Hi,
I'm a 4th Year Physiotherapy student from Australia who was hoping to get some opinions from some experienced musculoskeletal physio's who have perhaps had experience with a case like mine before. I would love to tell you that this was a patient of mine, but it is my own and is currently interfering with my clinical placements, so if anyone has any ideas I would love to hear them ASAP.

The Case
CMx: 21 year old female presents with sharp stabbing L-sided chest pain on top of dull ache radiating down the left arm 4/52 ago. No history of trauma or unusual chest/shoulder activity - no neck pain. Taken to hospital E.D where an ECG was performed - showing no abnormalities. Patient was given panadol then nurofen and finally Tramadol (with little effect) and told to go home. On follow up appointment with GP, FBE was ordered including CRP and thyroid function again with no abnormal findings. No recent history of chest infection resulting in increased coughing/sneezing.
PMx: Contracted Psittacosis in April 2005 resulting in pleural rub and right sided costochondral stiffness/pain in the 6-8rib lasting 3 months. No further problems since.
Pain pattern: Mostly good during the morning/day. Stabbing pain commences parasternally to the left (at about the 4th costosternal joint) at 12-2pm every day, increasing in severity until night (at it's worst) where the patient has difficulty falling asleep secondary to nagging ache. Arm/shoulder pain commences when chest pain at it's worst 5/10 VAS. Usually sitting around 3/10 from 2pm onward. Been taking 2 x Panadol for symptomatic pain relief and the occasional 2 x Nurofen when desperate. Unable to use Tramadol on clinics due to drowsy side effects on top of poor sleep.
Aggs: Driving (sustained horizontal flexion), opening heavy doors (ache more intensely afterwards, manual physiotherapy techniques, increased physical activity (walking) etc.
Eases: Nurofen seemed to take the edge off the pain, but I have had to go off it to protect my GI tract. Avoiding aggs (which is not possible on a neurology clinic)
Sx: Patient is on a neurology clinical placement and also works as a sports trainer on weekends for a State Athletics body taking care of athletes. Ideally wants to return to painfree activity.

Objective:
Obs: Patient has adopted anterior shoulder posture in sitting and standing. (?Pain from pull of anterior chest musculature)
Palpation: 4th costosternal joint painful on palpation, slight swelling detected. Palpation aggravates pain ++. Muscle tightness - latent trigger points in L upper traps and both pec major/minor do not replicate pain. Unable to adequately assess AP mvmt of costosternal joint by self.
AROM: (Shoulder, Tx spine, Neck) all painfree normal AROM.

I am thinking maybe my case fits a clinical picture of Tietze's syndrome but was hoping to see whether anyone else had experience with a similar case, what Rx methods were used, and a rough timeline to resolution. I have already tried to do a literature search but have found a remarkable lack of information on how to manage an atraumatic costochondritis without undergoing a corticosteroid injection which will only mask the pain.

Any thoughts...?

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