Costosternal Syndrome

Abstract

Many patients with noncardiogenic chest pain suffer from costosternal joint pain. Most commonly, the costosternal joints become painful in response to inflammation as a result of overuse or misuse or in response to trauma secondary to acceleration-deceleration injuries or blunt trauma to the chest wall. With severe trauma, the joints may subluxate or dislocate. The costosternal joints are susceptible to the development of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter’s syndrome, and psoriatic arthritis. The joints are also subject to invasion by tumor from primary malignant tumors, including thymoma, or from metastatic disease. Physical examination of patients suffering from costosternal syndrome reveals that the patient vigorously attempts 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 patients who have sustained trauma to the anterior chest wall. The costosternal joints and adjacent intercostal muscles may be tender to palpation. The patient may also complain of a clicking sensation with joint movement.

Keywords

chest wall pain, costosternal joint, costosternal syndrome, osteoarthritis, sports injury, diagnostic sonography, ultrasound guided injection, intraarticular injection, noncariogenic chest pain, chest pain

ICD-10 CODE R07.9

The Clinical Syndrome

Many patients with noncardiogenic chest pain suffer from costosternal joint pain. Most commonly, the costosternal joints become painful in response to inflammation as a result of overuse or misuse or in response to trauma secondary to acceleration-deceleration injuries or blunt trauma to the chest wall ( Fig. 61.1 ). With severe trauma, the joints may subluxate or dislocate. The costosternal joints are susceptible to the development of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter’s syndrome, and psoriatic arthritis. The joints are also subject to invasion by tumor from primary malignant tumors, including thymoma, or from metastatic disease.

Signs and Symptoms

Physical examination reveals that the patient vigorously attempts 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 patients who have sustained trauma to the anterior chest wall. The costosternal joints and adjacent intercostal muscles may be tender to palpation. The patient may also complain of a clicking sensation with joint movement.

Testing

Plain radiographs are indicated for all patients who present with pain that is thought to be emanating from the costosternal joints, to rule out occult bony disorders, including tumor ( Fig. 61.2 ). If trauma is present, radionuclide bone scanning may be useful 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 and ultrasound imaging of the joints are indicated if joint instability or occult mass is suspected or to elucidate the cause of the pain further ( Fig. 61.3 ). The injection technique described later serves as both a diagnostic and a therapeutic maneuver.