Tietze syndrome is a benign

inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...

of one or more of the

costal cartilage Costal cartilage, also known as rib cartilage, are bars of hyaline cartilage that serve to prolong the ribs forward and contribute to the elasticity of the walls of the thorax. Costal cartilage is only found at the anterior ends of the ribs, pr ...

s. It was first described in 1921 by German surgeon Alexander Tietze and was subsequently named after him. The condition is characterized by tenderness and painful swelling of the anterior (front)

chest wall The thoracic wall or chest wall is the boundary of the thoracic cavity. Structure The bony skeletal part of the thoracic wall is the rib cage, and the rest is made up of muscle, skin, and fasciae. The chest wall has 10 layers, namely (from ...

at the costochondral (rib to cartilage), sternocostal (cartilage to sternum), or sternoclavicular (clavicle to sternum) junctions. Tietze syndrome affects the true ribs and has a predilection for the 2nd and 3rd ribs, commonly affecting only a single joint. In environments such as the emergency department, an estimated 20-50% of non-cardiac chest pain is due to a musculoskeletal cause. Despite musculoskeletal conditions such as Tietze syndrome being a common reason for visits to the emergency room, they are frequently misdiagnosed as

angina pectoris Angina, also known as angina pectoris, is chest pain or pressure, usually caused by insufficient blood flow to the heart muscle (myocardium). It is most commonly a symptom of coronary artery disease. Angina is typically the result of part ...

pleurisy Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (Pulmonary pleurae, pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant d ...

, and other serious

cardiopulmonary In vertebrates, the circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of the heart an ...

conditions due to similar presentation. Though Tietze syndrome can be misdiagnosed, life-threatening conditions with similar symptoms such as

myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when Ischemia, blood flow decreases or stops in one of the coronary arteries of the heart, causing infarction (tissue death) to the heart muscle. The most common symptom ...

(heart attack) should be ruled out prior to diagnosis of other conditions. Tietze syndrome is often confused with

costochondritis Costochondritis, also known as chest wall pain syndrome or costosternal syndrome, is a benign inflammation of the upper Costochondral joint, costochondral (rib to cartilage) and costosternal joint, sternocostal (cartilage to sternum) joints. 90% ...

. Tietze syndrome is differentiated from costochondritis by swelling of the costal cartilages, which does not appear in costochondritis. Additionally, costochondritis affects the 2nd to 5th ribs while Tietze syndrome typically affects the 2nd or 3rd rib.

Presentation

Tietze syndrome typically presents unilaterally at a single joint of the anterior chest wall, with 70% of patients having tenderness and swelling on only one side, usually at the 2nd or 3rd rib. Research has described the condition to be both sudden and gradual, varying by the individual. Pain and swelling from Tietze syndrome are typically chronic and intermittent and can last from a few days to several weeks. The most common symptom of Tietze syndrome is pain, primarily in the

chest The thorax (: thoraces or thoraxes) or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main di ...

, but can also radiate to the

shoulder The human shoulder is made up of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone) as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder m ...

and arm. The pain has been described as aching, gripping, neuralgic, sharp, dull, and even described as "gas pains". The symptoms of Tietze syndrome have been reported to be exacerbated by sneezing, coughing, deep inhalation, and overall physical exertion. Tenderness and swelling of the affected joint are important symptoms of Tietze syndrome and differentiate the condition from

. It has also been suggested that discomfort can be further aggravated due to restricted shoulder and chest movement.

Cause

The true

etiology Etiology (; alternatively spelled aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek word ''()'', meaning "giving a reason for" (). More completely, etiology is the study of the causes, origins ...

of Tietze syndrome has not been established, though several theories have been proposed. One popular theory is based on observations that many patients begin developing symptoms following a

respiratory infection Respiratory tract infections (RTIs) are infectious diseases involving the lower or upper respiratory tract. An infection of this type usually is further classified as an upper respiratory tract infection (URI or URTI) or a lower respiratory tra ...

and dry cough, with one study finding 51 out of 65 patients contracted Tietze syndrome after either a cough or respiratory infection. Thus, it has been hypothesized that the repetitive mild trauma of a severe cough from a respiratory infection may produce small tears in the

ligament A ligament is a type of fibrous connective tissue in the body that connects bones to other bones. It also connects flight feathers to bones, in dinosaurs and birds. All 30,000 species of amniotes (land animals with internal bones) have liga ...

called microtrauma, causing Tietze syndrome. However, this theory is disputed as it does not account for symptoms such as the onset of attacks while at rest as well as the fact that swelling sometimes develops before a cough. The respiratory infection has also been observed accompanying

rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and h ...

which, coupled with

leukocytosis Leukocytosis is a condition in which the white cell (leukocyte) count is above the normal range in the blood. It is frequently a sign of an inflammatory response, most commonly the result of infection, but may also occur following certain parasit ...

, neutrophilia,

c-reactive protein C-reactive protein (CRP) is an annular (ring-shaped) pentameric protein found in blood plasma, whose circulating concentrations rise in response to inflammation. It is an acute-phase protein of hepatic origin that increases following interleukin ...

(CRP), and elevated

erythrocyte sedimentation rate The erythrocyte sedimentation rate (ESR or sed rate) is the rate at which red blood cells in anticoagulated whole blood descend in a standardized tube over a period of one hour. It is a common hematology test, and is a non-specific measure of in ...

(ESR), suggest an infectious and rheumatoid factor, though the evidence is conflicting. Many theories such as

malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues a ...

chest trauma A chest injury, also known as chest trauma, is any form of physical injury to the chest including the ribs, heart and lungs. Chest injuries account for 25% of all deaths from traumatic injury. Typically chest injuries are caused by blunt mechanism ...

, and

tuberculosis Tuberculosis (TB), also known colloquially as the "white death", or historically as consumption, is a contagious disease usually caused by ''Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can al ...

, were thought to be among the potential causes but have since been disproven or left unsupported.

Diagnosis

Diagnosis Diagnosis (: diagnoses) is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in a lot of different academic discipline, disciplines, with variations in the use of logic, analytics, and experience, to determine " ...

for Tietze syndrome is primarily a clinical one, though some studies suggest the use of radiologic imaging. Musculoskeletal conditions are estimated to account for 20-50% of non-

cardiac The heart is a muscular organ found in humans and other animals. This organ pumps blood through the blood vessels. The heart and blood vessels together make the circulatory system. The pumped blood carries oxygen and nutrients to the tissu ...

related chest pain in the emergency department. Ruling out other conditions, especially potentially life-threatening ones such as

(heart attack) and

, is extremely important as they can present similarly to Tietze syndrome. These can usually be ruled out with diagnostic tools such as an electrocardiogram and a physical examination showing reproducible

tenderness, . After eliminating other possible conditions, physical examination is considered the most accurate tool in diagnosing Tietze syndrome. Physical examination consists of gentle pressure to the chest wall with a single finger to identify the location of the discomfort. Swelling and tenderness upon

palpation Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a health care practitioner, it is the process of feeling an object in or on the body to determine ...

at one or more of the costochondral, sternocostal, or sternoclavicular joints, is a distinctive trait of Tietze syndrome and is considered a positive diagnosis when found. There are some

pathological Pathology is the study of disease. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in the context of modern medical treatme ...

features that can be observed with Tietze syndrome, including degeneration of the

, increase in

vascularity Vascularity, in bodybuilding, is the condition of having many highly visible, prominent, and often extensively-ramified superficial veins. The skin appears "thin"—sometimes virtually transparent—due to an extreme reduction of subcutaneous fat ...

, and hypertrophic changes (enlarged cells). However, these features can only be identified from a

biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, an interventional radiologist, or an interventional cardiology, interventional cardiologist. The process involves the extraction of sampling (medicine), sample ...

. Some studies have begun exploring and defining the use of radiographic imaging for diagnosing Tietze syndrome. This includes

computed tomography A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

(CT),

magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...

(MRI),

bone scintigraphy A bone scan or bone scintigraphy is a nuclear medicine imaging technique used to help diagnose and assess different bone diseases. These include cancer of the bone or metastasis, location of bone inflammation and fractures (that may not be vis ...

, and

ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...

, though these are only case studies and the methods described have yet to be thoroughly investigated. Methods such as plain

radiographs Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical ("diagnostic" radiography and "therapeu ...

, better known as an x-ray, are helpful in the exclusion of other conditions, but not in the diagnosis of Tietze syndrome. Some researchers believe that ultrasound is superior to other available imaging methods, as it can visualize the increased volume, swelling, and structural changes of the

Differential diagnosis

The symptoms of Tietze syndrome can display as a wide variety of conditions, making it difficult to diagnose, especially to physicians unaware of the condition. Due to its presentation, Tietze syndrome can be misdiagnosed as a number of conditions, including

(heart attack),

, and

neoplasms A neoplasm () is a type of abnormal and excessive growth of tissue (biology), tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tiss ...

Costochondritis Costochondritis, also known as chest wall pain syndrome or costosternal syndrome, is a benign inflammation of the upper Costochondral joint, costochondral (rib to cartilage) and costosternal joint, sternocostal (cartilage to sternum) joints. 90% ...

is most commonly confused with Tietze syndrome, as they have similar symptoms and can both affect the costochondral and sternocostal joints. Costochondritis is considered a more common condition and is not associated with any swelling to the affected joints, which is the defining distinction between the two. Tietze syndrome commonly affects the 2nd or 3rd rib and typically occurs among a younger age group, while costochondritis affects the 2nd to 5th ribs and has been found to occur in older individuals, usually over the age of 40. In addition,

can diagnose Tietze syndrome, whereas costochondritis relies heavily on physical examination and

medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and ev ...

. Another condition that can be confused for Tietze syndrome and costochondritis is slipping rib syndrome (SRS). All three conditions are associated with chest pain as well as inflammation of the costal cartilage. Unlike both costochondritis and Tietze syndrome, which affect some of the true ribs (1st to 7th), SRS affects the false ribs (8th to 10th). SRS is characterized by the partial dislocation, or

subluxation A subluxation is an incomplete or partial dislocation of a joint or organ. According to the World Health Organization, a subluxation is a "significant structural displacement" and is therefore visible on static imaging studies, such as X-rays. ...

, of the joints between the costal cartilages. This causes

, irritated

intercostal nerves The intercostal nerves are part of the somatic nervous system, and arise from the anterior rami of the thoracic spinal nerves from T1 to T11. The intercostal nerves are distributed chiefly to the thoracic pleura and abdominal peritoneum, and dif ...

, and straining of the

intercostal muscles The intercostal muscles comprise many different groups of muscles that run between the ribs, and help form and move the chest wall. The intercostal muscles are mainly involved in the mechanical aspect of breathing by helping expand and shrink th ...

. SRS can cause abdominal and back pain, which costochondritis does not. Tietze syndrome and SRS can both present with radiating pain to the

and arm, and both conditions can be diagnosed with

, though SRS requires a more complex dynamic ultrasound. The vast differential diagnosis also includes: * Pleural diseases including

pneumonia Pneumonia is an Inflammation, inflammatory condition of the lung primarily affecting the small air sacs known as Pulmonary alveolus, alveoli. Symptoms typically include some combination of Cough#Classification, productive or dry cough, ches ...

pulmonary embolism Pulmonary embolism (PE) is a blockage of an pulmonary artery, artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include dyspnea, shortness of breath, chest pain ...

, and

pneumothorax A pneumothorax is collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and dyspnea, shortness of breath. In a minority of cases, a one-way valve is ...

. * Rheumatic disorders such as

ankylosing spondylitis Ankylosing spondylitis (AS) is a type of arthritis from the disease spectrum of axial spondyloarthritis. It is characterized by long-term inflammation of the joints of the spine, typically where the spine joins the pelvis. With AS, eye and bow ...

, and

rheumatic fever Rheumatic fever (RF) is an inflammation#Disorders, inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops two to four weeks after a Streptococcal pharyngitis, streptococcal throat infection. Si ...

. *

Arthritis Arthritis is a general medical term used to describe a disorder that affects joints. Symptoms generally include joint pain and stiffness. Other symptoms may include redness, warmth, Joint effusion, swelling, and decreased range of motion of ...

of the

costal cartilages Costal cartilage, also known as rib cartilage, are bars of hyaline cartilage that serve to prolong the ribs forward and contribute to the elasticity of the walls of the thorax. Costal cartilage is only found at the anterior ends of the ribs, prov ...

, including

septic arthritis Acute septic arthritis, infectious arthritis, suppurative arthritis, pyogenic arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typica ...

(pyogenic), monoarthritis, and

psoriatic arthritis Psoriatic arthritis (PsA) is a long-term inflammatory arthritis that may occur in some people affected by the autoimmune disease psoriasis. The classic features of psoriatic arthritis include dactylitis (sausage-like swelling of the fingers ...

. *

Neoplasms A neoplasm () is a type of abnormal and excessive growth of tissue (biology), tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tiss ...

, both

benign Malignancy () is the tendency of a medical condition to become progressively worse; the term is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous benign tumor, ''benign'' tumor in that a malig ...

and

malignant Malignancy () is the tendency of a medical condition to become progressively worse; the term is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous benign tumor, ''benign'' tumor in that a malig ...

(cancerous), including

chondroma A chondroma is a benign cartilaginous tumor, which is encapsulated with a lobular growing pattern. Tumor cells (chondrocytes, cartilaginous cells) resemble normal cells and produce the cartilaginous matrix (amorphous, basophilic material). Prese ...

osteochondroma Osteochondroma is the most common benign tumor of bone. The tumors take the form of cartilage-capped bony projections or outgrowth on the surface of bones ( exostoses). It is characterized as a type of overgrowth that can occur in any bone where ...

multiple myeloma Multiple myeloma (MM), also known as plasma cell myeloma and simply myeloma, is a cancer of plasma cells, a type of white blood cell that normally produces antibody, antibodies. Often, no symptoms are noticed initially. As it progresses, bone ...

osteosarcoma An osteosarcoma (OS) or osteogenic sarcoma (OGS) is a cancerous tumor in a bone. Specifically, it is an aggressive malignant neoplasm that arises from primitive transformed cells of mesenchyme, mesenchymal origin (and thus a sarcoma) and that exhi ...

Hodgkin lymphoma Hodgkin lymphoma (HL) is a type of lymphoma in which cancer originates from a specific type of white blood cell called lymphocytes, where multinucleated Reed–Sternberg cells (RS cells) are present in the lymph nodes. The condition was named a ...

, and

carcinoma Carcinoma is a malignancy that develops from epithelial cells. Specifically, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that arises from cells originating in the endodermal, mesoder ...

. * Nerve pain, specifically intercostal

neuritis Neuritis (), from the Greek ), is inflammation of a nerve or the general inflammation of the peripheral nervous system. Inflammation, and frequently concomitant demyelination, cause impaired transmission of neural signals and leads to aberrant ne ...

and intercostal

neuropathy Peripheral neuropathy, often shortened to neuropathy, refers to damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland function, and/or organ function depending on which nerve fibers are affected. Neuropa ...

. *

Aortic dissection Aortic dissection (AD) occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. In most cases, this is associated with a sudden onset of agonizing ches ...

, a serious condition involving a tear in the body's largest

artery An artery () is a blood vessel in humans and most other animals that takes oxygenated blood away from the heart in the systemic circulation to one or more parts of the body. Exceptions that carry deoxygenated blood are the pulmonary arteries in ...

Treatment

Tietze syndrome is considered to be a self-limiting condition that usually resolves within a few months with rest.

Management Management (or managing) is the administration of organizations, whether businesses, nonprofit organizations, or a Government agency, government bodies through business administration, Nonprofit studies, nonprofit management, or the political s ...

for Tietze syndrome usually consists of

analgesics An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in s ...

and

nonsteroidal anti-inflammatory drugs A nonsteroidal compound is a drug that is not a steroid nor a steroid derivative. Nonsteroidal anti-inflammatory drugs (NSAIDs) are distinguished from corticosteroids as a class of anti-inflammatory agents. List of nonsteroidal steroid receptor mod ...

(NSAIDs) such as

ibuprofen Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain, fever, and inflammation. This includes dysmenorrhea, painful menstrual periods, migraines, and rheumatoid arthritis. It can be taken oral administration, ...

aspirin Aspirin () is the genericized trademark for acetylsalicylic acid (ASA), a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and inflammation, and as an antithrombotic. Specific inflammatory conditions that aspirin is ...

acetaminophen Paracetamol, or acetaminophen, is a non-opioid analgesic and antipyretic agent used to treat fever and mild to moderate pain. It is a widely available over-the-counter drug sold under various brand names, including Tylenol and Panadol. Parac ...

(paracetamol), and

naproxen Naproxen, sold under the brand name Aleve among others, is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain, menstrual cramps, and inflammatory diseases such as rheumatoid arthritis, gout and fever. It is taken orally. It ...

. Other methods of management include

manual therapy Manual therapy, or manipulative therapy, is a treatment primarily used by physical therapists, occupational therapists, and massage therapists to treat musculoskeletal pain and disability. It mostly includes kneading and manipulation of muscle ...

and local heat application. These are intended to relieve pain and are not expected to treat or cure Tietze syndrome as the condition is expected to resolve on its own.

Intercostal nerve block

nerve block Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. #Local anesthetic nerve block, Local anesthetic nerve block (sometimes referred to as simply "nerve b ...

can be utilized in cases where symptom management is not satisfactory in relieving pain. This is usually a nerve-blocking injection that consists of a combination of

steroids A steroid is an organic compound with four fused rings (designated A, B, C, and D) arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter mem ...

such as

hydrocortisone Hydrocortisone is the name for the hormone cortisol when supplied as a medication. It is a corticosteroid and works as an anti-inflammatory and by immune suppression. Uses include conditions such as adrenocortical insufficiency, adrenogenit ...

, and

anesthetics An anesthetic (American English) or anaesthetic (British English; see spelling differences) is a drug used to induce anesthesia ⁠— ⁠in other words, to result in a temporary loss of sensation or awareness. They may be divided into tw ...

such as

lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia and ventricular fibrillation. When used for local anae ...

and

procaine Procaine is a local anesthetic drug of the amino ester group. It is most commonly used in dental procedures to numb the area around a tooth and is also used to reduce the pain of intramuscular injection of penicillin. Owing to the ubiquity of ...

, which is typically administered under

guidance. One study used a combination of triamcinolone hexacetonide and 2%

in 9 patients and after a week, found an average 82% decrease in size of the affected

when assessing with ultrasound as well as a significant improvement of symptoms clinically. However, the long-term effectiveness of the injection is disputed, with multiple researchers describing recurrence of symptoms and repetitive injections.

Surgical intervention

refractory In materials science, a refractory (or refractory material) is a material that is resistant to decomposition by heat or chemical attack and that retains its strength and rigidity at high temperatures. They are inorganic, non-metallic compound ...

cases of Tietze syndrome, where the condition is resistant to other conservative treatment options,

surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

is considered. Surgery is uncommon for cases of Tietze syndrome, as many describe Tietze syndrome as manageable under less invasive options. The use of surgery in this context refers to the resection of the affected

and some of the surrounding areas. Some surgeons have resected cartilage matching the symptoms of Tietze syndrome under the assumption the cartilage was tubercular. One study describes a case in which surgeons resected a large amount of cartilage, including minutely hypertrophied tissue, as a previous resection failed to relieve symptoms which is believed to be due to improperly resected

margins Margin may refer to: Physical or graphical edges *Margin (typography), the white space that surrounds the content of a page *Continental margin, the zone of the ocean floor that separates the thin oceanic crust from thick continental crust *Leaf ...

. There is limited literature on surgical treatment of this disease, and overall research on the treatment of severe, chronic forms of Tietze syndrome.

History

Tietze syndrome was named after and first described in 1921 by German surgeon Alexander Tietze. Tietze first cited 4 cases in Germany of painful swelling where he originally believed the condition was as a result of tuberculosis or wartime malnutrition.

References

External links

{{Osteochondropathy Syndromes with musculoskeletal abnormalities Musculoskeletal disorders