Understanding Costochondritis: Causes, Symptoms and Physiotherapy Treatment Options

Costochondritis is an inflammation of the cartilage that connects the ribs to the sternum, typically causing chest pain that may worsen with movement or pressure on the affected area. It affects both children and adults, other common diagnoses that causes chest pain includes respiratory and psychogenic conditions.

 

Understanding the Chest Anatomy

Ribs consist of bone and cartilage; cartilage acts as an elastic bridge between the rib and sternum. Ribs move with respiration, trunk motion or upper extremity movement. The ribs connect to both the front (anterior) and back (posterior) parts of the body through various joints:

Anterior rib connections include:

• First rib: Connects to the manubrium via a rigid fusion.
• Ribs 2-7: Attach to the sternum via cartilage at synovial-lined joints.
• Ribs 8-10: Attach to the rib above via cartilage, often with synovial-lined interchondral articulations.
• Ribs 11-12: Do not connect to any anterior structure.

Thoracic Wall Innervation:

• Primarily supplied by intercostal nerves.
• Impingement of these nerves from rib or cartilage movement can cause pain.

Referred Pain:

• Shoulder girdle muscles (originating in the lower cervical region) retain cervical innervation, which may lead to chest wall pain from cervical or shoulder issues.

Causes of Costochondritis 

• Trauma or injury
• Physical strain during intense exercise
• Repetitive movements
• Respiratory infections
• Rheumatoid arthritis
• Osteoarthritis

 

Signs and Symptoms of Costochondritis 

• chest pain, mostly unilateral
• tenderness over the affected ribs or cartilage
• pain with movement or actions like coughing or sneezing
• pain often radiates to other areas like the back or abdomen
• no visible swelling

Costochondritis vs. Tietze Syndrome

Diagnosing Costochondritis

As a physiotherapist, the diagnosis of costochondritis primarily involves a detailed clinical assessment and physical examination to rule out other potential causes of chest pain, particularly cardiac or respiratory issues. 

Differential Diagnosis

• Myocardial infarction (heart attack)
• Angina
• Tietze syndrome
• Rib fracture
• Slipping rib syndrome
• Gastroesophageal reflux disease (GERD)
• Pulmonary embolism
• Pneumonia
• Pneumothorax
• Fibromyalgia

 

Physiotherapy Management of Costochondritis

Physiotherapy management of costochondritis focuses on reducing pain, managing inflammation, restoring mobility, and preventing recurrence. Here’s a detailed approach:

Patient Education and Reassurance

• Educate patients on the benign nature of costochondritis.
• Reassure that symptoms may last weeks to months, typically resolving within one year.

Pain and Inflammation Management

• Encourage the patient to avoid activities that exacerbate pain, such as heavy lifting, strenuous exercise or repetitive upper-body movements, to allow the inflamed area to heal.
• Apply ice packs (cryotherapy) over the painful area for 15-20 minutes several times daily, especially in the acute phase, to reduce inflammation.
• After the acute phase, heat application can help relieve muscle tension around the chest wall.
• Consider cough suppressants if coughing exacerbates symptoms.

Medications include:

• Acetaminophen
• Nonsteroidal anti-inflammatory drugs (NSAIDs) if safe and appropriate
• Analgesics if needed
• Consider local injections of lidocaine (Xylocaine) and corticosteroid for severe cases

 

Therapeutic Exercises

Gentle Range of Motion (ROM) Exercises

Begin with gentle ROM exercises for the upper back, shoulders and chest to maintain mobility without causing pain.

Stretching Exercises

• Pectoral Stretch: Stretch the pectoral muscles by gently leaning into a doorway with arms at shoulder level.
• Thoracic Extension Stretch: Encourage thoracic extension over a foam roller to open the chest and improve posture.

Strengthening Exercises (Gradual Progression)

• Strengthen the muscles surrounding the thoracic spine, shoulders and core to provide better support and reduce pressure on the chest.
• Focus on scapular stability exercises, such as wall slides or scapular retractions, which can alleviate strain on the rib joints.
• Engage the core with exercises like modified planks, which support the thoracic area and help with postural alignment.

 

Manual Therapy Techniques

• Perform gentle mobilizations of the thoracic spine and ribs to reduce stiffness and improve overall mobility in the chest area.
• Apply myofascial release techniques around the chest wall, shoulder girdle and upper back to alleviate muscle tension that may contribute to the pain.
• Gently release tension in the pectoral muscles, intercostal muscles, and paraspinal muscles, which can help relieve stress on the costochondral junctions.

Breathing Exercises

• Diaphragmatic Breathing: Train the patient in diaphragmatic (belly) breathing to reduce reliance on accessory breathing muscles, which can ease pressure on the chest wall.
• Pursed-Lip Breathing: Teach this technique to control breathing during pain episodes or physical activity, as it can reduce discomfort and improve relaxation.

Postural Education and Ergonomic Modifications

• Educate the patient on maintaining a relaxed, upright posture to reduce stress on the costochondral joints. Teach postural awareness exercises, especially for activities like sitting, lifting and carrying.
• Review their workspace and daily activities, recommending ergonomic adjustments to minimize strain on the chest and upper body. For example, suggest a desk setup that promotes neutral alignment of the shoulders and spine.

Once pain levels decrease, guide the patient through a graded return-to-activity program, including gradually increasing exercises and avoiding any movements that strain the chest. Monitor and schedule follow-up sessions to track progress, adjust treatment, and address any concerns.