Joint inflammation can cause chest wall pain
Able to get up on the exam table, but obviously not feeling her best, the high school student tried to be helpful when explaining her symptoms. She was somewhat congested, but her main complaint was chest pain.
The young lady participated in gym class but was not involved in competitive sports. She had no known injury to her chest wall and had not been experiencing shortness of breath with exertion. The girl's blood pressure was fine and her oxygen level was a very respectable 98 percent. Her heart exam revealed a normal rhythm without any murmurs or abnormal clicks, and her lungs were clear throughout.
I had the teen lay down and pressed along both sides of her sternum (breast bone), and she winced with pain when I reached the right border. Mom suddenly had a thought, recalling that finals week had just ended. Her daughter had recently pulled an all-nighter bent over her desk as she completed a complex — and quite good, I might add, having seen a shot of it saved on a smartphone — drawing for her advanced art class.
With the student's recent history of prolonged hunching and repetitive use of her right arm, her normal cardiac and lung findings, and the point tenderness elicited along her right sternum, it appeared that the girl was suffering from a case of costochondritis. I recommended over-the-counter pain medications and rest, and as always, asked the family to call back if symptoms were not gradually resolving or were, in fact, worsening.
As Drs. Anne Proulx and Teresa Zryd explain in their American Family Physician article, costochondritis is a specific type of front chest wall pain caused by joint inflammation. Affected joints include those joining the bony parts of the ribs to their front cartilaginous sections at the costochondral junctions, as well as the joints which go on to connect these "elastic bridges" of rib cartilage to the outer edges of the sternum at the chondrosternal joints.
Proulx and Zyrd report that costochondritis is a common, self-limited condition accounting for about 14 percent of adolescent chest pain. The authors note that several rib levels can be affected during an episode of costochondritis and that, while pushing on an affected area of rib cartilage usually reproduces the child's pain, the examiner should find no hardness or swelling at this area of tenderness.
The pain of costochondritis is typically one-sided according to the authors, and can occur following prolonged bouts of coughing, periods of vigorous exercise, or activities requiring use of the shoulder, arm and hand. The chest wall condition can be further aggravated by additional exertion or even by deep breathing.
The family physicians find that costochondritis treatment is relatively straight forward, involving use of pain medications such as acetaminophen or nonsteroidal anti-inflammatory drugs, application of heat or ice, and limitation of activities which exacerbate the symptoms. Physical therapy is occasionally prescribed for cases of costochondritis, but only very rarely are lidocaine-corticosteroid injections indicated.
Proulx and Zyrd caution that these chest wall symptoms can persist for weeks or even months, but remind patients that, unlike many other causes of chest pain, costochondritis is considered a relatively benign condition.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.
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