Abstract
Tietze’s syndrome is a frequent cause of chest wall pain. Distinct from the more common costosternal syndrome, Tietze’s syndrome was first described in 1921 and is characterized by acute, painful swelling of the costal cartilage. In fact, painful swelling of the second and third costochondral joints is the sine qua non of Tietze’s syndrome; such swelling is absent in costosternal syndrome. Also distinguishing the two syndromes is the age of onset: whereas costosternal syndrome usually occurs no earlier than the fourth decade of life, Tietze’s syndrome is a disease of the second and third decades. The onset is acute and is often associated with a concurrent viral infection of the respiratory tract. Investigators have postulated that microtrauma to the costosternal joints from serve coughing or heavy labor may be the cause of Tietze’s syndrome.
Physical examination reveals that patients suffering from Tietze’s syndrome vigorously attempt to splint the joints by keeping the shoulders stiffly in a neutral position. Pain is reproduced with active protraction or retraction of the shoulder, deep inspiration, and full elevation of the arm. Shrugging of the shoulder may also reproduce the pain. Coughing may be difficult, leading to inadequate pulmonary toilet in some patients. The costosternal joints, especially the second and third, are swollen and exquisitely tender to palpation. This swollen costochondral joint sign is pathognomonic for Tietze’s syndrome (Fig. 65.2). The adjacent intercostal muscles may also be tender to palpation. The patient may complain of a clicking sensation with movement of the joint.
Keywords
chest wall pain, Tietze’s syndrome, osteoarthritis, sports injury, diagnostic sonography, ultrasound guided injection, intraarticular injection, chest pain, noncardiogenic chest pain, devil’s grip
ICD-10 CODE M94.0
The Clinical Syndrome
Tietze’s syndrome is a frequent cause of chest wall pain. Distinct from the more common costosternal syndrome, Tietze’s syndrome was first described in 1921 and is characterized by acute, painful swelling of the costal cartilage. In fact, painful swelling of the second and third costochondral joints is the sine qua non of Tietze’s syndrome ( Fig. 65.1 ); such swelling is absent in costosternal syndrome. Also distinguishing the two syndromes is the age of onset: whereas costosternal syndrome usually occurs no earlier than the fourth decade of life, Tietze’s syndrome is a disease of the second and third decades. The onset is acute and is often associated with a concurrent viral infection of the respiratory tract. Investigators have postulated that microtrauma to the costosternal joints from serve coughing or heavy labor may be the cause of Tietze’s syndrome.
Signs and Symptoms
Physical examination reveals that patients suffering from Tietze’s syndrome vigorously attempt to splint the joints by keeping the shoulders stiffly in a neutral position. Pain is reproduced with active protraction or retraction of the shoulder, deep inspiration, and full elevation of the arm. Shrugging of the shoulder may also reproduce the pain. Coughing may be difficult, leading to inadequate pulmonary toilet in some patients. The costosternal joints, especially the second and third, are swollen and exquisitely tender to palpation. This swollen costochondral joint sign is pathognomonic for Tietze’s syndrome ( Fig. 65.2 ). The adjacent intercostal muscles may also be tender to palpation. The patient may complain of a clicking sensation with movement of the joint.
Testing
Plain radiographs are indicated for all patients who present with pain thought to be emanating from the costosternal joints, to rule out occult bony disorders, including tumor. If trauma is present, radionuclide bone scanning should be considered to exclude occult fractures of the ribs or sternum. Based on the patient’s clinical presentation, additional testing may be indicated, including a complete blood count, prostate-specific antigen level, erythrocyte sedimentation rate, and antinuclear antibody testing. Laboratory evaluation for collagen vascular disease is indicated in patients suffering from costosternal joint pain if other joints are involved. Magnetic resonance imaging of the joints is indicated if joint instability or occult mass is suspected or to confirm the diagnosis ( Fig. 65.3 ). The injection technique described later serves as both a diagnostic and a therapeutic maneuver.
