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JaniTakatalo

Tietze's Syndrome and Costochondritis

Typical signs and symptoms of Tietze's syndrome are pain, marked tenderness on palpation, and swelling, most commonly around one costochondral junction.
Costochondritis is a similar painful condition to Tietze's syndrome but without swelling in the symptomatic area.
The aetiology usually remains unclear but the onset of symptoms may be preceded by exceptional straining of the thorax.
The diagnosis is a clinical diagnosis of exclusion, and the condition will resolve spontaneously within a few weeks or months.

Tietze's syndrome is distinctly less common than costochondritis.
Well under 10% of patients complaining of musculoskeletal thoracic pain are estimated to suffer from Tietze's syndrome, whereas the incidence of costochondritis may be as high as 30% in a population with similar symptoms.

Most typically, symptoms are located at the second or third costochondral junction. In 70-80% of the cases they are unilateral and in the area of just a single costal cartilage.
- They rarely occur at adjacent costochondral junctions and/or bilaterally.
- Tietze's syndrome may also occur in the sternoclavicular joint or, rarely, in the xiphoid process.
In addition to being swollen, the painful area may feel warm and be reddish.

Costochondritis usually occurs unilaterally at the second to fifth costochondral junctions and often at several junctions at the same time.
- Deep inspiration, coughing, sneezing, bending or twisting the upper body, physical strain and movements of upper extremities may aggravate the pain.

Cause of pain	Workup
Rib (stress) fracture Fractures of the Ribs and Pelvis	History, rib compression test
Slipping rib syndrome	History, symptoms in the lower thorax
Myofascial symptoms and muscle injuries Muscle Injuries (pectoral muscle, oblique abdominal muscles, anterior serratus muscle, superior posterior serratus muscle, rhomboid muscle, subclavius muscle, etc.)	History and palpation
Osteoarthritis of the sternoclavicular joint	History and imaging
Seronegative arthritis, ankylosing spondylitis or other spondyloarthropathy Ankylosing Spondylitis and Axial Spondyloarthritis with possible inflammation of the sternoclavicular joint	History; usually more extensive symptoms
Fibromyalgia Fibromyalgia	Workup of fibromyalgia by questionnaire, for example
Intervertebral disc prolapse in the thoracic spine	More extensive pain within a dermatome, usually provoked by rotation of the thoracic spine
Shingles Shingles (Herpes Zoster)	More extensive pain within a dermatome, skin blisters appearing in a few days
Pneumonia Pneumonia	Fever, general condition, findings on auscultation, laboratory tests and chest X-ray
Symptoms of cardiac origin, such as coronary artery disease Chronic Coronary Syndrome (Coronary Heart Disease)	Patient history, auscultation, laboratory tests and ECG
Malignancy, such as lymphoma Lymphomas	General condition, laboratory tests and imaging

Imaging is not necessary for diagnosis.
- There are no imaging findings specific for costochondritis.
- Swelling of cartilage may be seen on ultrasound examination or computerized tomography in patients with Tietze's syndrome, magnetic resonance imaging additionally may show swelling of subchondral bone.
Histopathological studies in patients with Tietze's syndrome have revealed chronic inflammation, fibrosis and ossification.

Both Tietze's syndrome and costochondritis often resolve spontaneously in a few weeks or months but in some patients the symptoms persist (for up to 1-2 years, after which they usually resolve spontaneously).
- Costochondritis has also been found to recur in some patients.
It is essential to inform patients and to convince them that the conditions are benign.
Local cold therapy or heat therapy can be tried.
Movements causing pain should be kept to a minimum as long as there are symptoms.
Paracetamol or an NSAID for a few days can be tried for pain.
In prolonged Tietze's syndrome (continuing for more than 6 months), injection of a glucocorticoid/local anaesthetic into the site of pain may be helpful. If the first injection is clearly helpful, the treatment can be repeated as considered individually appropriate.
In costochondritis, it is probably not worthwhile to use a glucocorticoid injection; local anaesthesia may be indicated in severe, prolonged cases (the response is usually of very limited duration).
In prolonged costochondritis, physiotherapy, including manual therapy, may be used to maintain/increase the mobility of the ribs and upper back.

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