Tietze syndrome is a disease in which an inflammatory process develops in the joints that unite the ribs with the sternum. These structures are called costochondral joints (or union of the ribs with their costal cartilage). This disorder also affects the soft tissues that are nearby.
“Patients frequently visit the emergency room with acute chest pain. While some potentially life-threatening disorders may cause the pain, in approximately 80% of cases, the chest pain source is benign, and musculoskeletal chest pain accounts for nearly 20%–50% of those cases. Thus, pain caused by benign and pathological conditions of the chest wall encountered in the emergency department is sometimes incorrectly attributed to angina pectoris or pleuritic and other serious cardiopulmonary diseases.
Tietze syndrome is an inflammatory ailment characterized by chest pain and costochondral junction swelling with an unknown cause. Tietze first described the syndrome in 1921 as a non-suppurative, benign, painful superior chondrosternal joint swelling. Pain caused by this disease is frequently referred to the emergency department and occasionally misdiagnosed as pleurisy, angina pectoris, or other severe cardiopulmonary disorders. This information may help raise awareness of the clinical presentation and the management of this disease among emergency physicians. Emergency physicians must be aware that musculoskeletal chest pain causes are frequent but often overlooked.
Usually presents in both male and female adults under the age of 40. The source of this condition is not known. No causal link has been found between Tietze syndrome and occupation, geography, or ethnicity; however, there have been clustered cases. Results of the few pathological studies conducted vary from no unusual findings to degradation and swelling of the costal cartilage with associated minimal inflammation of the perichondrium.”1
Tietze syndrome has been shown to occur in patients between 20 to 40 years old, but it can also develop at any age. It has a close relationship with costochondritis, a condition in which the cartilage of the ribs is inflamed.
“Costochondritis is a more common condition characterized by tenderness and pain of the chondrosternal joints without swelling. The term costochondritis is used interchangeably with costosternal syndrome and chest wall syndrome, and definitions are not consistent. These syndromes are all characterized by pain and local tenderness at the costochondral or chondrosternal articulations, or even at the xiphoid process, but without the inflammation and swelling seen in Tietze syndrome. Many patients are left untreated and undiagnosed, possibly leading to further unnecessary examinations or cost.”2
“Costochondritis, also known as sternocostal syndrome, chondrogenic or front chest wall syndrome, is often confused with Tietze’s syndrome. Significant differences between these two disease entities are presented below:”3
Normally, patients suffering from Tietze syndrome may experience a series of alterations. For example, sensitivity to heat, redness, increased pressure in the affected area, swelling or enlargement of the region between the ribs and the sternum, and pain that is usually located between the fourth and sixth rib to the left of the sternum. This pain may have different levels of intensity. Sometimes, this discomfort is so strong that it can even be confused with a heart attack. The sensation can radiate to other nearby areas, such as the abdomen or shoulders. In any case, the discomfort worsens when the patient executes a series of physical activities involving the thorax, for example, breathing deep, sneezing, sudden movements of the arms, etc.
“The symptoms of Tietze’s syndrome are not characteristic and include point pain within the anterior half of the chest wall radiating to the shoulder and arm, exacerbated by sneezing, deep breathing and torsional movements of the torso. During the exacerbation of symptoms of Tietze’s syndrome, additionally, there was observed increased palpation tenderness within the occupied sternocostal joint, leukocytosis, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and body temperature to 38°C. Tietze’s syndrome may be additionally accompanied by dermatological symptoms such as palm and plantar pustulosis and psoriasis.
In physical examination, in over 70% of patients, one side of the thorax is swollen and there is noted palpable tenderness of the sternocostal joint, most often the second and/or third rib. It is recommended that during the physical examination, with a single finger, one should apply gentle pressure to the front, lateral and posterior chest wall in order to accurately locate the discomfort.
Currently, even though the cause of this illness remains unknown it is believed that most commonly it is caused by micro-injuries and/or infection of the airways.
This syndrome of clinical symptoms was first described in 1921 by the German professor of surgery Alexander Tietze, who was an assistant to Jan Mikulicz-Radecki. The etiopathogenesis of Tietze’s syndrome remains poorly understood.”3
However, several clinical studies have been able to identify a series of risk factors. Among the possible triggers of this alteration are:
- Some types of traumas to the thorax, such as a fall or a car accident.
- Repetition of movements that involve the chest area, such as coughing. This could speed up the consequences of wear and tear of the cartilage involved, giving rise to subsequent inflammation.
- Performing intense physical exercises such as lifting heavy objects. It can also damage already weakened cartilage.
- Presence of tumors in the sternochondral
- Certain types of rheumatism.
- Development of secondary diseases that may affect cartilage, like tuberculosis.
Pain is experienced when:
- Heavy breathing (i.e. no intense exercise)
- Repetitive motions (tennis, baseball, scrubbing floors, etc.)
- Lying on your back usually, ads pressure to the breastbone.”4
Specialists can identify this disorder easily and discard others with similar characteristics. The most commonly used tests to achieve this objective are:
- A physical exam: the doctor can check the symptoms that the patient presents related to Tietze syndrome. Also, a study of your medical history will assist in a proper diagnosis.
- Internal imaging tests. With these, the doctor will analyze the thickening of the cartilage caused by the inflammation that it suffers. Commonly, radiography and magnetic resonance (MRI) are used.
- Routine tests such as blood and urine tests.
- An electrocardiogram (EKG).
- A biopsy
“Ultrasound imaging is the most common method, which shows swelling of soft tissues at the site of the ongoing inflammatory process. In turn, the nuclear magnetic resonance (NMR) very accurately shows inflammatory changes in the surrounding fat tissue along with bone marrow edema causing compression and close adherence of the joint surfaces forming the articulation. There are no destructive changes in cartilage and bone. Another recommended method is skeletal scintigraphy using technetium-99 or radioactive gallium.
Diagnosis is a clinical one, as there are no characteristic laboratory or radiographic findings. Full characterization of the chest pain is needed regarding the site, onset, radiation, and exacerbating and relieving factors. Reproducible chest wall tenderness helps to rule out acute coronary syndrome in patients with acute chest pain in an early stage of the evaluation process. Manual palpation of pain and motion of muscles and joints of the chest wall and cervicothoracic spine are important; however, pain localization does not help with differential diagnosis, since pain localization of acute coronary disease does not differ from that experienced by patients with chest wall syndrome, gastroesophageal reflux disease, or psychogenic chest pain. Interestingly, one study showed that the final diagnosis in patients presenting acute chest pain in the emergency room was chest wall syndrome in 46.6%, acute coronary disease in 14.8%, and psychogenic disorders in 9.5%. Gastroesophageal reflux disease and hypertension were seen in 3.5% and 4.0% of the patients with chest pain, respectively.”1
In a patient with symptoms like chest tightness, it is always necessary to make a differential diagnosis that includes Tietze syndrome. It is rare, but sometimes the characteristic pain of this pathology can simulate the ischemic pain of cardiovascular origin. The most frequent etiology, in this case, is acute myocardial infarction and angina pectoris. If the ischemia is compensated, angina can resemble the inflammation that is typical of Tietze syndrome.
“Emergency physicians must be aware of the management and clinical presentation of Tietze syndrome to avoid further unnecessary anxiety, time, and expense.
The expedient accurate diagnosis of Tietze’s Syndrome is important for the physical and emotional well-being of a patient and avoids overlooking more dangerous pathologies.
Various pain management strategies are offered. In the emergency department, many received ketorolac and warm compresses. Upon discharge, they elected to continue ibuprofen, at increased doses, as well as use warm compresses. They have also prescribed oxycodone for breakthrough pain.”5
“Prolotherapy is a method of injection treatment designed to stimulate healing.
Many different types of musculoskeletal injuries and pain lend themselves to prolotherapy
treatment including low back and neck pain, chronic sprains and/or strains, whiplash injuries, tennis and golfer’s elbow, knee, ankle, shoulder or other joint pain, chronic tendonitis/tendinosis, and musculoskeletal pain related to osteoarthritis.
Prolotherapy works by raising growth factor levels or effectiveness to promote tissue repair or growth. It can be used years after the initial pain or problem began, as long as the patient is healthy. Prolotherapy works by causing a temporary, low-grade inflammation at the site of ligament or tendon weakness (fibro-osseous junction), “tricking” the body into initiating a new healing cascade. Inflammation activates fibroblasts to the area, which synthesize precursors to mature collagen and thereby reinforcing connective tissue. This inflammatory stimulus raises the level of growth factors to resume or initiate a new connective tissue repair sequence to complete one which had prematurely aborted or never started. Prolotherapy is also known as “regenerative injection therapy (RIT),” “non-surgical tendon, ligament, and joint reconstruction,” or “growth factor stimulation injection therapy.” 6
“Prolotherapy could be performed safely and is a method with a favorable long term treatment for Tietze Syndrome. It may be the ideal procedure for patients with drugs side effects and adverse events especially for those with limited liver and kidney reserve or significant comorbidities.
Twenty-one patients underwent prolotherapy (group 1) and thirteen underwent conservative therapy with analgesics (group 2). A visual analog score (VAS) was recorded for measurement of pain intensity in all patients before (Pre VAS) and after injection first day (VAS1), first week (VAS2) and fourth week (VAS3). Group 2 were received the systemic nonsteroidal anti-inflammatory drug. VAS score was recorded similarly at the same times (Pre VAS, VAS1, VAS2, VAS3), and clinical effects were compared between the two groups.
Results: The mean VAS score (mm) before prolotherapy was 7.10 in patients who received prolotherapy, and 7.14 mm in patients who treated nonsteroidal anti-inflammatory drug. The mean VAS after the first injection was 2.19 mm and dropped to 1.52 mm after the third injection. The mean VAS after the nonsteroidal anti-inflammatory drug treatment dropped 2.62 mm and during the same scores to 3 weeks later. There was no significant difference between group 1 and group 2 in the sex, and comorbidity. Also, there was no significant difference between group 1 and group 2 in clinical and radiological evidence. The prolotherapy group showed a faster recovery, including significantly reduced clinic findings (p: 0.001). Third VAS is a significant finding for the prolotherapy group.”7
“A paced respiration methodology and self-control procedure was developed to reduce respiratory irregularities associated with disabling Tietze’s syndrome pain. Treatment was directed at producing normal respiratory activity and reducing involuntary deep inspirations. Training led to within- and between-sessions reductions in respiratory irregularity and pain frequency, and to increases in self-reported activity levels. Two- and 5-month follow-up sessions showed that improvements were maintained but at an attenuated level. Possible respiration biofeedback or self-monitoring treatments of this syndrome are also discussed.”8
(1) Sawada, K., Ihoriya, H., Yamada, T., Yumoto, T., Tsukahara, K., Osako, T., … & Nakao, A. (2019). A patient presenting painful chest wall swelling: Tietze syndrome. World journal of emergency medicine, 10(2), 122. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340818/
(2) Collins, M. J., Arns, T. A., Frank, R. M., Cvetanovich, G. L., Black, A., Romeo, A. A., … & Forsythe, B. (2017). Publication rates of podium presentations at the American Shoulder and Elbow Surgeons annual open versus closed meetings 2008 to 2012. JSES open access, 1(1), 35-38. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340828/
(3) Rokicki, W., Rokicki, M., & Rydel, M. (2018). What do we know about Tietze’s syndrome?. Kardiochirurgia i torakochirurgia polska= Polish journal of cardio-thoracic surgery, 15(3), 180. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6180027/
(4) Rahman, H. (2013). Treatments for Tietze’s Syndrome Available online at https://www.scribd.com/document/148439424/Treatments-for-Tietze-Syndrome
(5) Grodin, L., & Farina, G. (2013). Tietze’s Syndrome in the emergency department: A rare etiology of atraumatic chest pain. Case Reports in Clinical Medicine, 2(03), 208. Available online at https://file.scirp.org/pdf/CRCM_2013060516263430.pdf
(6) Alderman, D. (2007). Prolotherapy For Low Back Pain. Practical Pain Management, 7(4), 58-63. Available online at https://prolotherapy.com/low_back_ppm.pdf
(7) Senturk, E., Sahin, E., & Serter, S. (2017). Prolotherapy: an effective therapy for Tietze syndrome. Journal of back and musculoskeletal rehabilitation, 30(5), 975-978. Available online at https://www.pubfacts.com/detail/28505950/Prolotherapy-An-effective-therapy-for-Tietze-syndrome
(8) Jones, G. E., & Evans, P. A. (1980). Treatment of Tietze’s syndrome pain through paced respiration. Biofeedback and Self-regulation, 5(2), 295-303. Available online at https://www.researchgate.net/publication/15802382_Treatment_of_Tietze’s_syndrome_pain_through_paced_respiration