Costosternal Joint Injection Technique for Tietze Syndrome

Indications and Clinical Considerations

A variety of other painful conditions affect the costosternal joints and occur with a much greater frequency than Tietze syndrome. The costosternal joints are susceptible to developing arthritis, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, and psoriatic arthritis. The joints often are traumatized during acceleration–deceleration injuries and blunt trauma to the chest. With severe trauma, the joints may sublux or dislocate. Overuse or misuse also can result in acute inflammation of the costosternal joint, which can be quite debilitating. The joints also are subject to invasion by tumor either from primary malignancies, including thymoma, or from metastatic disease.

Tietze syndrome is distinct from costosternal syndrome. First described in 1921, Tietze syndrome is characterized by acute painful swelling of the costal cartilages. The second and third costal cartilages are most commonly involved, and, in contradistinction to costosternal syndrome, which usually occurs no earlier than the fourth decade, Tietze syndrome is a disease of the second and third decades. The onset is acute and often associated with a concurrent viral respiratory tract infection ( Fig. 108.1 ). It has been postulated that microtrauma to the costosternal joints from severe coughing or heavy labor may be the cause of Tietze syndrome. Painful swelling of the second and third costochondral joints is the sine qua non of Tietze syndrome ( Fig. 108.2 ). Such swelling is absent in costosternal syndrome, which occurs much more frequently than Tietze syndrome.

Physical examination reveals that the patient with Tietze syndrome will vigorously attempt to splint the joints by keeping the shoulders stiffly in a neutral position. Pain is reproduced with active protraction or retraction of the shoulder, deep inspiration, and full elevation of the arm. Shrugging of the shoulder also may reproduce the pain. Coughing may be difficult, and this may lead to inadequate pulmonary toilet in patients with Tietze syndrome. The costosternal joints, especially the second and third, are swollen and exquisitely tender to palpation. The adjacent intercostal muscles also may be tender to palpation. The patient also may report a clicking sensation with movement of the joint.

Plain radiographs are indicated for all patients with pain thought to be emanating from the costosternal joints to rule out occult bony disease, including tumor. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, prostate-specific antigen, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging, computed tomography scanning, and/or ultrasound imaging of the joints is indicated if joint instability or an occult mass is suspected ( Figs. 108.3 and 108.4 ). The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The cartilage of the true ribs articulates with the sternum via the costosternal joints ( Fig. 108.5 ). The cartilage of the first rib articulates directly with the manubrium of the sternum and is a synarthrodial joint that allows a limited gliding movement. The cartilage of the second through sixth ribs articulates with the body of the sternum via true arthrodial joints. These joints are surrounded by a thin articular capsule. The costosternal joints are strengthened by ligaments but can be subluxed or dislocated by blunt trauma to the anterior chest. Posterior to the costosternal joint are the structures of the mediastinum. These structures are susceptible to needle-induced trauma if the needle is placed too deeply. The pleural space may be entered if the needle is placed too deeply and laterally, and pneumothorax may result.