ChiroACCESS Clinical Review



Costochondritis: Diagnosis

This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

Lead Author(s): 

Dwain M. Daniel, D.C.

  

How this evidence was rated:

Strength of Recommendation Taxonomy (SORT)



Published on

January 18, 2011

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CostochondritisThe diagnosis of costochondritis (CC), when it is present, is relatively easy to establish when confronted in a patient experiencing anterior chest pain.  However the dire consequence of missing a concurrent cardiovascular event, pulmonary embolism (PE) or pneumonia when making this diagnosis places an extra burden upon the diagnosing physician.  A review of the literature reveals several sobering facts.  Miller et al found in their study of 17737 patients who were diagnosed with non-cardiac chest pain and released from the hospital emergency rooms, 4.3% had definite evidence of adverse cardiac events or unstable angina (1).  A second study of 108 patients that were diagnosed with non-cardiac chest pain found 2.7% had died within 1 year of heart disease or emphysema.  This study also reported  6% of patients with presumed CC were also experiencing myocardial infarction (MI) (2).
 
Other study findings which are of interest when dealing with a patient with chest pain follow:
  • Musculoskeletal presentation of chest pain is far more common in general practice than in emergency rooms, 36% compared to 6% (3).
  • The percent of chest pain that remains undiagnosed after 1 year is approximately 11% (2;4)
  • Causes of chest pain in the emergency room (4):
    • Cardiac diseases: 51.7%
    • Pulmonary disease: 14.2%
    • Gastro-esophageal diseases:  2.4%
    • Musculoskeletal pathology: 7.1%
    • Somatization disorders: 9.2%
    • Other: 4.3%
    • Unknown: 11.1%
An aid to identifying high risk patients for MI, PE and pneumonia with anterior chest pain are prediction rules that are well accepted in the literature.  The American Family Physician recently published an article detailing the these prediction rules which are available in more detail at http://www.aafp.org/afp/2005/1115/p2012.html (5).  A brief synopsis of these rules follows:
 
Rouan Decision Rule for MI
  • Age greater than 60 years
  • Diaphoresis
  • History of MI or angina
  • Pain described as pressure
  • Radiating pain
Cayley indicates chest pain radiating to both arms, hypotension, S3 gallop, dyspnea and hyperlipidemia are associated with increased risk of MI (5). 
 
Wells Model for PE
  • Clinical signs of deep vein thrombosis (DVT)
  • PE most likely diagnosis
  • Patient experienced 3 or more consecutive days of bedrest in last 4 weeks
  • Previous diagnosis of DVT
  • Hemoptysis
  • Cancer treatment that is ongoing or during past 6 months
Diehr Rule for Pneumonia
  • Myalgia
  • Night sweats
  • Sputum production all day
  • Respiratory rate more than 25
  • Temperature over 100 degrees
  • Presence of rhinorrhea and/or sore throat decrease probability
Chest wall syndrome is a term to describe pain arising from the chest wall that is musculoskeletal in origin.  It is a term which includes CC as well as several other sources of musculoskeletal pain.  Verdon et al provided 6 characteristics of chest wall syndrome (CWS) that help to distinguish CWS from other more serious conditions (6).  These include:
 
Pain is
  • Not squeezing or oppressive:  Odds Ratio (OR) 2.52 (1.21-5.28)
  • Localized on the left or median left part of the chest wall:  OR 2.26 (1.58-3.28)
  • Well localized on the chest wall:  OR 2.10 (1.37-3.22)
  • Non-exercise induced pain:  OR 1.58 (1.00-2.49)
  • Influenced by movement or posture:  OR 1.54 (1.06-2.24
  • Reproducible by palpation:  5.72 (1.20-5.28)

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References

1. 

Miller CD, Lindsell CJ, Khandelwal S, Chandra A, Pollack CV, Tiffany BR, et al. Is the initial diagnostic impression of "noncardiac chest pain" adequate to exclude cardiac disease? Ann Emerg Med 2004 Dec;44(6):565-74.

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2. 

Spalding L, Reay E, Kelly C. Cause and outcome of atypical chest pain in patients admitted to hospital. J R Soc Med 2003 Mar;96(3):122-5.

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3. 

Yelland M, Cayley WE, Jr., Vach W. An algorithm for the diagnosis and management of chest pain in primary care. Med Clin North Am 2010 Mar;94(2):349-74.

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4. 

Knockaert DC, Buntinx F, Stoens N, Bruyninckx R, Delooz H. Chest pain in the emergency department: the broad spectrum of causes. Eur J Emerg Med 2002 Mar;9(1):25-30.

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5. 

Cayley WE, Jr. Diagnosing the cause of chest pain. Am Fam Physician 2005 Nov 15;72(10):2012-21.

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6. 

Verdon F, Burnand B, Herzig L, Junod M, Pecoud A, Favrat B. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract 2007;8:51.

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7. 

Christensen HW, Vach W, Manniche C, Haghfelt T, Hartvigsen L, Hoilund-Carlsen PF. Palpation for muscular tenderness in the anterior chest wall: an observer reliability study. J Manipulative Physiol Ther 2003 Oct;26(8):469-75.

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Peyton FW. Unexpected frequency of idiopathic costochondral pain. Obstet Gynecol 1983 Nov;62(5):605-8.

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Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil 1992 Feb;73(2):147-9.

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11. 

Walsh TD. Costochondritis. N Engl J Med 1977 Nov 10;297(19):1071.

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12. 

Brunse MH, Stochkendahl MJ, Vach W, Kongsted A, Poulsen E, Hartvigsen J, et al. Examination of musculoskeletal chest pain - An inter-observer reliability study. Man Ther 2009 Dec 2.

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Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician 2009 Sep 15;80(6):617-20.

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14. 

Stochkendahl MJ, Christensen HW. Chest pain in focal musculoskeletal disorders. Med Clin North Am 2010 Mar;94(2):259-73.

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15. 

Fam AG. Approach to musculoskeletal chest wall pain. Prim Care 1988 Dec;15(4):767-82.

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16. 

Aspegren D, Hyde T, Miller M. Conservative treatment of a female collegiate volleyball player with costochondritis. J Manipulative Physiol Ther 2007 May;30(4):321-5.

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