Tietze syndrome

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Not to be confused with Tietz syndrome.
Tietze syndrome
nerve blocks, surgical intervention

Tietze syndrome is a benign

true ribs
and has a predilection for the 2nd and 3rd ribs, commonly affecting only a single joint.

In environments such as the emergency department, an estimated 20-50% of non-cardiac chest pain is due to a musculoskeletal cause.

cardiopulmonary conditions due to similar presentation. Though Tietze syndrome can be misdiagnosed, life-threatening conditions with similar symptoms such as myocardial infarction
(heart attack) should be ruled out prior to diagnosis of other conditions.

Tietze syndrome is often confused with costochondritis. Tietze syndrome is differentiated from costochondritis by swelling of the costal cartilages, which does not appear in costochondritis. Additionally, costochondritis affects the 2nd to 5th ribs while Tietze syndrome typically affects the 2nd or 3rd rib.

Presentation

Tietze syndrome typically presents unilaterally at a single joint of the anterior chest wall, with 70% of patients having tenderness and swelling on only one side, usually at the 2nd or 3rd rib.[2][3] Research has described the condition to be both sudden[4] and gradual, varying by the individual.[5][6] Pain and swelling from Tietze syndrome are typically chronic and intermittent and can last from a few days to several weeks.[6]

The most common symptom of Tietze syndrome is pain, primarily in the

shoulder and arm.[2][6] The pain has been described as aching, gripping, neuralgic, sharp, dull, and even described as "gas pains".[3] The symptoms of Tietze syndrome have been reported to be exacerbated by sneezing, coughing, deep inhalation, and overall physical exertion.[5][7] Tenderness and swelling of the affected joint are important symptoms of Tietze syndrome and differentiate the condition from costochondritis.[8][9] It has also been suggested that discomfort can be further aggravated due to restricted shoulder and chest movement.[10]

Cause

The true

rheumatoid factor, though the evidence is conflicting.[15] Many theories such as malnutrition,[17][18] chest trauma,[10] and tuberculosis,[17] were thought to be among the potential causes but have since been disproven or left unsupported.[4][12][14]

Diagnosis

electrocardiogram and a physical examination showing reproducible chest wall tenderness, .[1][6] After eliminating other possible conditions, physical examination is considered the most accurate tool in diagnosing Tietze syndrome. Physical examination consists of gentle pressure to the chest wall with a single finger to identify the location of the discomfort.[2] Swelling and tenderness upon palpation at one or more of the costochondral, sternocostal, or sternoclavicular joints, is a distinctive trait of Tietze syndrome and is considered a positive diagnosis when found.[2][3]

There are some

computed tomography (CT),[21] magnetic resonance imaging (MRI),[22] bone scintigraphy,[23] and ultrasound,[24] though these are only case studies and the methods described have yet to be thoroughly investigated.[22] Methods such as plain radiographs, better known as an x-ray, are helpful in the exclusion of other conditions, but not in the diagnosis of Tietze syndrome.[6][8] Some researchers believe that ultrasound is superior to other available imaging methods, as it can visualize the increased volume, swelling, and structural changes of the costal cartilage.[2][8]

Differential diagnosis

The symptoms of Tietze syndrome can display as a wide variety of conditions, making it difficult to diagnose, especially to physicians unaware of the condition.

angina pectoris, and neoplasms.[6][8][10]

Costochondritis is most commonly confused with Tietze syndrome, as they have similar symptoms and can both affect the costochondral and sternocostal joints. Costochondritis is considered a more common condition and is not associated with any swelling to the affected joints, which is the defining distinction between the two.[2][5] Tietze syndrome commonly affects the 2nd or 3rd rib and typically occurs among a younger age group,[2] while costochondritis affects the 2nd to 5th ribs and has been found to occur in older individuals, usually over the age of 40. In addition, ultrasound can diagnose Tietze syndrome, whereas costochondritis relies heavily on physical examination and medical history.[8]

Another condition that can be confused for Tietze syndrome and costochondritis is

false ribs (8th to 10th). SRS is characterized by the partial dislocation, or subluxation, of the joints between the costal cartilages.[26] This causes inflammation, irritated intercostal nerves, and straining of the intercostal muscles. SRS can cause abdominal and back pain, which costochondritis does not.[27] Tietze syndrome and SRS can both present with radiating pain to the shoulder and arm, and both conditions can be diagnosed with ultrasound, though SRS requires a more complex dynamic ultrasound.[28]

The vast differential diagnosis also includes:

Treatment

Tietze syndrome is considered to be a

acetaminophen (paracetamol), and naproxen.[29] Other methods of management include manual therapy and local heat application.[1][14]
These are intended to relieve pain and are not expected to treat or cure Tietze syndrome as the condition is expected to resolve on its own.

Intercostal nerve block

A

nerve-blocking injection that consists of a combination of steroids such as hydrocortisone, and anesthetics such as lidocaine and procaine, which is typically administered under ultrasound guidance.[6][8] One study used a combination of triamcinolone hexacetonide and 2% lidocaine in 9 patients and after a week, found an average 82% decrease in size of the affected costal cartilage when assessing with ultrasound as well as a significant improvement of symptoms clinically.[24] However, the long-term effectiveness of the injection is disputed, with multiple researchers describing recurrence of symptoms and repetitive injections.[6][29]

Surgical intervention

In

conservative treatment options, surgery is considered.[2][3] Surgery is uncommon for cases of Tietze syndrome, as many describe Tietze syndrome as manageable under less invasive options.[10] The use of surgery in this context refers to the resection of the affected costal cartilages and some of the surrounding areas.[2] Some surgeons have resected cartilage matching the symptoms of Tietze syndrome under the assumption the cartilage was tubercular.[4] One study describes a case in which surgeons resected a large amount of cartilage, including minutely hypertrophied tissue, as a previous resection failed to relieve symptoms which is believed to be due to improperly resected margins.[29] There is limited literature on surgical treatment of this disease,[30] and overall research on the treatment of severe, chronic forms of Tietze syndrome.[29]

History

Tietze syndrome was named after and first described in 1921 by German surgeon Alexander Tietze.[17] Tietze first cited 4 cases in Germany of painful swelling where he originally believed the condition was as a result of tuberculosis or wartime malnutrition.[18]

References

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  2. ^
    PMID 30310397
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  3. ^
    PMID 13372573
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  4. ^
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  5. ^
    PMID 20380955
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  6. ^
    doi:10.1002/art.1780050306
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  7. PMID 13340574
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  8. ^
    PMID 29025153
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  9. ^
    PMID 3285453
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  10. ^
    S2CID 7942778
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  11. ^
    PMID 14413814
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  12. ^
    PMID 13044558
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  13. ^
    S2CID 216159576
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  14. ^
    PMID 13221462
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  15. ^
    S2CID 13298760
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  16. ^
    PMID 17921807
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  17. ^ a b c Tietze A (1921). "Über eine eigenartige Häufung von Fällen mit Dystrophie der Rippenknorpel" [About a strange accumulation of cases with dystrophy of the costal cartilage]. Berliner klinische Wochenschrift (in German). 58: 829–31.
  18. ^
    PMID 13570735
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  19. S2CID 40467215
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  20. PMID 4141710
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  21. S2CID 7068641
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  22. ^
    PMID 19032818
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  23. PMID 10365077
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  24. ^
    PMID 9189056
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  25. S2CID 54554663
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  26. PMID 27245407
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  27. S2CID 51920821
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  28. S2CID 57448080
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  29. ^
    PMID 29153814
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  30. PMID 13826637
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External links

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