Tietze syndrome is a disease from the group of chondropathies, accompanied by aseptic inflammation of one or more upper rib cartilages in the area of their articulation with the sternum. It is manifested by local soreness at the site of the lesion, which increases with pressure, palpation and deep breathing. As a rule, it occurs for no apparent reason, in some cases there may be a connection with physical exertion, operations in the chest area, etc. The diagnosis is made on the basis of complaints and examination data after excluding more serious pathologies using radiography, ultrasound, CT and other studies. Treatment is usually conservative: NSAIDs, blockades, physiotherapy.
M94.0 Cartilaginous rib joint syndrome [Tietze]
Tietze syndrome (rib-cartilage syndrome, rib chondritis) is an aseptic inflammation of one or more rib cartilages in the area of their junction with the sternum. Usually II-III, less often I and IV ribs suffer. As a rule, the process captures 1-2, less often – 3-4 edges. In 80% of cases, there is a unilateral lesion. The disease is accompanied by swelling and pain, sometimes radiating into the arm or chest. The causes of development are not fully understood. The treatment is conservative, the outcome is favorable.
The disease usually develops at the age of 20-40 years, although an earlier onset has been recorded – at the age of 12-14 years. According to most authors, men and women suffer equally often, but some researchers note that in adulthood, Tietze syndrome is more often detected in women.
Tietze syndrome causes
Although the causes of Tietze syndrome are not fully understood at the moment, there are several theories explaining the mechanism of development of this disease. The most popular is the traumatic theory. Many patients suffering from Tietze syndrome are athletes, engage in heavy physical labor, suffer from acute or chronic diseases accompanied by severe coughing, or have a history of rib injury.
Proponents of this theory believe that due to direct trauma, permanent microtrauma or overload of the shoulder girdle, cartilage is damaged, micro-fractures occur at the border of the bone and cartilage parts. This causes irritation of the suprachondria, from the poorly differentiated cells of which a new cartilage tissue is formed, somewhat different from normal. Excessive cartilage tissue compresses nerve fibers and causes pain syndrome. Currently, the traumatic theory is the most recognized in the scientific world and has the most confirmations.
Infectious-allergic theory. Followers of this theory find a connection between the development of Tietze syndrome and acute respiratory diseases suffered shortly before that, which provoked a decrease in immunity. This theory may also be supported by the more frequent development of the disease in people suffering from drug addiction, as well as in patients who have recently undergone chest surgery.
Alimentary-dystrophic theory. It is assumed that degenerative cartilage disorders occur due to impaired metabolism of calcium, vitamins C and B. This hypothesis was expressed by Tietze himself, who first described this syndrome in 1921, but at present the theory belongs to the category of doubtful, since it is not confirmed by objective data.
Tietze syndrome symptoms
Patients complain of acute or gradually increasing pains that are localized in the upper parts of the chest, next to the sternum. The pain is usually one-sided, it increases with deep breathing, coughing, sneezing and movements, can be given to the shoulder, arm or chest on the side of the lesion. Sometimes the pain syndrome is short-term, however, it is more often permanent, long-lasting and worries the patient for years. At the same time, there is an alternation of exacerbations and remissions. The general condition does not suffer during the period of exacerbation. On examination, pronounced local soreness is determined by palpation and pressure. A dense, clear fusiform swelling of 3-4 cm in size is revealed.
The diagnosis of Tietze syndrome is made by a specialist in the field of traumatology and orthopedics on the basis of clinical data, after excluding other diseases that could cause chest pain. And one of the main symptoms confirming the diagnosis is the presence of a characteristic clear and dense swelling, which is not detected in any other disease.
In the course of differential diagnosis, acute trauma, diseases of the cardiovascular system and internal organs that could cause similar symptoms, including various infectious diseases and the already mentioned malignant neoplasms, are excluded. If necessary, the patient is referred for blood tests, MRI, CT, ultrasound and other studies.
During X-ray examination in dynamics, it is possible to detect indistinct changes in the structure of cartilage. At the initial stages, the pathology is not determined. After a while, thickening and premature calcification of cartilage becomes noticeable, the appearance of bone and calcareous lumps along its edges. After a few more weeks, small periosteal deposits appear on the anterior ends of the bony part of the affected ribs, which causes the rib to thicken slightly, and the intercostal space narrows. In the later stages, fusion of cartilaginous and bony segments of the ribs, deforming osteoarthritis of the costal-sternal joints and bone growths are detected.
Radiography in Tietze syndrome has no independent significance at the time of diagnosis, since the first changes in radiographs become noticeable only 2-3 months after the onset of the disease. However, this study plays an important role in excluding all kinds of malignant tumors, both primary and metastatic.
In doubtful cases, computed tomography is shown, which allows to detect changes characteristic of the Tietze syndrome at earlier stages. Also, in the course of differential diagnosis with malignant neoplasms, Tc and Ga scanning and puncture biopsy can be performed, in which degenerative changes of cartilage and the absence of tumor elements are determined.
Due to its wide prevalence in adult patients, possible cardiovascular diseases and, first of all, coronary heart disease cause particular alertness. IHD is characterized by short-term pain (on average, an angina attack lasts 10-15 minutes), while with Tietze syndrome, pain can persist for hours, days, and even weeks. Unlike the Tietze syndrome, in ischemic disease, the pain syndrome is stopped by drugs from the nitroglycerin group. For the final exclusion of cardiovascular pathology, a number of analyzes and instrumental studies (ECG, etc.) are performed.
Tietze syndrome also has to be differentiated from rheumatic diseases (fibrositis, spondyloarthritis, rheumatoid arthritis) and local lesions of the cartilage and sternum (osteochondritis and xyphidalgia). To exclude rheumatic diseases, a number of special tests are performed. Osteochondritis is indicated by the absence of hypertrophy of the costal cartilage, xiphoidalgia – pain in the xiphoid process of the sternum that increases with pressure.
In some cases, the Tietze syndrome in its clinical picture may resemble intercostal neuralgia (both diseases are characterized by prolonged pain, which increases with movements, sneezing, coughing and deep breathing). The less pronounced pain syndrome, the presence of dense swelling in the area of rib cartilage and the absence of a zone of numbness along the intercostal space indicate in favor of the Tietze syndrome. There are no changes in the biochemical composition of blood, general blood and urine tests in Tietze syndrome. Immune reactions are normal.
Tietze syndrome treatment
Treatment is carried out by orthopedic traumatologists. Patients are on outpatient observation, hospitalization, as a rule, is not required. Patients are prescribed topical treatment using ointments and gels containing nonsteroidal anti-inflammatory drugs. Compresses with dimexide are also used. With severe pain syndrome, NSAIDs and painkillers are prescribed for oral administration.
With persistent pain in combination with signs of inflammation that cannot be stopped by taking analgesics and nonsteroidal anti-inflammatory drugs, a good effect is provided by the introduction of novocaine with hydrocortisone and hyaluronidase into the affected area (blockade of the pectoral muscle). In addition, physiotherapy, reflexology and manual therapy are used.
Extremely rarely, with the persistent course of the disease and the ineffectiveness of conservative therapy, surgical treatment is required, which consists in subcostal rib resection. Surgical intervention is performed under general or local anesthesia in a hospital setting.
- Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil. 1992 Feb;73(2):147-9. link
- Rokicki W, Rokicki M, Rydel M. What do we know about Tietze’s syndrome? Kardiochir Torakochirurgia Pol. 2018 Sep;15(3):180-182. link
- Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002;32(4):235-50. – link
- Fam AG, Smythe HA. Musculoskeletal chest wall pain. CMAJ. 1985 Sep 01;133(5):379-89.
- Sawada K, Ihoriya H, Yamada T, Yumoto T, Tsukahara K, Osako T, Naito H, Nakao A. A patient presenting painful chest wall swelling: Tietze syndrome. World J Emerg Med. 2019;10(2):122-124.