This 32 year old recreational player presented with right sided chest wall pain. He thought that this might have been related to training in the gym however he could not recall any definitive precipitant. The pain was quite diffuse and was felt from the axilla to the anterior chest wall. The pain was mechanical in nature (made worse by activity but improved by rest). He was otherwise healthy.
The only clinical examination finding of note was of localised tenderness about the sternocostal region on the right.
An x-ray series of the chest wall was normal. Given the diffuse nature of the player’s pain a SPECT, rather than an MRI scan, was arranged. Focal uptake is seen at the right anterior costochondral margin involving the anterior fourth rib. There is no discrete bony abnormality seen in this region on the corresponding CT images. These appearances suggest Tietze’s syndrome. There is normal rib uptake seen elsewhere and no other significant radiological abnormality.
A working diagnosis was made of Tietze’s syndrome based on clinical findings, these radiological findings and a mildly elevated CRP. Other blood markers were normal. After discussion about the treatment options this player declined a steroid injection and opted to manage his problem with NSAID and local treatments. His symptoms improved significantly over a three-month period.
Tietze’s syndrome is a benign, self-limiting disorder that usually involves either the sternocostal, sternoclavicular or costochondral joints. The 2nd and 3rd costochondral joints are the most common sites. In the majority of cases it is unilateral, with only one joint being affected. Most of the reported cases are associated with either unaccustomed exercise, excessive coughing or vomiting or a direct blow to the affected area. On examination there is frequently evidence of local inflammation and localised tenderness over the affected joint. Imaging studies such as ultrasound, scintigraphy or MRI can be used the confirm the presence of joint swelling and can exclude other conditions. Costochondritis presents with similar symptoms. In contrast to Tietze’s syndrome this condition generally involves multiple joints (usually the 2nd to 5th costochondral joints) and is less likely to be associated with local inflammation and swelling.
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