100: Costosternal Syndrome

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Costosternal Syndrome

Marta Imamura, MD; David A. Cassius, MD


Anterior chest wall syndrome


Costosternal chondrodynia

Atypical chest pain

ICD-9 Code

733.6  Tietze disease; costochondral junction syndrome and costochondritis


M94.0  Chondrocostal junction syndrome [Tietze], costochondritis


Costosternal syndrome is a frequent cause of anterior chest wall pain that affects the costosternal [16] or costochondral [2,47] joints. The pathogenesis of costosternal syndrome is still unknown [2,8]. Costosternal syndrome is considered an entity distinct from the rarely occurring Tietze syndrome [17,9] because it is a frequent cause of benign anterior chest wall pain. Also, as opposed to Tietze syndrome, it is not associated with local swelling of the involved costosternal or costochondral joints [17,9], and it usually occurs at multiple sites. The onset is usually after 40 years of age instead of at a young age as in Tietze syndrome, and it affects more women than men. A traumatic cause has been proposed [8], and currently it is suspected that repetitive overuse lesions of the costosternal joint and anterior chest [6,10] may be involved in the development of the degenerative changes found at the costosternal joint [11,12]. The costosternal joints may also be inflamed by osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, psoriatic arthritis, and the SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome [3,7,12]. Infections of the costosternal joints are associated with tuberculosis, fungus (mycetoma, pulmonary aspergilloma, candidal costochondritis [13]), and syphilis as well as with viruses. The costosternal joints may also be the site of tumor invasion either from a primary malignant neoplasm, such as a chondrosarcoma or thymoma, or from a metastatic carcinoma, most commonly from the breast, kidney, thyroid, bronchus, lung, or prostate [12,14]. Chondromas and multiple exostoses are the most common benign tumors.

Costosternal syndromes may be a primary condition or secondary to these diseases. The condition occurs more frequently in women (a ratio of 2 to 3:1) and at an older age; two thirds of the patients are older than 40 years [14, 7,8]. The left side is more often involved. Costosternal joint disease is 1.69 times more frequent in patients who undergo median sternotomy than in normal controls of the same age [15].


The most common symptom in costosternal syndrome is pain of the anterior chest wall, usually localized at the precordium or at the left parasternal region [8,16]. Pain can radiate superiorly toward the left shoulder and left arm [8,16] and also to the neck, scapula, and anterior chest. Pain mainly develops after postural changes and maneuvers that place stress over the chest wall structures [16] rather than with physical efforts, such as those related to pain of cardiac origin [16]. Cardiac etiology for chest wall pain should be considered and ruled out [17]. Cough, deep breathing, and chest and scapular movements usually aggravate pain [5,11]. In contrast to Tietze syndrome, in which only one costal cartilage is involved in the majority of the patients, multiple sites are present in 90% of patients with costosternal syndromes [1,2,79]. The second to the fifth costal cartilages are most commonly affected [13,5,8,9]. Pain intensity may vary; it usually occurs at rest [12] and lasts for several weeks or months [8,16].

Physical Examination

Inspection of the patient suffering from costosternal syndrome reveals that the patient vigorously attempts to splint the joints by keeping the shoulders stiffly in neutral position [12]. Differing from the Tietze syndrome, the costosternal syndrome has no visible spherical local swelling or any inflammatory signs at the costal cartilages [1,4,5,7,9]. Pain is reproduced by active protraction or retraction of the shoulder, deep inspiration, and elevation of the arm [12]. Palpation of the affected portions of the thoracic cage elicits local tenderness at multiple sites [9]. It may reproduce the patient’s spontaneous pain complaint, including its radiation [9,18,19]. Some authors, however, have not found pain reproduction on palpation [4,5,1619].

Several maneuvers have been found to be helpful in establishing the diagnosis [8,16]. Application of firm steady pressure to the following chest wall structures elicits the patient’s pain complaint: the sternum, the left and right parasternal junctions, the intercostal spaces, the ribs, the inframammary area, and the pectoralis major and left upper trapezius muscles [8,16,18]. All of these can precipitate pain similar in quality and location to the spontaneous pain [16]. Another maneuver, called the horizontal flexion test (Fig. 100.1), consists of having the arm flexed across the anterior chest with the application of steady prolonged traction in a horizontal direction while, at the same time, the patient’s head is rotated as far as possible toward the ipsilateral shoulder [2,6,8,10,16,18]. Another test, called the crowing rooster maneuver, consists of having the patient extend the neck as much as possible by looking toward the ceiling while the examiner, standing behind the patient, exerts traction on the posteriorly extended arms [2,8,16,18]. Associated myofascial pain syndrome of the intercostal, pectoralis major, pectoralis minor, and sternal muscles is a common feature of the syndrome. These muscles may be tender on palpation. Because this syndrome is usually confused with pain of cardiac [1,2,11,20,21], abdominal [2,9,16,22], or pulmonary [20] origin, a comprehensive history and physical examination are essential in all patients [8,18,19], including athletes [6,10].

FIGURE 100.1 Horizontal flexion test for the diagnosis of costosternal syndrome.
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