Costochondritis, also known as chest wall pain, costosternal syndrome, or costosternal chondrodynia[1] is an acute[2] and often temporary inflammation of the costal cartilage, the structure that connects each rib to the sternum at the costosternal joint. The condition is a common cause of chest pain.[4] Though costochondritis often resolves on its own, it can be a recurring condition that has little or no signs of onset. Costochondritis symptoms can be similar to the chest pain associated with a heart attack.[7] Unexplained chest pain is considered a medical emergency until life-threatening cardiac issues can be ruled out.[7] Severe cases of costal cartilage inflammation that also involve painful swelling are sometimes referred to as Tietze's syndrome, a term sometimes used interchangeably with costochondritis. However, some physicians view costochondritis and Tietze's syndrome as separate disease states due to the absence of costal cartilage swelling in costochondritis. Treatment options are quite limited and usually involve a combination of rest, analgesics, or anti-inflammatory medications.
[8] Cases with persistent discomfort may be managed with cortisone injections[6][8] or surgery may be indicated if the condition is severe. Individuals with costochondritis are typically instructed to avoid strenuous physical activity to prevent the onset of an attack. Pain or tenderness to palpation usually occurs on the sides of the sternum, affects multiple ribs, and is often worsened with coughing, deep breathing, or physical activity.[10] On physical examination, a physician inspects and feels the patient for swollen or tender areas, and can often produce the pain of costochondritis by moving the patient's rib cage or arms.[11] A factor that may aid in the differentiation of costochondritis from Tietze syndrome is the location of the pain on the sternum. Costochondritis typically affects the third, fourth, and fifth costosternal joints in contrast to Tietze's syndrome, which usually affects the second or third costosternal joint.[8] Pain from costochondritis typically resolves within one year.
In most cases of costochondritis, no cause is identified.[6] However, it may be the result of physical trauma (due to direct injury, strenuous lifting, or severe bouts of coughing), associated with scoliosis, ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, or a tumor (benign or cancerous).[13] Infection of the costosternal joint may cause costochondritis in rare cases. Most cases of infectious costochondritis are caused by Actinomyces, Staphylococcus aureus, Candida albicans, and Salmonella. In rare cases, Escherichia coli can be a cause of infectious costochondritis.[14] There is anecdotal evidence of costochondritic chest pain being associated with Vitamin D deficiency in some cases,[15] and multiple anecdotal reports that it could be associated with chest binding, as practiced by some members of the transgender community.[16] It also can be caused by Relapsing Polychondritis. The pathogenesis underlying the development of costochondritis remains unclear. Proposed mechanisms of injury include neurogenic inflammation, muscular imbalance, increased muscular pull on the rib,[12] mechanical dysfunction at the costotransverse joint of the rib,[12] or a derangement of the mechanical structure of the costochondral junction.
Sternum with sternocostal joints and cartilage Other causes of chest pain similar to that produced by costochondritis may include, but are not limited to the following:[7][17] Costochondritis may be treated with physical therapy (including ultrasonic, TENS, with or without nerve stimulation) or with medication. Treatment may involve the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or other pain relief medications (analgesics) such as acetaminophen.[4] Severe cases of costochondritis may call for the use of opioid medications such as hydrocodone or oxycodone, tricyclic antidepressant medications such as amitriptyline for pain from chronic costochondritis, or anti-epileptic drugs such as gabapentin may be used.[19] Oral or injected corticosteroids may be used for cases of costochondritis unresponsive to treatment by NSAIDs; however, this treatment has not been the subject of study by rigorous randomized controlled trials and its practice is currently based on clinical experience.
[20] Rest from stressful physical activity is often advised during the recovery period. Costochondritis is a common condition and is responsible for 30% of emergency room chest pain related visits. One-fifth of visits to the primary care physician are for musculoskeletal chest pain; of this 20% of primary care office visits, 13% is due to costochondritis.[7] Costochondritis cases are most often seen in people older than age 40 and occurs more often in women. ^ a b c ^ a b c d e ^ a b c d e f g hICD-9-CM:268.0 - Rickets, Active268.2 - Osteomalacia, Unspecified268.9 - Vitamin D Deficiency, Unspecified; Vitamin D deficiency is a nutritional disorder characterized in adults by softening of the bones. In children it manifests as rickets and in adults as osteomalacia. Vitamin D is an essential nutrient that increases serum calcium levels by facilitating calcium absorption and mobilizing calcium from bone. It also absorbs calcium and phosphorous from the diet. Without vitamin D, these minerals are not absorbed in sufficient quantities.
Because calcium and phosphorous are important in forming and maintaining healthy bones and teeth, a deficiency in vitamin D has a profound effect on these structures. Vitamin D deficiency is a relatively rare condition since it is found in many foods such as fortified milk, margarine, eggs, liver, fish, and fish oils. The body can also make vitamin D when the skin is exposed to sunlight. A lack of vitamin D in the diet is usually only seen in strict vegetarians (vegans) who avoid all animal products including dairy products and eggs. Individuals who avoid exposure to sunlight or wear protective sunscreen may limit the body's ability to make vitamin D, thereby increasing the need to rely on dietary sources. Another cause of vitamin D deficiency is an inability of the body to absorb the vitamin during digestion (malabsorption) or an inability to process the vitamin once it is absorbed. These individuals may experience a deficiency despite a healthy, balanced diet and normal sun exposure.
Certain medications used to treat seizures can also cause vitamin D deficiency. The recommended daily allowance (RDA) for vitamin D is 400 IU.Incidence and Prevalence: The overall incidence of osteomalacia is 1 in every 1,000 individuals. Pregnancy and breastfeeding increase a woman's need for vitamin D and therefore increase the risk of deficiency. Women are affected slightly more often than men.The risk of developing osteomalacia is higher in those who are housebound, institutionalized, elderly, poor, or required by custom to be completely covered when outdoors. Those with dark skin are also at increased risk. Certain diseases of the kidney, pancreas, liver, intestines, or stomach may also increase the risk of vitamin D deficiency. Alcoholics, individuals with eating disorders such as anorexia nervosa or bulimia nervosa, and those who follow diets that severely limit certain foods (fad diets) have a greater risk of developing vitamin D deficiency. Individuals who abuse laxatives are also at increased risk.
History: Individuals may complain of bone pain particularly around the hips. Muscle weakness is also commonly reported. Some individuals may feel such discomfort and weakness that they choose to remain in bed. Fracturing bones after only minor trauma is also significant history. Individuals may report other symptoms such as tiredness (fatigue), muscle pain, loss of appetite (anorexia), unintentional weight loss, numbness around the mouth, tingling and/or numbness of the extremities (hands, arms, legs, feet), or muscle spasms (tetany) of the hands or feet. Lack of calcium can also cause confusion, memory loss, depression, and hallucinations.Physical exam: The exam may reveal that the individual has lost inches in height due to collapse of the vertebrae. Reported bone pain is usually dull and spread over a large area (diffuse). Muscle weakness may be evident in the muscles close to the affected bone(s). Questioning the individual on dietary habits may reveal a lack of food sources that are typically rich in vitamin D.
Further questioning may also reveal that the individual avoids being outdoors or carefully applies sunscreen before leaving the house.Tests: Routine blood tests reveal abnormal levels of calcium and phosphate. An x-ray and/or CT of the bone(s) confirm the diagnosis. In most cases, these tests in combination with symptoms and history is sufficient for a definitive diagnosis, however, in unusual cases, a bone biopsy may be necessary to determine the extent of the mineral loss.When vitamin D deficiency is caused by lack of sunlight or poor diet, individuals are given oral vitamin D supplements for up to 4 months. Calcium supplements may also be given. If the deficiency is due to an underlying condition that prevents absorption or metabolism of vitamin D, successful treatment depends on treatment of the underlying condition. These individuals may require larger doses of vitamin D as well as megadoses of calcium. Depending on the nature of the underlying disease, these supplements may need to be given by injection.
Controlled exposure to sunlight or a sunlamp may also be prescribed. Treatment for osteoporosis may also be needed. All individuals require regular follow-up visits with their doctor to monitor progress.Individuals whose deficiency is due to inadequate sunlight or poor diet are usually completely cured after 6 months of vitamin D supplements and/or sunlight exposure. If an underlying condition is causing or contributing to vitamin D deficiency, this disorder must be treated for a successful outcome. plications of vitamin D deficiency include bone fractures, infection of the bones (osteomyelitis), kidney (renal) failure, renal tubular acidosis, or seizures. In addition, individuals are often deficient in other vitamins and/or minerals as well as vitamin D, complicating the condition.In most cases, work restrictions and accommodations are not necessary. For some individuals, heavy lifting and other strenuous work may need to be discontinued or adjusted. Work schedule flexibility may be required following the diagnosis to accommodate regular examinations at the physician's office.
However, if symptoms are severe, individuals may require extended sick leave from work until symptoms begin to subside.Regarding diagnosis:Has individual complained of bone pain (particularly in the hips) or fatigue and paresthesias of fingers or hands? Does individual have risk factors for vitamin D deficiency such as inadequate consumption of dairy products (such as vegans, or those with lactose intolerance or those who do not have access to dairy products)? Has individual been housebound or lacked exposure to sunlight? Are they taking any medications that could cause the deficiency? Was the vitamin deficiency detected with serological testing? If not, was a bone biopsy indicated? If the diagnosis was uncertain, were other conditions with similar symptoms such as osteoporosis, Paget's disease of bone, and cancer, ruled out?Regarding treatment:Were vitamin D and/or calcium supplements prescribed? Is individual taking the recommended dose at the recommended times? Is individual eating a healthy, balanced diet?
Are foods rich in vitamin D being consumed? Would individual benefit from consultation with a nutritionist/dietitian? Does individual spend time outdoors or in a sunny window? Is individual also being treated for osteoporosis?Regarding prognosis:Based on the underlying cause, what was the expected outcome? Is individual a strict vegetarian? Does individual have any underlying conditions (malnutrition, pregnancy or epilepsy) that could impact recovery? Did individual experience any associated conditions or complications (such as bone fractures, osteomyelitis, renal disorders, or seizures) that could impact recovery and prognosis?GeneralBeers, Mark H., et al., eds. "Vitamin D Deficiency and Dependency." Merck Manual of Medical Information. 2nd Home Online ed. New York: Pocket Books, 1997. Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must include your email address, in order for us to respond.