Non-Cardiac Chest Wall Pain: Costochondritis
by David S. Klein, MD, FACA, FACPM, FAAMIMS
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.
Dr. David Klein has practiced pain medicine for the past 25 years and is the author of over 50 published articles and textbook chapters and has lectured extensively. He is a member of the American Board of Anesthesiology, American Board of Pain Medicine, American Academy of Pain Management, American Board of Minimally Invasive Medicine & Surgery, and has Sub-Specialty Certification in Pain by the American Board of Anesthesiologists.
Dr. Klein is presently the Medical Director of the Pain Center of Orlando, located at 225 W. SR 434, Suite #205, Longwood, Florida. 32750.
Telephone: 407-679-3337.
FAX: 407-678-7246.
www.suffernomore.com
My daughter is 15 and has her first flare in November 2007. What do you recommend for the pain aside from the prescription meds mentioned? We use RAN B (homeopathic) and it helped at first, but now, seems to take longer to work. Her flares now come on suddenly and last a week, she's missing so much school, and is depressed that she cannot be a typical 15 yr old...help
Posted by: Mari Waters | January 29, 2009 at 08:59 PM
I have suffered from Costo for 5 years due to a very bad viral infection. I can't take NSAIDS as i suffer from asthma. My GP has besically told me that there is nothing he can do for me. I take Amitryptyline for nerve pain and codrydromol when i flare badly. As you can imagine im very upset for it to have gone on this long, but im desperate for some kind of help with my healing. I was hoping you might be able to sugest somthing.
REgards Nicola
Cardiff UK
Posted by: Nicola Howcroft | January 30, 2009 at 07:34 AM
I have been having pain under my right breast for over a year now. I first went to my OBGYN with it last year and she first thought that it might be costochondritis caused by carrying a backpack on my right side. She tried putting me on a regimen of 800 mg of ibuprophen 3 times a day for 5 days and it did nothing. I notice that the pain is more intense a week or two before my period so I thought maybe it was hormone related. However, the pain is always there it's just more intense before my period. My OBGYN also told me to stop wearing underwire bras but for the most part she was not sure why the pain was continueing. So now I've seen a breast specialist and she thinks it may be nerve damage or fibrocystic. She gave me a regimen of taking vit E and primrose oil as well as no caffeine, no underwire bra, and ibuprophen (200mg 3 tmes a day) for 6 wks. Still no change in pain. I'm at a loss here. I had a mammo, chest xray, and sono last year. Should I have all this done again? Or should I suggest an MRI? What should I do?
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Proper exercise and balance diet are the key to have a healthy body and if you have a healthy body. Then there is a big possibility that a person could no longer suffer from chest pain.
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Proper exercise and balance diet are the key to have a healthy body and if you have a healthy body. Then there is a big possibility that a person could no longer suffer from chest pain.Thanks for sharing such a very helpful information.
Posted by: left chest pain | August 16, 2011 at 08:21 AM
Proper exercise and balance diet are the key to have a healthy body and if you have a healthy body. Then there is a big possibility that a person could no longer suffer from chest pain.Thanks for sharing such a very helpful information.
Posted by: left chest pain | August 16, 2011 at 08:24 AM