Tietze's Syndrome (Costochondritis)

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...?

I feel you have done a thorough enough examination, but meanwhile I liked to suggest other possibilities, some rather unlikely others more likely.
Digestive problems? since the pain starts around 12-2 PM it could have to do with indigestion (but not very likely due to the aggrevation).
Active triggerpoints in the area, You have to check thouroughly both dorsal and ventral, check with p.e. referred pain charts if the patern of your patient resembles any of the triggerpoints on the charts. If there is any resemblance check it out!
You do mention the all clear for the thoracic spine but what about the costo/vertabral joints?
I have had a patient with the Tietze's Syndrome, I guess, I chose at the time after having tried several devices like ultra sound because of the highly irritable state of the problem without any effect and send the patient back for injection therapy (which I did and do not like). I did not though checked out the suggested alternatives! (one learnes and thinks every day) A possible low irretable means would be taping of the costchondrial area although I would have no clue how to succeed.
Best of luck

Hi
have u ruled out a rhomboids trigger pt with tharacic myofacial pain syndrome??

Although it is said that Tietze's Syndrome is self limiting but there could be the possibility of myofascial pain syndrome. The following muscles could refer pain to the area of chest.

Front of Chest pain:

Pectoralis major
Pectoralis minor
Scaleni
Sternocleidomastoid
Sternalis
Iliocostalis cervicis
Subclavius
External abdominal oblique

Iliocostalis cervicis and external abdominal oblique refer a spillover pain pattern while the rest of muscles refer an essential pain pattern.

Side of the Chest pain:

Serratus Anterior
Latissimus dorsi

Serratus anterior refers an essentail pain pattern while the latissimus dorsi refers a spillover pain pattern.

If the trigger points are recognized, initiate the appropriate trigger point therapy.

Ultrasound could be beneficial in treating the Osteitis- local and perifocal ( 1-2 watt per square centimeters) and Periostitis (0.8-2.5 watts per square centimeters) 10-20 numbers of treatment being required.

Hi,

I am from Sydney too (but not there at the moment!)

It sounds like a classic rib problem. I have seen loads of them.

If you want an experienced physio to assess it, I would recommend that you ring Barbara Hungerford on 02 9719 9114 - speak to the secretary to see who she recommends near where you live (where do you live?). They will tell you who they trust with the sort of problem that you have.

From your history, sounds like an anteriorly displaced rib. There are techniques available to sort that out - but Sydney Uni don't exactly teach them! However, I know that it works (Level 3b and Level 4 evidence) so don't be put off.

If you need anything, let me know. I will be back in June 07. Finishing my masters in Perth at the moment...don't like sydney uni for a musculoskeletal masters (or sports for that matter)!

Neurospast: Definately not digestive. I was given an antacid whilst in the ED with absolutely no effect other than making my mouth feel like a chalkboard. And the pain was not a substernal burning characteristic of reflux/eosophagitis.
I now have mutiple areas of increased tone in my left side and a number of latent trigger points, but none that replicate my pain. And my Ax of the Tx spine included costovertebral palpation with no significant findings. A slight increase in tenderness at the level of T4, but nothing that reproduces or radiates.

arkesh_physio: No I don't believe so. My trigger points and associated muscle tightness was not present initially. It has only been a factor in the last 2 weeks (while I've been more physical on clincs....surprise, surprise!)

sdkashif: I checked out most of the major muscles that refer to the anterior chest wall, but at the initial onset, there were no abnormalities or TrP's noticeable. It is always possible that it is Sternalis to blame, but I have been unable to clear that for obvious reasons. I have subsequently developed some trigger points which I am certain are from compensation/protective behaviours and from physical and psychological stress as well as fatigue (from the resulting lack of sleep).

alophysio: I'm currently a bit of a nomad living out of a bag between Melbourne (breifly), Bendigo and Daylesford (In Victoria) and my regular physio is a 1- 1 1/2 hour drive away. That diagnosis did cross my mind briefly, but is it possible to sublux a rib with no history of increased physical activity/trauma? Just wondering. I would have gotten my clinical supervisor to have a bit of a look, but she admitted that she wasn't so confident with rib-type problems.

Hmmm, Why did i assume you were from Sydney???

Anyway, You can still ring Barb's place and ask who in Melbourne / Vic does this stuff. It is not a common treatment technique.

I have lots of questions for you!

Is there anything that you can do to help the pain - e.g. when you open the door (heavy) can you push into the rib to see if it stabilises?

Have you tried to self manip your T/S. I know that sounds wild but a lot of people do it just by extending their T/S with their hand behind the back. I am NOT telling you to manip your spine just to see - just asking if you have already tried it or it has happened accidently. Don't do it if you haven't.

Have you had a cold lately? Coughing or sneezing can do it.

have you changed bra types lately? A bra too tight, esp with underwire can cause altered rib function

You mention T4 being tender. Also, 4th rib is tender. Have you recently started any exercise that you are unaccustomed to? Often external obliques being overactive can cause splinting of the T/S up to and including T 5 via the 5th ribs. This can then cause T4 to move excessively over T5 causing your rib dysfunction +/- T4 problems. A common giveaway is that you will have a crease above the umbilicus.

You mention radiating pain down the left arm. Exactly where is it and where does it go?

Seated arm lift...Sit and FF one arm to about 90deg. Does it require more effort compared to the other side? Does "core" activation help - i suggest a gentle anterior pelvic floor contraction?

Please answer the above - i am more than happy to help!

Bristol UK Calling - I have a patient that sounds very similar - Reading with interest, please keep the ideas coming! Do we know anyone to refer to in BRISTOL UK Area

Hi. You can contact Barbara Hungerford via her website on www.amta.com.au and ask her who she knows in UK...

I am sure there are others but that is how i get my information.

Good luck

Your symptoms are entirely consistant with referred pain from the upper thoracic and lower cervical spine. Facet joint irritations derived from a spinal protective response. It is not useful to consider your spine to be uninvolved on the basis of either "feel", or active movement tests. Neither is it unusual to have referred events without complaining of similar local spinal joint pain.
The prospect of your ribs somehow developing pain discrete to themselves with no trauma is close to nil, presuming no abherent growths or tumors. Similar likelihood of rib displacement anteriorly , and even if found to be so , is more likely an univolved artifact or antalgic response.
A pair of trained hands will quickly discern the responses to movement at the upper thoracic facet joints, which are very likely to exhibit resistance to and tenderness with passive movements. If those hands are also skilled at mobilisation , you will find a ready and long term solution to your problem.
Cheers

Hi Ginger,

Just to be clear - are you saying that the likelihood that rib dysfunction is close to nil?? That the problem is more likely facet joint?

Just checking because i figure that the rib moves quite often with respiration, that the intercostal nerve winds very close to the rib head and most of the ribs articulate to a vertbral body both above and below as well as a transverse process. Not only that, the sympathatic trunk runs closer to the rib joints than the facet joints.

Is there a reason why you don't think rib dysfunction is the main cause in this case?

Ribs don't misbehave unless they are traumatised. The same cannot be said for intrevertebral joints and their associated nerves. protective responses are the root cause of spinal pain , normal behaviour of facet joints ( movements ) are not generally associated with inflammatory events and pain, protected behaviour is. It is the everyday business of my clinical life over more than twenty years to turn off protected spinal responses and return pain free movement, in that time I have yet to come across a rib that misbehaved, plenty that were sore because of referred pain from facet joints however. The odds of ribs going wrong are infinitely small, compared to the strong likelihood of facet joint/nerve involvement.

Why is that Ginger?

From my knowledge of anatomy, the facet joints do not move nearly as much as the rib joints do - and there are far more rib joints than facet joints.

The proximity of the rib head to the sympathetic chain is more likely to lead to problems than a facet joint.

The ribs have far more muscles attaching to them than the facet joints. The facet joints have multifidus which has questionable torque producing ability vs the ribs with the long and powerful erector spinae, serratus, obliques etc etc.

Lastly, what is your evidence that a rib dysfunction is infinitely small - just your opinion?

Thanks for your reply in anticipation. I have been asking many questions about continuous mobilisation but the answers have not been forthcoming.

If you prefer a private conversation, please PM me.

PS, i did as you requested and looked up rehab edge and your post there and then got back to you but s=you still haven't replied....

Thanks Alophysio. I'm sure there's plenty more of us wondering the same as every post by Ginger seems to claim continuous mobilisation of facet joints is the answer to EVERYTHING! Is it a case of if the only tool you have is a hammer, then all you will see are nails?

Thanks sfinn.

I did not mean to be rude (i jusr reread what i wrote - obviously frustrated at the time!).

In fact, i would much rather someone do the continuous mobilisations as Ginger suggests than to just stick someone on electrotherapy...I just want to know WHY someone believes in something and what the postulated mechanisms are.

Even if the theory is "wrong", the fact that she no doubt gets good results is still valid (level 4 evidence - it is still evidence!).

My personal opinion from what i can gather on CM is that it might be neurophysiological effects causing reflex relaxation of the local muscles (either by joint mobes, soft tissue/trigger points to multifidus etc). No doubt the facet joints are moving but i am pretty sure there are studies out there that demonstrate that a mobilisation at the target level mobilises up to 3 or 4 levels away. So by doing 20 mins of the mobilisations, a "reset" happens to the neuro system that changes somatic and autonomic nerve function. The spinal neural supply is incredibly complicated and intricate (and wonderful).

So whilst i question Ginger's statements, i would still support her in a heartbeat over someone who advocated electrotherapy (if you like, you can check out the SWD for LBP thread!!!!)

THanks again.

Hey guys , theres a strong hint in Mr Sfinn's post that he has been reading RE, I remember seeing that exact same statement there a year ago.
alophysio, your summary of postulated physiology of the cause /effect relationship with CM is good. Like most theories , it is the language that sets the message in the mind of the reader , either the proposed cascade fits with a certain valued or cherished scenario or it doesn't . Sometimes this "fit " thing may contribute to unnecessary criticism or a fight to preserve the sense of verisimilitude that goes with familiarity.
What is certain , at least as far as my daily observations of joint behaviour and pain goes , is that CM has a lot to offer.
When I drifted into MSK treatments, after some short but meaningful explorations of geriatrics, neuro, cardiothoracic and rehab options in my own career, I realised immediately that I had good hands. Sounds conceited I know.
I milked a house cow on the farm by hand from the age of eight. You gain a lot of strength and sensitivity milking. Cows don't like being brutalised , neither do they give milk with weak attempts at the skillfull art of freehand milking. Long afterwards, I realised at the age of 26, when I was a professional fisherman, that I spent at least as much time "fixing" people as I did fishing and made the decision to become a physio.
Hands are fantastic tools. With a pair of them I can consider the movement dynamics of a range of body parts, perform therapeutic interventions on those with severe pain , that by the actions of my hands alone, benefit those whose lives had been dominated by pain and the fear of more of the same.
I love my work. Love seeing the looks of satisfaction on the faces of those who have had their "mysterious " shoulder pain , diagnosed as "rotator cuff syndrome " immediately and effectively eliminated with just twenty minutes of hands on attention to their neck. Who would deny the thrill ,of being the only one in the team of interested observers of this and a variety of other referred pain problems,who is the one who can , with only a pair of hands , make this problem dissapear and not come back.
Ahh but I wax lyrical , when I should be answering questions about hammers.
Yep, I'm a hammer, let me at them there nails.

Ginger, you are a funny bird...

In defence of sfinn, it does seem like all things can be cured by CM - perhaps it is the delivery of the message rather than its the content that sfinn was alluding to?

I still believe that you are born with hands to do manual therapy - I have seen many good physios with very average hands - they tend to move away from manual therapy into exercise rehab and get good results. But good manual therapists they aren't...

Thanks

Thanks alophysio and Sfinn, does me good to rev up now and then. How about a new thread about something of mutual interest. Suggestions........
dura.
pfs.
swimming
gardening
existential argument on the models proposed by nietzsche as interpreted by my cat.