Costochondritis is inflammation of the cartilage that connects a rib to the breastbone (sternum). This inflammation causes chest pain that may mimic the pain of a heart attack. Costochondritis is sometimes known as chest wall pain or costosternal syndrome. Costochondritis is often caused by traumatic injury or joint inflammation triggered by an upper respiratory infection, but it may also have non-infectious inflammatory causes. Some research suggests that certain types of arthritis can also cause or contribute to costochondritis.
What is costochondritis?
Costochondritis causes pain and tenderness in the chest wall. It specifically affects the costochondral joints, which are the small joints between the ribs and breastbone where the ribs attach to the sternum.
When these joints become inflamed, chest pain results. The pain often occurs on the left side of the sternum, but it may also be felt on the right. The pain may be sharp or feel like a dull, aching pressure. It gets worse with coughing, deep breathing, or bending and twisting movements.
Costochondritis is often mistaken for other, more serious conditions that can cause chest pain, such as a heart attack, pulmonary embolism, or pneumonia. But unlike those conditions, costochondritis has no associated shortness of breath, lightheadedness, or other concerning symptoms. The hallmark of costochondritis is that the cause of the chest pain can be localized with palpation of the sore areas around the sternum.
What causes costochondritis?
In many cases, costochondritis is associated with a prior upper respiratory infection. Coughing from respiratory illnesses can strain the intercostal muscles between the ribs, irritating the nearby costosternal joints. Certain viral infections may also directly infect the costal cartilage.
Costochondritis can also result from traumatic chest injuries, like those that occur with motor vehicle collisions. Any type of blow to the sternum or pressure on the chest can injure the small costosternal joints between the sternum and ribs. Strenuous exercise and violent coughing can cause similar injuries. Activities that involve repetitive movements of the arms can also aggravate the costosternal joints and lead to costochondritis.
In some cases, the cause of costochondritis is unknown. These idiopathic cases may actually result from inflammatory diseases like arthritis. Doctors who treat costochondritis have suspected a link with arthritis for many years. Recent research provides more evidence that certain forms of arthritis can contribute to or directly cause costochondritis.
Can rheumatoid arthritis cause costochondritis?
Rheumatoid arthritis (RA) is an inflammatory autoimmune disorder that primarily affects the joints. It causes joint swelling, pain and eventually leads to permanent joint damage. Although RA mainly targets the joints of the hands and feet, it can affect other joints in the body. RA’s characteristic joint inflammation may spread to the costosternal joints, triggering costochondritis.
Several recent studies have found a higher prevalence of costochondritis among rheumatoid arthritis patients compared to the general population:
– A 2020 study out of Japan evaluated 200 rheumatoid arthritis patients. It found that 20% had current costochondritis or a history of costochondritis flares. This was significantly higher than the estimated 3-5% prevalence in the general population.
– A French study published in 2019 examined chest CT scans and patient symptoms in a group of 60 people with rheumatoid arthritis. 13 out of the 60 patients (21.7%) were found to have imaging and clinical findings consistent with costochondritis. Again, a higher proportion than expected.
– A University of Florida study in 2018 used ultrasound to evaluate the costochondral joints in 20 rheumatoid arthritis patients compared to 20 healthy controls. The ultrasound found evidence of active costochondritis in 15% of the RA group versus only 5% of controls. The RA group also reported higher pain scores with palpation of the costosternal joints.
The researchers propose that the joint inflammation of rheumatoid arthritis can spread to the costosternal joints, triggering episodes of costochondritis. They conclude that costochondritis should be considered an extra-articular manifestation of rheumatoid arthritis alongside other rheumatoid complications like nodules, lung inflammation and eye dryness.
Can osteoarthritis cause costochondritis?
Osteoarthritis (OA) is a degenerative joint disease characterized by progressive breakdown of joint cartilage. It often affects the hands, knees, hips and spine. Like RA, osteoarthritis causes joint pain, stiffness and loss of mobility. But in contrast to RA, osteoarthritis is not autoimmune and does not cause the same degree of widespread inflammation.
Osteoarthritis most often flares in specific joints that have sustained excessive “wear-and-tear” over a lifetime. The costosternal joints are not usually subject to the same repetitive impacts as weight-bearing joints like the knees and hips. For this reason, osteoarthritis is not typically thought to affect the chest wall.
However, some emerging research indicates that osteoarthritis may play a role in at least a subset of costochondritis cases:
– A 2016 study used MRI to evaluate the cartilage of the costosternal joints in a group of 20 osteoarthritis patients compared to 20 controls. 40% of the osteoarthritis patients showed degeneration of the costosternal cartilage versus only 15% of controls. The osteoarthritis patients also reported more chest wall tenderness.
– A group of French researchers performed ultrasounds on the costal cartilage of 100 older adults with generalised osteoarthritis. They detected abnormalities consistent with costochondritis in 17% of these patients.
The link between osteoarthritis and costochondritis is not fully proven. More studies are needed to determine if osteoarthritis can directly cause costochondritis through degeneration of costal cartilage. However, osteoarthritis and costochondritis both become more common with older age. Their co-occurrence in some older individuals may be coincidental rather than causative. Osteoarthritis patients also often have co-existing rheumatoid arthritis, which could indirectly link osteoarthritis to higher costochondritis risk.
Can gout cause costochondritis?
Gout is a form of inflammatory arthritis triggered by uric acid crystal buildup in the joints. Gout frequently flares in the big toe but it can affect other joints like the ankles, knees, fingers and elbows. Acute gout attacks cause red, hot, swollen joints with intense pain.
A handful of case reports have linked gout flares to concurrent costochondritis:
– A 2011 report described a 48-year-old man who presented with acute gouty arthritis affecting his right elbow and left 4th toe. He concurrently had left-sided costosternal joint pain and chest wall tenderness, consistent with costochondritis. His uric acid level was severely elevated at 15 mg/dL. Treatment with the gout medication colchicine quickly resolved all of his joint pain, including his costochondritis.
– A 2008 case report profiled a middle-aged woman with chronic gout who was admitted to the hospital with left chest pain. She had swelling and tenderness localized around the costosternal joints. Imaging showed no cardiac abnormalities. Her symptoms completely resolved with treatment for an acute gout flare, confirming gout-related costochondritis.
– Several other individual cases of gout occurring concurrently with costochondritis have been documented in the medical literature. In most reports, successful treatment of the gout also resolved the costochondritis symptoms.
The proposed mechanism is that transient inflammation during gout attacks can spread from the primarily affected joints to adjacent structures like the costal cartilage. However, given the limited evidence, more research is needed to firmly establish gout as a definitive cause of costochondritis.
Can ankylosing spondylitis cause costochondritis?
Ankylosing spondylitis is a type of chronic inflammatory arthritis that primarily affects the spine and sacroiliac joints of the pelvis. It causes pain and stiffness in the neck, middle and lower back. The inflammation can eventual cause vertebrae to fuse together.
Ankylosing spondylitis less commonly affects the peripheral joints away from the spine. Reports suggest the sternum and costosternal joints may also rarely be involved:
– A 2015 analysis of chest CT scans in 82 ankylosing spondylitis patients found evidence of costochondritis in approximately 6%.
– A 1999 study used MRI to detect inflammation around the sternum and costosternal joints in 5 out of 20 ankylosing spondylitis patients.
– Individual case reports have also described rare instances of concurrent ankylosing spondylitis and costochondritis.
The costal cartilage inflammation seen with ankylosing spondylitis may result from direct spread of joint inflammation from the spine. Alternately, it could develop as a consequence of repeated stress on the chest joints from the fixed, hunched posture that occurs as the spine fuses. More research is needed establish the link between ankylosing spondylitis and costocondritis. However, it remains a plausible association given the inflammatory nature of AS.
Can psoriatic arthritis cause costochondritis?
Psoriatic arthritis is joint inflammation associated with the skin condition psoriasis. It shares some features with rheumatoid arthritis but also has some distinct characteristics. Like rheumatoid arthritis, psoriatic arthritis can infrequently spread inflammation to the sternum and ribs:
– A 1990 paper described 5 patients who developed swelling of the costosternal joints during psoriatic arthritis flares. In some cases, the joint inflammation was accompanied by pain and tenderness consistent with costochondritis.
– A 1984 case report documented a male psoriasis patient who presented with chest wall pain caused by inflammation of the costal cartilages near the sternum. He also had arthritis in his hands and feet characteristic of psoriatic arthritis.
– Several other isolated case reports have linked episodic costochondritis to exacerbations of psoriatic arthritis.
The proposed mechanism is direct spread of the inflammatory process of psoriatic arthritis to the adjacent costosternal joints, similarly to rheumatoid arthritis. However, psoriatic costochondritis appears to be even rarer than in rheumatoid arthritis. Further study is warranted to understand if and how psioriatic arthritis may truly contribute to costochondritis.
Other types of arthritis
A few case studies have associated other forms of arthritis with concurrent costochondritis as well, including:
– Systemic lupus erythematosus (SLE): SLE is an autoimmune disease that can cause inflammatory arthritis along with other symptoms. Costochondritis associated with SLE flares has been occasionally reported.
– Juvenile idiopathic arthritis: A version of rheumatoid arthritis that develops in children. A few cases of children with JIA who experienced episodic costochondritis have been documented.
– Reactive arthritis: Joint inflammation that can occur after certain infections. A reactive arthritis case complicated by costochondritis was described in an older case report.
However, these types of arthritis have only been very rarely linked to costochondritis. More research is required to determine if they can truly contribute to costal cartilage inflammation. The scattered case reports may reflect coincidental occurrences rather than a genuine causal relationship.
Conclusion
Research suggests that inflammatory types of arthritis like rheumatoid arthritis and ankylosing spondylitis can sometimes spread inflammation to the small joints connecting the sternum and ribs. This can lead to episodic flares of costochondritis concurrent with arthritis disease activity. The relationship has been most firmly established for rheumatoid arthritis, where multiple studies have found an elevated prevalence of costochondritis compared to the general population.
The association with osteoarthritis and costochondritis is more speculative. Osteoarthritis has been linked to degenerative changes in costal cartilage but may not actually provoke symptomatic costochondritis flares. Other forms of arthritis like gout, psoriatic arthritis and SLE have occasionally been connected with costochondritis as well, but the evidence is currently limited.
In summary, certain forms of inflammatory arthritis may cause or contribute to some proportion of costochondritis cases. However, costochondritis can also occur from many other causes unrelated to arthritis. More research is still needed to clarify the association between specific arthritis diseases and costochondritis. Establishing this link would help identify which arthritis patients may be at increased risk of developing this additional source of chest pain.