Inflammatory Causes and Management of Rib Pain

Epidemiology

• Costochondritis accounts for approximately 42 % of all non‑traumatic chest‑wall pain cases, making it the most common inflammatory source of rib pain. 1
• In patients with axial spondyloarthritis, anterior chest‑wall pain is reported in 30–60 %, and involvement of the sternoclavicular or manubriosternal joints occurs in up to 50 % of these cases. 2

Pathophysiology

• Costochondritis is inflammation of the costochondral junctions where the ribs meet cartilage. 1
• Various arthritic diseases—including rheumatoid arthritis and osteoarthritis—can involve the costovertebral and costochondral joints, producing rib‑wall pain. 3

Clinical Diagnosis (Patients < 35 years, No Cardiac Risk)

• Diagnosis relies on objective, reproducible tenderness on palpation of the costochondral junctions; typical presentations do not require imaging. 1

Imaging and Further Evaluation (Patients ≥ 35 years or With Cardiac Risk)

• When infection or neoplasm is suspected, a chest radiograph should be obtained, recognizing that it is insensitive for cartilage abnormalities. 3

Risk Factors for Infectious Costochondritis

• Immunosuppression markedly increases the risk for infectious costochondritis, which may necessitate advanced imaging (CT/MRI) and possible surgical intervention. 2

Imaging and Diagnostic Strategies for Costochondritis

Advanced Imaging Modalities

• Computed tomography (CT) of the chest is recommended as the preferred imaging technique to assess the full extent of costochondral disease, characterize deep‑space involvement, and identify osseous changes such as cortical erosion or gas formation that may indicate serious infection. – American College of Radiology recommendation (Level III evidence) 4

Bone Scintigraphy Utility

• Bone scintigraphy should be considered when plain radiographs and CT scans are nondiagnostic, especially for screening the entire skeleton for occult inflammatory or infectious lesions; it demonstrates approximately 100 % sensitivity for detecting sternoclavicular joint inflammation. – American College of Radiology recommendation (Level II evidence) 4

Association with SAPHO Syndrome

• SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis) frequently involves the sternoclavicular region and presents with anterior chest‑wall pain that corresponds to increased radiotracer uptake on bone scintigraphy, aiding in differentiation from isolated costochondritis. – American College of Radiology recommendation (Level II evidence) 4