Costochondritis, also known as chest wall pain or Tietze syndrome, is inflammation of the cartilage that connects the ribs to the breastbone. It causes sudden, sharp chest pain that may mimic the pain of a heart attack or other serious medical conditions. Because the symptoms are similar, costochondritis is often mistaken for other disorders.
Heart attack
One of the most common conditions that costochondritis is mistaken for is a heart attack. The intense chest pain and pressure caused by costochondritis can resemble the chest pain associated with a heart attack. However, there are some key differences:
- Costochondritis pain is usually very localized to a small area of the chest wall. Heart attack pain tends to radiate down the left arm, up the neck/jaw, or into the back.
- Costochondritis pain is reproducible when pressing on the affected area of the ribs or breastbone. Pressing on these areas does not recreate or worsen heart attack pain.
- Costochondritis pain tends to be sharp and stabbing. Heart attack pain is often described as pressure, tightness, heaviness, or aching.
- Costochondritis pain comes and goes. Heart attack pain is persistent.
- Costochondritis is not associated with other heart attack symptoms like shortness of breath, sweating, nausea, or lightheadedness.
However, because the chest pain of costochondritis can sometimes feel similar to angina (chest pain from heart disease), it is always important to seek prompt medical evaluation. Doctors can run tests like EKGs and bloodwork to rule out a heart attack as the cause of chest pain.
Pulmonary embolism
A pulmonary embolism is a blood clot that has traveled to the arteries in the lungs. This can block blood flow and oxygen transport. Symptoms of a pulmonary embolism include:
- Sudden shortness of breath
- Chest pain, especially when breathing deeply
- Coughing, sometimes with bloody sputum
- Rapid heart rate and breathing
- Lightheadedness or passing out
Since pulmonary embolisms cause chest pain and difficulty breathing, they are sometimes confused with costochondritis. However, with costochondritis the chest pain is very localized along the sternum or ribs. Pain from a pulmonary embolism is usually deeper in the chest and described as pleuritic (worsens with a deep breath). A pulmonary embolism also causes other symptoms like shortness of breath, rapid heart rate, and lightheadedness that are not seen with costochondritis.
Pneumonia
Pneumonia is a lung infection that also causes chest pain along with:
- Fever and chills
- Cough with phlegm or mucus
- Shortness of breath
- Fatigue
With pneumonia, the chest pain tends to be deeper in the lungs and get worse when breathing deeply or coughing. Costochondritis chest pain is very superficial and localized along the breastbone and ribs. Pneumonia also causes other infectious symptoms like fever, cough, and fatigue that are not present with costochondritis inflammation.
Pleural effusion
A pleural effusion is a buildup of excess fluid between the layers of the pleura, which is the thin membrane covering the lungs. This can put pressure on the lungs and cause symptoms like:
- Chest pain when breathing deeply
- Shortness of breath
- Dry cough
Because pleural effusions can cause chest pain, they are sometimes mistaken for costochondritis. However, with a pleural effusion the chest pain tends to be deeper and more diffuse compared to the very localized, superficial pain of costochondritis along the sternum and ribs. Pleural effusions also cause shortness of breath not typically seen with costochondritis.
Pleurisy
Pleurisy refers to inflammation of the pleura, which are the lung’s lining membranes. Symptoms include:
- Sharp chest pain when breathing deeply or coughing
- Shortness of breath
- Dry cough
Since pleurisy causes painful breathing, some individuals initially think they have costochondritis when the true cause is pleural inflammation. Pleuritic chest pain does tend to be much worse when taking deep breaths compared to costochondritis pain. And costochondritis does not cause shortness of breath. Imaging tests like x-rays or CT scans can help differentiate between pleurisy and costochondritis.
Chest wall injuries
Injuries to the chest wall, such as bruising or fractured ribs from trauma or falls, can also mimic costochondritis pain. Symptoms of chest wall injuries include:
- Very localized chest pain and tenderness over the site of injury
- Pain that worsens with movement, deep breathing, or pressing on the area
- Swelling, bruising, or deformity over the injured ribs or breastbone
Both chest wall injuries and costochondritis cause upper chest pain and tenderness. But with an injury there is usually a history of trauma to that area. Pressing on the painful site typically reproduces the pain of an injury but not always with costochondritis inflammation. Imaging like x-rays can also detect rib fractures or other damage that would point more towards a chest wall injury.
Pericarditis
Pericarditis refers to inflammation of the pericardium, which is the membrane surrounding the heart. Symptoms include:
- Sharp, stabbing chest pain that may improve when sitting up and leaning forward
- Chest pain that gets worse when lying down or breathing deeply
- Low grade fever
Like costochondritis, pericarditis causes chest pain and tenderness. However, pericarditis pain is often relieved somewhat by sitting up and worsened by lying down. Costochondritis pain does not necessarily change with position. Pericarditis may also cause a low grade fever not seen with costochondritis. Imaging tests and EKGs can help distinguish between the two conditions.
Angina
Angina refers to chest pain that occurs when the heart is not getting enough blood flow and oxygen. Symptoms include:
- Heaviness, squeezing, tightness, pressure, or aching in the chest
- Chest pain that radiates to the arms, neck, jaw, or back
- Chest pain triggered by exertion or stress
While both can cause chest pain, angina pain tends to feel more like pressure or tightness versus the sharper, more severe pain of costochondritis. Also, angina pain typically radiates to other areas like the arm and is triggered by physical exertion. Costochondritis pain is very localized and is not necessarily brought on by activity. As always, cardiac causes should be evaluated with testing.
Hiatal hernia
A hiatal hernia is when part of the stomach bulges up through the diaphragm into the chest cavity. Symptoms include:
- Burning or aching chest pain
- Pain that worsens when bending over or lying down
- Bitter taste in the mouth
- Belching
Hiatal hernias can mimic costochondritis as they both cause chest pain and tenderness. However, hiatal hernia pain is usually lower down along the sternum and may have a burning quality versus the sharper pain of costochondritis higher up on the chest. Individuals with hiatal hernia may also experience symptoms of reflux like a bitter taste in the mouth. Imaging tests can confirm a hiatal hernia.
Panic attack
A panic attack involves a sudden surge of intense anxiety, fear, and stress. Symptoms include:
- Pounding heart
- Chest pain or tightness
- Trouble breathing
- Dizziness, shakiness
- Nausea
- Choking sensation
Since panic attacks cause chest tightness and difficulty breathing, they can sometimes be confused with costochondritis initially. However, panic attacks also involve intense mental symptoms like fear of dying, losing control, or “going crazy” that are absent with costochondritis. The chest pain of an attack feels more like tightness versus the sharper, stabbing pain of costochondritis inflammation. Attacks also come on rapidly and resolve within minutes, unlike the longer-lasting pain of costochondritis.
Gastroesophageal reflux disease (GERD)
GERD occurs when stomach acid frequently flows back up into the esophagus. Typical symptoms include:
- Heartburn
- Regurgitation of food/liquid
- Bitter or sour taste in the mouth
Although GERD does not directly cause chest wall pain, some of the acid reflux can irritate the nerves that supply the chest and create a feeling of tightness or pressure. So in some cases, GERD may mimic or overlap with costochondritis pain. Individuals with GERD also experience other symptoms like heartburn, regurgitation, and a sour taste that are not present with isolated costochondritis. Treatment with acid-blocking medications can help clarify if GERD is a factor.
Shingles
Shingles is a viral infection caused by the reactivation of the varicella zoster virus that causes chickenpox. Symptoms include:
- Tingling, burning pain
- Rash with fluid-filled blisters
- Itching
When shingles affects the chest wall along the nerve routes of the upper back and chest, it can sometimes mimic costochondritis pain. However, shingles will also cause a characteristic rash and itching that does not occur with costochondritis inflammation. Shingles pain also tends to be more burning versus the sharper chest wall pain of costochondritis.
Anxiety
Anxiety refers to excessive apprehension, worry, and fear about real or imagined situations and symptoms. While a full-blown panic attack (discussed above) causes distinctive symptoms, generalized anxiety can also amplify and mimic certain features of costochondritis like:
- Chest tightness
- Hyper-focus on chest sensations
- Fear of serious illness causing the symptoms
Individuals with severe anxiety may become very preoccupied with the chest pain and pressure caused by costochondritis, even when investigations rule out a heart attack or other dangerous conditions. Learning to control anxiety through techniques like cognitive behavioral therapy can help reduce this hyper-focus on costochondritis chest pain.
Chest muscle strain
The chest contains large muscles like the pectoralis major and minor that can become strained due to overuse injuries and excessive physical activity. Symptoms of a chest muscle strain include:
- Sharp pain when using the injured muscle
- Muscle tenderness
- Swelling
- Bruising
Since chest muscle strains cause localized pain like costochondritis, occasionally they can be mistaken for this condition initially. However, strains cause exquisite tenderness over the affected muscle and pain with using that muscle. Costochondritis tenderness is specifically over the cartilage and bones of the sternum and ribs. Imaging like MRI can help distinguish musculoskeletal strains from inflammation of the costochondral joints.
Myocarditis
Myocarditis refers to inflammation of the heart muscle itself. Symptoms include:
- Chest pain that may mimic a heart attack
- Shortness of breath
- Rapid or irregular heartbeats
- Fatigue
Because myocarditis causes chest pain, it can sometimes be confused with costochondritis initially. However, myocarditis chest pain is usually more diffuse versus the very localized pain of costochondritis along the sternum and ribs. Myocarditis also causes other heart-related symptoms like palpitations and shortness of breath not seen with costochondritis. Cardiac testing like EKGs and troponin blood tests can readily distinguish myocarditis from costochondritis.
Precordial catch syndrome
Precordial catch syndrome causes episodes of sharp, stabbing chest pain thought to arise from pinched nerves in the chest wall. Symptoms include:
- Very brief, severe chest pain, often described as catching or tearing
- Pain lasting only seconds to minutes
- Occurs when resting and resolves rapidly with movement or stretching
Precordial catch syndrome is essentially a variant of costochondritis. The main difference is the duration of pain, with precordial catch causing very brief but intense episodes of chest pain versus the more persistent inflammation of costochondritis. But given the similarities, precordial catch syndrome is essentially on the same spectrum as costochondritis in terms of the location and nature of the chest pain.
Tietze syndrome
Tietze syndrome is an alternative name for costochondritis. The two terms refer to the same condition – inflammation of the cartilage connections between the ribs and breastbone. So while sometimes considered distinct disorders, Tietze syndrome and costochondritis are in fact synonymous. The chest wall pain and tenderness caused by both arise from this cartilage inflammation.
Conclusion:
Due to the sudden onset of chest pain, costochondritis is often mistaken for more serious causes like heart attack and pulmonary embolism. However, the very localized, reproducible nature of costochondritis pain over the ribs and breastbone can help distinguish it from these other conditions causing more diffuse chest pain. Sometimes testing like EKGs, X-rays, and lab work may be needed to definitively rule out certain disorders before confirming a diagnosis of costochondritis. But being aware of the typical features and location of costochondritis pain helps avoid excessive testing and worry in those with this benign source of chest wall irritation.