Jill St. John, BSN: A 25-Year-Old Female With Chest Wall Pain and a Cold

Learning Objectives

  • Learn the common causes of chest wall pain.

  • Develop an understanding of the unique anatomy of the chest wall.

  • Develop an understanding of the anatomy of the costosternal joint.

  • Develop an understanding of the causes of Tietze syndrome.

  • Develop an understanding of the differential diagnosis of Tietze syndrome.

  • Learn the clinical presentation of Tietze syndrome.

  • Learn how to examine the chest wall.

  • Learn how to use physical examination to identify Tietze syndrome.

  • Develop an understanding of the treatment options for Tietze syndrome.

Jill St. John

Jill St. John is a 25-year-old emergency department (ED) nurse with the chief complaint of, “I have a bad cold and it hurts to cough.” Jill stated that she picked up an upper respiratory tract infection while working in the ED, and over the past 4 days, she began experiencing severe pain and swelling at the top of her sternum. She denied any antecedent trauma but noted that she was having trouble coughing because of the pain. “Doctor, I am afraid I am going to get pneumonia. It hurts so bad to cough that I am having trouble clearing secretions. It really hurts when I raise my arms. I know that I look a mess, but it just hurts too much to brush out my hair. I’ve been taking Motrin around the clock, but the pain really isn’t a lot better. This is about the worst cold I have ever had, but the pain is why I came to see you. I wonder if I separated a cartilage from all the coughing?” I asked Jill if she ever had any pain in her anterior chest before, and she shook her head no.

She said that on the first day when she was coming down with her cold that she might have had a mild fever, but she denied chills or other constitutional symptoms. “I knew it was just a cold, so I figured I would get better on my own, but then this pain started. I’ve already missed three shifts at work, and we are really shorthanded.” I asked Jill what made her pain better, and she said that a heating pad helped the pain a little, but the Motrin wasn’t doing much more than upsetting her stomach. She noted that between being congested and having pain in the chest wall, she wasn’t getting much sleep.

I asked Jill about any antecedent chest wall trauma, and she shook her head no. She volunteered, “Doctor, I am never sick, but this has really knocked me on my butt. I feel like the upper part of my sternum is swollen, and it is very tender when I palpate it. Something isn’t right. Like I said, I may have separated a cartilage or something.”

I asked Jill to point with one finger to show me where it hurt the most. She pointed to the left side of her sternum at about the third costosternal cartilage. “Doctor, it really hurts all around this area, and when I cough, it’s pretty rough.”

On physical examination, Jill was afebrile. Her respirations were 16, and her pulse was 79 and regular. Her oxygen saturation on room air was 98. Her blood pressure was 120/70. Jill’s head, eyes, ears, nose, throat (HEENT) exam was consistent with a bad upper respiratory tract infection. Her nares were red, and she looked miserable. In spite of her upper respiratory symptoms, her lungs were clear, although I could hear some upper airway secretions that cleared when I had Jill cough. Her cardiac examination was normal. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Visual inspection of the chest wall revealed there was swelling over the second and third costosternal joints on the right consistent with a positive swollen costosternal joint sign. Palpation of the affected costosternal joints revealed that they felt a little warm. There was marked tenderness to palpation of the area overlying the right second and third intercostal joints. The examination of the remainder of her chest wall was normal, as was examination of her other major joints. A careful neurologic examination of the upper extremities revealed no evidence of peripheral neuropathy or entrapment neuropathy. Deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

  • History of onset of anterior chest wall pain associated with an upper respiratory tract infection

  • No history of previous significant chest wall pain

  • Minimal fever and no chills or other constitutional symptoms

  • Severe chest wall pain when coughing

  • Pain to palpation of the upper costosternal cartilages

  • Swelling of the upper costosternal cartilages noted by patient

  • Exacerbation of pain when elevating the upper extremities

The Physical Examination

  • Patient is afebrile

  • Point tenderness to palpation of the second and third costosternal cartilage on the right

  • Swelling of the second and third costosternal cartilage on the right

  • Warmth over the second and third costosternal cartilage on the right

  • No evidence of pneumonia

  • Positive swollen costosternal joint sign

Other Findings of Note

  • Normal HEENT examination

  • Normal cardiovascular examination

  • Normal pulmonary examination

  • Normal abdominal examination

  • No peripheral edema

  • Normal neurologic examination

  • Examination of major joints normal

What Tests Would You Like to Order?

The following test was ordered:

  • Plain radiographs of the sternum

Test Results

The plain radiographs of the sternum revealed mild swelling of the second and third costosternal joints on the right.

Clinical Correlation—Putting It All Together

What is the diagnosis?

  • Tietze syndrome

The Science Behind the Diagnosis


The cartilage of the true ribs articulates with the sternum via the costosternal joints ( Fig. 4.1 ). The cartilage of the first rib articulates directly with the manubrium of the sternum and is a synarthrodial joint that allows a limited gliding movement. The cartilage of the second through sixth ribs articulates with the body of the sternum via true arthrodial joints. These joints are surrounded by a thin articular capsule. The costosternal joints are strengthened by ligaments but can be subluxed or dislocated by blunt trauma to the anterior chest. Posterior to the costosternal joint are the structures of the mediastinum. These structures are susceptible to needle-induced trauma if the needle is placed too deeply. The pleural space may be entered if the needle is placed too deeply and laterally, and pneumothorax may result ( Fig. 4.2 ).

Jun 18, 2022 | Posted by in PAIN MEDICINE | Comments Off on Jill St. John, BSN: A 25-Year-Old Female With Chest Wall Pain and a Cold

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