Generality
Costochondritis is a painful thoracic syndrome resulting from inflammation of the cartilages connected to the upper ribs of the thoracic cage.
The most characteristic symptom is chest pain; this is generally widespread, that is it can also radiate to the abdomen or back. Costochondritis does not cause swelling.
Canonical therapy includes rest, administration of anti-inflammatories, different applications of hot and / or cold packs a day and physical treatments (such as physiotherapy).
The use of more invasive therapies, in this case opiates and corticosteroids, occurs only when the previous therapeutic remedies have not provided the desired results.
Anatomical recall on rib cage and ribs
The thoracic cage is the skeletal structure placed in the upper part of the human body, exactly between the neck and the diaphragm, which serves to protect vital organs, such as the heart and lungs, and important blood vessels, such as the aorta, the veins, etc.
According to anatomy manuals, the rib cage includes:
- Later, the 12 thoracic vertebrae ;
- Latero-anteriorly, 12 pairs of ribs (or ribs );
- Anteriorly, the costal cartilages and a bone called the sternum .
At their front end, the ribs articulate with the costal cartilages.
Consisting of hyaline cartilaginous tissue, the costal cartilages of the first 7 pairs of upper ribs make direct contact with the sternum; those of the eighth, the ninth and the tenth pair are joined to the costal cartilages of the immediately superior pair (therefore the octaves to the sevenths, the ninths to the octaves etc); finally, those of the eleventh and twelfth pair are free (or "floating").
The space between the overlapping ribs is called the intercostal space . In the intercostal space reside the so-called intercostal muscles - which play a fundamental role in expanding the thoracic cage, during the respiratory acts - numerous nerve endings ( intercostal nerves ), arterial blood vessels and venous blood vessels.
What is costochondritis?
Costochondritis is a set of symptoms and signs, the result of an inflammation of the costal cartilages connected to the first seven pairs of ribs.
Doctors have coined several costochondritis synonyms, including: chest wall syndrome, costosternal syndrome and costosternal chondrite .
COSTOCONDRITE AND TIETZE SYNDROME ARE THE SAME WHAT?
In reading the definition and symptomatology of costochondritis, an inexperienced person could exchange the aforementioned condition for another similar inflammatory process, known as Tietze syndrome .
However, costochondritis and Tietze's syndrome show not inconsiderable differences, both in terms of causes and in terms of symptoms.
In the next chapters, we will also treat these differences.
Epidemiology
Costochondritis can affect people of all ages; however, according to some statistical studies, it appears to be more widespread among adults over the age of 40.
Although not particularly common in young people, it is the leading cause of chest pain among children and adolescents. In fact, according to some research, it would be attributed to it about 30% of juvenile cases of chest pain.
The majority of patients suffering from costosternal syndrome are female: in percentage terms, exactly 70% of affected people.
Causes
Despite numerous studies on the subject, doctors and researchers have only identified some possible causes of costochondritis. In fact, for some types of patients, the origin of the inflammation remains unknown.
Possible triggers for costochondritis include:
- Physical trauma to the chest . Traumatic events, which can cause costochondritis, are strokes received at the rib cage during contact sports such as rugby, football, ice hockey and American football.
- Excessive physical efforts . For example, some forms of costochondritis arise after the repeated lifting of very heavy objects, an exhausting sporting activity or even a persistent and long-lasting cough.
- Different forms of arthritis . Medical studies have shown that, in some cases, costochondritis is associated with the presence of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis.
- Some bacterial, viral and fungal infections . The list of infectious diseases capable of causing costochondritis includes: tuberculosis, syphilis, candida, salmonella, infections with actinomycetes or Staphylococcus aureus, aspergillosis and viral infections of the respiratory tract.
- Tumors located elsewhere in the body . Some breast, thyroid or lung neoplasms can cause the onset of costochondritis.
- Fibromyalgia . It is a rheumatic disease that affects the musculoskeletal system, characterized by chronic and diffuse pain, increased muscle tension and stiffness in numerous sites of the musculoskeletal system.
The term fibromyalgia derives from the union of three words: "fibro", which refers to the fibrous tissue of tendons and ligaments, "mio", which means muscle or muscles, and finally "algia", which means pain.
The association between fibromyalgia and costochondritis is explained by the presence, at the level of the costal cartilages, of ligaments and joints.
RISK FACTORS
Doctors have not yet clarified why only some individuals develop costochondritis in the presence of one of the conditions listed above (chest trauma, infectious diseases, etc.).
According to their hypotheses, the explanation could lie in the presence of certain favoring factors, which, however, the research conducted so far have not yet outlined.
Female sex as a risk factor
Since women with costochondritis are decidedly more than men, various medical texts report membership in the female sex as possible risk factors.
COMPARISON WITH THE TIETZE SYNDROME
Unlike the case of costochondritis, no scientific investigation, conducted to date, has also identified a single cause triggering Tietze's syndrome.
The researchers considered different situations and developed various hypotheses, but without any appreciable scientific feedback.
The hypothesized causes include:
- The presence of upper respiratory tract infections, such as laryngitis and sinusitis.
- The presence of strong and repeated coughing and / or retching, which strongly stresses the thoracic region.
- Chest trauma.
- Excessive chest tension due to extreme physical exertion.
- The after-effects of a chest radiotherapy, performed for example several years before for the treatment of a neoplasm.
Symptoms and Complications
The characteristic symptom of costochondritis is chest pain .
This feeling has very particular characteristics:
- it is widespread and mainly affects the left side of the chest;
- it can be acute and persistent or, alternatively, only appear under pressure;
- it is often the cause of numbness, which is also widespread;
- worsens in the following situations: with chest movements, when the chest undergoes microtraumas (NB: a microtrauma could also be a cough), during deep breaths and when a respiratory airway infection occurs.
Which are the most affected ribs?
Generally, pain appears between the fourth and fifth ribs or between the fifth and sixth ribs. This is probably due to the fact that in the costal cartilages of the aforementioned coasts lies the point of origin of the inflammatory process.
WHAT DOES DIFFUSED PAIN MEAN?
Widespread pain means that the pain sensation affects a large and inaccurate anatomical area.
In patients with costochondritis, pain may radiate from the chest to the back or from the chest to the abdomen. Furthermore, it often also involves the shoulders and arms (as stated, it mainly affects the left side of the body).
COMPARISON WITH THE TIETZE SYNDROME
People with Tietze syndrome experience well-localized chest pain and a sense of numbness (ie limited to a precise area of the chest) and show swelling, in the area of pain.
Swelling is a clinical sign generally absent in subjects with costochondritis; therefore it represents a very important element during the diagnostic path.
COMPLAINTS WITH THE HEART ATTACK
Widespread pain on the left side of the chest, with shoulder and arm involvement, is a clinical manifestation that also characterizes the heart attack (known as myocardial infarction) and myocardial ischemia .
Therefore, in some particular cases (for example potentially cardiopathic individuals), the two diseases can be confused for each other.
Clearly, it has much more serious consequences exchanging a heart attack for costochondritis than vice versa.
WHEN TO REFER TO THE DOCTOR?
Any suspected chest pain deserves immediate medical examination, aimed at identifying the triggering causes.
To justify this concern is the symptomatological similarity existing between costochondritis and heart attack or myocardial ischemia.
COMPLICATIONS
Costochondritis can give complications when deep breathing is particularly difficult or when it is the result of an infection and it continues to get worse.
A fairly typical signal of a costochondritis due to an infection with a tendency to worsen is the presence of high and persistent fever .
Diagnosis
Usually, doctors diagnose costochondritis using a thorough physical examination and several instrumental tests.
It is good, however, to point out that the use of instrumental procedures serves, exclusively, for the exclusion of all those pathologies capable of causing the same symptoms as the costosternal syndrome. The latter, in fact, does not present any appreciable characteristic using any radiological instrumentation or a laboratory test.
EXAMINATION OBJECTIVE
Physical examination is essential, as the information it provides is crucial to achieving a correct final diagnosis.
During its realization, first of all, the doctor asks the patient to describe the symptomatology. Typical questions are:
- What are the disorders perceived?
- When did the first symptoms appear? Was there an event or situation that triggered them?
- What movements or gestures enhance the symptoms?
So, after this series of short and simple questions, visit him in person and look for any particular clinical signs on the area or on the painful areas.
Diagnostic importance of the absence of swelling
The clinical feature that allows doctors to distinguish costochondritis from Tietze syndrome is the absence of swelling . As the reader will remember, in fact, unlike people with Tietze's syndrome, people with costosternal syndrome do not have any swollen area.
INSTRUMENTAL TESTS
Among the instrumental tests that the doctor usually uses are: X-rays, electrocardiograms, CT (Computerized Axial Tomography) and nuclear magnetic resonance (NMR).
These tests allow us to understand whether the symptomatology is due to a cardiac or pulmonary problem (NB: chest pain is a characteristic symptom also of diseases or pathological conditions affecting the lungs).
Treatment
Generally, doctors treat costochondritis using a conservative therapy, which includes:
- The administration of non-steroidal anti-inflammatory drugs.
- A period of absolute rest.
- The application of hot and / or cold compresses on the most painful area.
- Physical treatments, including physiotherapy and TENS
If these remedies should somehow fail or not resolve the problem definitively, more invasive treatments are needed: in the above cases, doctors use doses of opiates and tricyclic antidepressants or corticosteroid injections.
For all those cases of costochondritis sustained by a bacterial infection, the therapy also includes the use of antibiotics .
NON-STEROID ANTI-INFLAMMATORY MEDICINES
Non-steroidal anti-inflammatory drugs ( NSAIDs ) are medicines that reduce inflammation.
In most cases of costochondritis, they guarantee a significant improvement in symptoms, since, with their administration, the pain falls dramatically.
The duration of NSAID-based treatment is not quantifiable, except after observing how the patient responds to treatment: immediate answers imply few assumptions; vice versa, slow responses require significantly longer hiring.
The most widely used NSAIDs in the case of costochondritis are ibuprofen, naproxen and aspirin.
Side effects and contraindications of NSAIDs
Prolonged intake of NSAIDs may damage the liver or alter some function of the latter. Therefore, to prevent the onset of such problems, doctors advise patients at risk to undergo periodic blood tests.
Another possible side effect is damage to the gastric mucosa.
NSAIDs are contraindicated in patients suffering from asthma, high blood pressure, kidney problems and heart problems. They would also be in the presence of gastritis and peptic ulcer, but, in these situations, doctors can limit the damage to the gastric mucosa with the prescription of a gastroprotector.
Finally, remember that children and young people should not take aspirin.
REST
For rest, the doctors intend abstention from any work and motor activity that can somehow exacerbate the symptoms.
Failure to observe an adequate rest period results in longer healing times.
The only activities granted, during this important phase of therapy, are those that do not stress the painful area, such as walking.
HOT / COLD PACKS
Doctors advise applying hot and / or cold packs to the most painful area, because:
- Heat is useful against rheumatic pains.
- Cold is a powerful natural anti-inflammatory.
For applications to provide appreciable results, it is good to repeat them several times a day, for several minutes.
PHYSICAL TREATMENTS
The most prescribed physical treatments in case of costochondritis consist in physiotherapy exercises - in this case stretching for the chest muscles - and in the so-called transcutaneous electrical nerve stimulation ( TENS ).
TENS is a particular medical technique, which involves the infusion of some electrical discharges aimed at reducing the transmission of painful signals. Electrical discharges originate from electrodes, similar to patches to be applied to the skin.
CORTICOSTEROIDS
Corticosteroids are the most powerful and best-performing anti-inflammatory drugs.
However, prolonged use can cause unpleasant, and in some cases even serious, side effects, such as high blood pressure or diabetes mellitus.
In light of this, the reader can easily guess why doctors prefer to adopt, in the first instance, an anti-inflammatory therapy based on NSAIDs and resort to corticosteroids only in extreme situations.
In the case of costochondritis, the administration of corticosteroids takes place by local injection (ie the doctor injects the drug directly into the most painful chest area).
Drawbacks of prolonged injections
If continued over time, local injections can damage the rib cartilages and induce other problems. Therefore, to overcome this drawback, doctors and pharmacologists have developed long-acting corticosteroids, which it is sufficient to inject a couple of times during the entire treatment period.
These particular corticosteroids are also called long-acting .
Major side effects of corticosteroids.
- Arterial hypertension and water retention
- Hyperglycemia, insulin resistance and diabetes mellitus
- Osteoporosis
- Increased body weight due to the increase in fat mass
- Swelling and facial tension
- Susceptibility to infections
- Susceptibility to accidents
- Psychosis
- Morning insomnia
OPPIACEI AND TRICYCLIC ANTIDEPRESSANTS
Doctors resort to opiates - usually to the hydrocodone / paracetamol and oxycodone / paracetamol combinations - when the pain caused by costochondritis is very intense.
Instead, they introduce tricyclic antidepressants, in this case the amitriptyline, when the pain sensation has become chronic.
IS IT POSSIBLE TO HEAL WITHOUT ANY TREATMENT?
Most cases of costochondritis can resolve spontaneously. However, it is always better to use the aforementioned treatments, as, in the absence of specific treatment, the healing process is very slow and can last up to several months.
Prognosis
If the diagnosis is early and treatment is timely, the prognosis is generally positive. In fact, in these situations, the chances of complete recovery are very high.
The situation in which the patient neglects the symptoms and the therapies is decidedly different: in cases like these, the prognosis becomes negative, since the costochondritis could assume the connotations of a chronic inflammation.
