often to blame. Once used chiefly by large women, this type of garment is now much more commonly encountered in the general female population. 

Treatment is accomplished with oral anti-inflammatories, combined with topical anti-inflammatories.   Generally, agents such as Naprosyn®, Flurbiprofen and Ketoprofen work most rapidly, but a variety of others work, as well.  Topical anti-inflammatory agents include Voltarin®, compounded Ketoprofen/Flurbiprofen, and OTC MSM cream (Kinkease™). Relief can be expected to be rapid, but injections may be necessary to expedite the healing process as well as to provide immediate pain relief, thereby providing clinical demonstration as to the skeletal etiology of the chest pain.

Injections are best accomplished using the smallest available needle, thereby minimizing trauma due to the injection, itself.  The use of a 27 gauge needle reduces collateral damage due to the injection, and volumes of injectate should not exceed 0.5 ml. When performing the injections, it is best to have the patient in a comfortable sitting position, the needle is gently advanced until touching the periosteum of the rib.  If performed in the lateral to medial direction, with the needle at an acute angle, the needle bevel will enter the joint space.  Care must be given to avoid hitting visceral structures, such as the heart or lungs. Relief of pain can be expected within 60 seconds of proper performance of this procedure.  It is useful to note that the under-wires can and should be removed, using a pair of scissors and a pair of needle-nosed pliers. 

Duration of treatment can be expected to last 8 weeks, or longer, and the use of the topical agents should extend several weeks after the amelioration of symptoms. 

About David S Klein, MD 149 Articles
David S. Klein, MD, FACA, FACPM was born in Washington, DC, and was raised in Chevy Chase, Maryland. He completed his undergraduate education at the University of Maryland with degrees in Chemistry and Psychology. Medical School was completed at the University of Maryland at Baltimore, followed by Internship in General Surgery at the University of North Carolina and Residency in Anesthesiology at the Duke University, Durham, North Carolina. Dr Klein has been practicing medicine since 1983, concentrating in Pain Medicine, Minimally Invasive Medicine and Surgery, and Neuroendocrinology. Earning Board Certification in Anesthesiology, Dr. Klein was elected Fellow in the American College of Anesthesiology, and he was elected Fellow in the American College of Pain Medicine. He is currently an adjunct Associate Professor at the University of Central Florida, School of Medicine. He has focused his private practice on treating patients with hormone imbalance issues, nutritional deficiency related medical problems as well as pain related issues and impairment. With a highly-complex, CLIA licensed laboratory in-house, he has been able to provide rapid-turn around analysis efficiently and cost-effectively. Lecturing extensively nationally as well as internationally, Dr. Klein has authored many articles on topics relating to pain, injury and nutritionally modulated illness. His radio show, “Pain Free Living,” received top ratings during the 6 years it was on the air. Currently practicing in Longwood, Florida, Dr. Klein practices entirely in the office setting.