Arthritis of the ribs

Symptoms and Signs of Costochondritis

Costochondritis Causes

Costochondritis is an inflammatory process. Nevertheless, it usually has no definite cause. Repeated minor trauma to the chest wall or viral respiratory infections can cause costochondritis. Occasionally, costochondritis as a result of bacterial infections can occur in people who use recreational IV drugs or who have had surgery to their upper chest. Costochondritis can also be a feature of relapsing polychondritis, reactive arthritis, fibromyalgia, and injury.

Different types of infectious diseases can cause costochondritis, although this is uncommon.

  • Viral: Costochondritis commonly occurs with viral respiratory infections because of the inflammation of costochondral junctions from the viral infection itself or from the strain of coughing.
  • Bacterial: Costochondritis may occur after surgery and be caused by bacterial infections.
  • Fungal: Fungal infections are rare causes of costochondritis.

Costochondritis can also occur with certain forms of arthritis, such as ankylosing spondylitis and psoriatic arthritis, and is sometimes associated with breastbone pain (sternum pain) in these conditions. Costochondritis can occur in people with fibromyalgia.

Costochondritis

This material must not be used for commercial purposes, or in any hospital or medical facility. Failure to comply may result in legal action.

Medically reviewed by Drugs.com. Last updated on Sep 24, 2019.

  • Disease Reference
  • Care Notes
  • Medication List
  • Q & A

What is costochondritis?

Costochondritis is a condition that causes pain in the cartilage that connect your ribs to your sternum (breastbone). Cartilage is the tough, bendable tissue that protects your bones.

What causes costochondritis?

The cause of costochondritis may be unknown, or it may be caused by any of the following:

  • Chest injury: An injury to your chest may cause costochondritis.
  • Strain: Activities that strain your chest wall muscles can lead to costochondritis. This includes hard coughing. Strain can also occur while you are playing sports with repeated arm movements, such as rowing, weightlifting, and volleyball.
  • Infection: Lung or chest infections can increase your risk of costochondritis.
  • Inflammatory diseases: Diseases that cause swelling around your joints, such as rheumatoid arthritis, increase your risk of costochondritis.

What are the signs and symptoms of costochondritis?

Costochondritis causes pain in the area where your sternum joins with your ribs. The pain may come and go, and may get worse over time. The pain may be sharp, or dull and aching. It may be painful to touch your chest. The pain may spread to your back, abdomen, or down your arm. It may get worse when you move, breathe deeply, or push or lift an object. The pain may make it hard for you to sleep or do your usual activities.

How is costochondritis diagnosed?

Your healthcare provider will ask you about your signs and symptoms. He will also do a physical exam. He will touch your chest and may move your arms to see if this causes pain.

How is costochondritis treated?

Costochondritis pain may go away without treatment, usually within a year. Your treatment depends on the cause of your costochondritis. You may need any of the following:

  • Acetaminophen: This medicine decreases pain. Acetaminophen is available without a doctor’s order. Ask how much to take and how often to take it. Follow directions. Acetaminophen can cause liver damage if not taken correctly.
  • NSAIDs , such as ibuprofen, help decrease swelling, pain, and fever. This medicine is available with or without a doctor’s order. NSAIDs can cause stomach bleeding or kidney problems in certain people. If you take blood thinner medicine, always ask if NSAIDs are safe for you. Always read the medicine label and follow directions. Do not give these medicines to children under 6 months of age without direction from your child’s healthcare provider.

What can I do to help decrease the pain caused by costochondritis?

  • Rest: You may need to rest and avoid painful movements and activities. Do not carry objects, such as a purse or backpack, if this causes pain. Avoid activities such as weightlifting until your pain decreases or goes away. Ask your healthcare provider which activities are best for you to do while you recover.
  • Heat: Heat helps decrease pain in some patients. Apply heat on the area for 20 to 30 minutes every 2 hours for as many days as directed.
  • Ice: Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a towel and place it on the painful area for 15 to 20 minutes every hour or as directed.
  • Stretching exercises: Gentle stretching may help your symptoms. Stand in a doorway and put your hands on the door frame at the level of your ears or shoulders. Take 1 step forward and gently stretch your chest. Try this with your hands higher up on the doorway.

When should I contact my healthcare provider?

  • You have a fever.
  • The painful areas of your chest look swollen, red, and feel warm to the touch.
  • You cannot sleep because of the pain.
  • You have questions or concerns about your condition or care.

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your healthcare providers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

© Copyright IBM Corporation 2019 Information is for End User’s use only and may not be sold, redistributed or otherwise used for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or IBM Watson Health

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Medical Disclaimer

Learn more about Costochondritis

Associated drugs

  • Costochondritis

IBM Watson Micromedex

  • Chest Pain
  • Chest Wall Pain
  • Chest Wall Pain in Children
  • Noncardiac Chest Pain
  • Osteopenia

Mayo Clinic Reference

  • Costochondritis

What causes pain in the sternum?

Share on PinterestThe sternum is located at the front of the chest and is connected to the ribs.

Sternum pain is usually caused by problems with the muscles and bones near the sternum and not the sternum itself.

Pain felt just behind or below the sternum is called substernal pain and is sometimes caused by gastrointestinal problems.

Some of the most common causes of sternum and substernal pain are:

  • costochondritis
  • collarbone injuries
  • sternoclavicular joint injury
  • hernia
  • sternum fracture
  • acid reflux
  • muscular strain or bruise

Costochondritis is the most common cause of sternum pain and occurs when the cartilage between the sternum and ribs becomes inflamed and irritated.

Costochondritis can sometimes occur as the result of osteoarthritis but may also happen for no apparent reason.

The symptoms of costochondritis include:

  • sharp pain on the side of the sternum area
  • pain that worsens with a deep breath or a cough
  • discomfort in the ribs

Costochondritis is usually not a cause for concern. However, people experiencing symptoms of costochondritis may want to consult a doctor if their symptoms worsen or do not go away.

Sternoclavicular joint injury

The sternoclavicular joint connects the top of the sternum to the collarbone. Injuries to this joint generally cause pain and discomfort at the top of the sternum in the upper chest area.

People experiencing sternum pain due to a sternoclavicular joint injury will often experience the following:

  • mild pain or swelling in the upper chest area
  • difficulty or pain when moving the shoulder
  • popping or clicking around the joint

Collarbone injuries

Share on PinterestCollarbone injuries may lead to long-lasting pain or limited movement in the shoulder and upper chest.

While the collarbone itself is not part of the sternum, it is connected to the sternum by cartilage. Injuries to the collarbone may cause pain in the sternum area.

Collarbone injuries are often the result of trauma, such as a car accident or sports injury, although infections or arthritis can also cause them.

Symptoms of a collarbone injury include:

  • severe pain when raising the arm
  • bruising or swelling in the upper chest area
  • abnormal positioning or sagging of the shoulder
  • clicking and grinding in the shoulder joint

Hernia

Hernias may not be an obvious cause of pain near the chest. However, a hiatal hernia may cause substernal pain.

A hiatal hernia happens when the stomach moves out of its normal position up past the diaphragm and into the chest. Symptoms of a hiatal hernia include:

  • frequent burping
  • heartburn
  • vomiting blood
  • a feeling of fullness
  • trouble swallowing

People with substernal pain and symptoms of a hiatal hernia should see a doctor for prompt treatment.

Sternum fracture

Like a fracture in other parts of the body, sternum fractures can cause a lot of pain. Sternum fractures usually occur as a direct result of trauma, such as a car accident or sports injury.

People who believe they may have a sternum fracture should seek immediate medical attention, as the heart and lungs may also be injured.

Symptoms of a sternum fracture include:

  • pain during inhaling or coughing
  • swelling over the sternum
  • difficulty breathing

Acid reflux or GERD

Acid reflux happens when stomach acid wears away the lining of the windpipe (esophagus). This happens primarily in people with gastroesophageal reflux disease (GERD).

Acid reflux may cause substernal pain and discomfort in the chest and is generally accompanied by a burning feeling.

Pain in this region can also be caused by inflammation or a spasm of the windpipe. People with GERD should talk to their doctor about how to prevent further damage to this area.

Muscular strain or bruise

The sternum and ribs have many muscles attached to them. These muscles can be pulled or strained by severe coughing or strenuous activity involving the arms or torso.

Injuries or trauma can result in bruising to these muscles, which may cause them to ache.

What Is Costochondritis? The Alarming Arthritis Chest Pain You Might Not Know About

If you’re like me, you probably won’t have heard of costochondritis until you or someone you know is diagnosed with it. I speak from experience because costochondritis, an inflammation of the segments of cartilage — called costosternal joints — that connect the ribs to the breastbone, wasn’t even on my radar when I went to the emergency room late one recent night with pain and tightness in my chest.

Turns out I’m far from the first person with costochondritis to show up in the ER thinking they might be having a heart attack. According to one study, 30 percent of patients who went to the ER with chest pain had costochondritis.

Costochondritis and Arthritis: What’s the Link?

Costochondritis is not as common as inflammation in the joints of the hands, elbows, knees, or feet, but if you have inflammatory arthritis like rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis, you may also be more likely to get costochondritis.

“When you have a condition that predisposes you to inflammation over multiple joints, you have increased susceptibility to developing it,” says Vinicius Domingues, MD, a rheumatologist in Daytona Beach, Florida, and medical advisor for CreakyJoints.

Though costochondritis can happen at any age, it is more common in people over 40 and, like inflammatory arthritis, it affects women more than men — 70 percent versus 30 percent.

Symptoms of Costochondritis

The most common symptom of costochondritis is pain and tenderness in the chest that’s typically described as sharp, aching, or pressure-like.

The ribs and breastbone connect in seven different places and pain can occur at any of them or even at more than one location. Costochondritis often occurs on just one side and frequently on the left side, which is why it’s often mistaken as a symptom of a heart attack.

One tipoff that it’s not a cardiac event is that your chest is painful to the touch (something that doesn’t happen when you’re having a heart attack). My doctor diagnosed my costochondritis by pressing on my chest, which hurt like hell.

Other clues it’s costochondritis: Pain is often exacerbated by upper body movement and deep breathing, even if it’s just reaching up into a high cupboard or blow-drying your hair (yes, again, I speak from experience). Moving the arm on the affected side will usually also cause pain.

But remember: Any time you experience chest pain, you should seek medical attention. Don’t attempt to assess for yourself whether or not you may be having costochondritis, a heart attack, or something else.

Causes of Costochondritis

If you live with a form of inflammatory arthritis, that may be all it takes for the costochondral joint to become inflamed. Other reasons for costochondritis include:

  • Strain from coughing
  • Injury to your chest
  • Infections, including respiratory tract infections or post-op infections
  • Physical strain from repeated exercise or sudden exertion

According to my doctor it doesn’t take much to develop costochondritis from exertion. Because I developed costochondritis around the holidays, she asked if I’d recently lifted a turkey. I traced it to a vigorous workout on the elliptical machine followed the next day by some strenuous yardwork.

Treatment for Costochondritis

The pain from costochondritis often goes away on its own in a few days or weeks, but it can also take up to a few months or longer. It’s unusual for costochondritis to become chronic, says Dr. Domingues.

Treatment includes rest, ice or moist heat (if you can stand the cold, Dr. Domingues suggests alternating each for 20 minutes a few times a day), and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, and aspirin. Here are answers to common patient questions about taking NSAIDs.

Of course, refrain from any physical activity that makes the pain worse. I found the pain from costochondritis to be exhausting so I laid quietly in bed on my stomach as much as possible (laying on my back seemed to exacerbate the pain). It took about a week for my pain to go away completely. If yours persists, physical therapy and/or steroid injections can help. The good news: By all accounts, these remedies are rarely necessary.

Track Your Arthritis Symptoms

Use our ArthritisPower app to track your symptoms and disease activity and share your results with your doctor. Learn more and sign up here.

Keep Reading

  • Back Pain in Rheumatoid Arthritis: What Causes It, and How to Treat It
  • How Inflammatory Arthritis Affects Your Lungs
  • 11 Ways to Describe Arthritis So Other People Get What It Really Feels Like

Conditions Related to Inflammatory Arthritis

There are many conditions related to inflammatory arthritis. Some conditions exhibit symptoms similar to those of inflammatory arthritis, some are autoimmune disorders that can result from inflammatory arthritis, and some occur in conjunction with inflammatory arthritis.

  • Adhesive capsulitis – also known as “frozen shoulder,” the connective tissue surrounding the joint becomes stiff and inflamed causing extreme pain and greatly restricting movement.
  • Adult onset Still’s disease – a form of arthritis characterized by high spiking fevers and a salmon-colored rash. Still’s disease is more common in children.
  • Caplan’s syndrome – an inflammation and scarring of the lungs in people with rheumatoid arthritis who have exposure to coal dust, as in a mine.
  • Carpal tunnel syndrome – a painful progressive condition caused by compression of the median nerve in the wrist. People with rheumatoid arthritis are at increased risk of developing carpal tunnel syndrome.
  • Watch: Carpal Tunnel Syndrome Video

  • Celiac disease – an autoimmune disorder of the small intestine that causes malabsorption of nutrients and can eventually cause osteopenia or osteoporosis.
  • See How Gluten Can Cause Joint Pain

    advertisement

  • Chronic recurrent multifocal osteomyelitis – a rare childhood disease involving swelling of bones of the arms, legs, and collarbone. It is an inherited auto-inflammatory disorder that may also be considered an autoimmune disease.
  • Chronic synovitis – a general term describing diseases involving joint inflammation in children.
  • Complex regional pain syndrome – a chronic progressive disease characterized by severe pain and swelling. While it can cause osteoporosis, the condition is also believed to have an immunological component.
  • Costosternal syndrome – a painful inflammation of the intercostal cartilage connecting the ribs to the sternum. Sometimes referred to as Costochondritis or Tietze syndrome (if accompanied by swelling).
  • Cryoglobulinemia – the presence of abnormal protein molecules in the blood causing circulation problems to the extremities, especially at low temperatures.

In This Article:

  • Types of Arthritis
  • Degenerative Arthritis
  • Conditions Related to Degenerative Arthritis
  • Inflammatory Arthritis
  • Conditions Related to Inflammatory Arthritis
  • Dermatomyositis – a connective tissue disease characterized by inflammation of the muscles and the skin. The condition is believed to be caused either by viral infection or an autoimmune reaction.
  • Diabetic finger sclerosis – a complication of diabetes, causing a hardening of the skin and connective tissue in the fingers, thus causing stiffness.
  • Duchenne muscular dystrophy – one of the most prevalent types of muscular dystrophy, characterized by rapid muscle degeneration.
  • Dupuytren’s contracture – an abnormal thickening of tissues in the palm and fingers that can cause the fingers to curl.
  • Eosinophilic fasciitis (Shulman’s syndrome) – a condition in which the muscle tissue underneath the skin becomes swollen and thick. People with eosinophilic fasciitis have a build up of eosinophils—a type of white blood cell—in the affected tissue. Some patients also develop arthritis.
  • Familial Mediterranean fever – an inherited auto inflammatory disorder characterized by recurrent episodes of fever and inflammation of the abdominal membrane.
  • Felty syndrome – a form of RA with fever and many other symptoms including weight loss, recurrent infections, peripheral neuropathy, and carpal tunnel syndrome, among others.
  • Fibromyalgia – a widespread musculoskeletal pain and fatigue disorder. Twenty to thirty percent of patients with RA and systemic lupus erythematosus may also have fibromyalgia.
  • See Fibromyalgia or Not? 6 Conditions to Know

  • Giant cell/Temporal arteritis – a condition involving swelling of the arteries in the head, neck, and arms, reducing blood flow. This condition often accompanies polymyalgia rheumatica.
  • Goodpasture’s syndrome – a disease in which the immune system makes antibodies targeted to attack the lungs and kidneys.
  • Hemochromatosis –an inherited disorder that causes the body to absorb and store excessive amounts of iron. Arthritis can result from the build up of iron.
  • Hypertrophic osteoarthopathy – a syndrome causing clubbing of the fingers and toes, enlargement of the extremities, and painful swollen joints. The condition is caused secondary to lung disease or bacterial infection.
  • Immune complex disease – a condition characterized by the formation of immune complexes—clusters of interlocking antigens and antibodies. In some cases, they become trapped in the tissues of the body setting off reactions that cause inflammation and tissue damage.
  • Inflammatory Bowel Disease (including ulcerative colitis and Crohn’s) – a group of inflammatory conditions of the colon and small intestine. Arthritis is a common complaint of people with IBD.
  • Juvenile rheumatoid arthritis – arthritis that causes joint inflammation and stiffness in a child of 16 years of age or less. Any joint can be affected, and inflammation may greatly limit mobility.
  • Jaccoud’s arthropathy – a joint disease that occurs after rheumatic fever, often in the hands and feet. The condition can also occur alongside rheumatoid arthritis or lupus.
  • Kawasaki disease – a disease affecting the lymph nodes of the immune system and other parts of the body, with the greatest affect on the blood vessels.
  • Löfgren’s syndrome – the association of swollen lymph tissue and small, painful, red nodules under the skin with joint pain.
  • Malignant synovioma – a cancerous tumor that develops in tendon and joint tissues.
  • Mixed connective tissue disease (MCTD) – overlapping connective tissue disorders—including systemic lupus erythematosus, polymyositis, and scleroderma—that cannot be diagnosed more specifically. There are often arthritic manifestations of these disorders.
  • Multicentric reticulohistiocytosis – a rare systemic disease in which cells grow out of control and are destructive to joint and skin tissues.
  • Nodular panniculitis (Weber-Christian disease) – a skin condition featuring recurring inflammation of the fat layer of the skin. Fatigue, fever, and joint pain frequently occur.
  • Overlap syndrome – a term used to describe when sclerosis (thickening or hardening of tissues) appears in association with features of other connective tissues diseases including systemic lupus erythematosus, polymyositis, or dermatomyositis.
  • Palindromic rheumatism – a rare type of inflammatory arthritis characterized by recurrent attacks of painful swelling of the joints and surrounding tissues.
  • Polychondritis – a chronic disorder of the cartilage characterized by recurrent episodes of inflammation, believed to be caused by an immune system disorder. Commonly affected sites include the ears, nose, joints, spine, and trachea.
  • Polymyalgia rheumatica – a rheumatic disorder associated with moderate to severe muscle pain and stiffness, most commonly in the neck, shoulders, and hips. Patients often experience fatigue, mild fever, and an overall feeling of illness.
  • Polymyositis – a disease of the muscle featuring inflammation of the muscle fibers. Though the cause of the disease is unknown, it begins when immune cells spontaneously invade seemingly healthy muscles.
  • Raynaud’s phenomenon – a condition resulting from poor circulation in the extremities. It occurs secondary to many inflammatory connective tissue diseases.
  • Restless leg syndrome (RLS) – the irresistible urge to move the body to stop uncomfortable sensations. RLS is often associated with autoimmune disorders such as Sjögren’s syndrome, celiac disease, and rheumatoid arthritis.
  • Sarcoidosis – a disease causing inflammation of the body’s tissues along with small bumps called nodules or granulomas.
  • Scleroderma – a group of diseases involving the abnormal growth of connective tissue supporting the skin and internal organs. Hardened skin can cause pain and stiffness in the joints.
    • CREST syndrome
    • Linear scleroderma
  • Seronegative arthritis – inflammatory arthritis in which antibodies usually present are missing from the blood, making it difficult to diagnose a specific rheumatic condition like rheumatoid arthritis or lupus. Once time has passed and other diagnoses can be ruled out, this condition is typically diagnosed as rheumatoid arthritis.

advertisement

  • Sweet’s syndrome – a skin disease characterized by sudden fever, painful, scaly patches of skin, and an increase in white blood cells. Symptoms often include headache and joint pain.
  • Sjögren’s syndrome – an autoimmune disease characterized by excessive production of antibodies directed to attack tissues throughout the body. It often occurs along with rheumatoid arthritis.
  • Tarsal tunnel syndrome – an entrapment of the tibial nerve running the length of the leg to the inside of the ankle. Pressure placed on the tendon, such as inflammation or swelling from RA, puts patients at increased risk for this problem.
  • Traumatic arthritis – joint disease resulting from direct or indirect injury to the joint. During the healing process, bones and other structures may grow abnormally causing friction and damage in the joint space.
  • Undifferentiated connective tissue disease – a term used to describe patients who exhibit features strongly suggestive of connective tissue disease, but unable to be diagnosed as a specific disorder.

Costochondritis and Rheumatoid Arthritis: What You Need to Know

Costochondritis is caused by inflammation of the cartilage that connects your breastbone, also known as your sternum, to your ribs. The pain associated with this condition can closely mimic a heart attack or other cardiac problems, but a report published in January 2017 in the German journal Der Internist suggests that as many as 50 percent of all chest pains are caused by musculoskeletal disorders.

Common Causes of Costochondritis

There are rubbery segments of cartilage — called costosternal joints — that attach the ribs to the breastbone, and chest pain can occur when the cartilage in those joints gets inflamed. “Costochondritis is typically a result of some sort of mechanical stress, like you coughed too hard or you reached too far and pulled something,” says Harry L. Gewanter, MD, a pediatric rheumatologist in Richmond, Virginia. For example, chest pain symptoms could occur after you physically strain yourself moving furniture. While these symptoms can be extremely painful, the condition is not life-threatening.

RELATED: Don’t miss these lifestyle tips from people who have RA. Find answers on Tippi.

Costochondritis Symptoms Can Be Scary

The hallmark symptom of costochondritis is pain in the chest wall of varying intensity, and it tends to be described as “sharp,” “aching,” or “pressure-like,” according to research published in September 2009 in the journal American Family Physician. The pain can become even worse with upper body movement or by breathing deeply, since it involves joints that flex when you inhale. Although the second to fifth costochondral joints of the ribs are most frequently affected — and especially ribs three and four — it can impact any of the seven rib junctions. Pain can take place in multiple sites, but it’s most frequently unilateral, which means it takes place on only one side of the body. “It can feel like someone stuck a knife in you, and it can take your breath away,” says Dr. Gewanter.

Naturally, intense symptoms can be scary, as Kelly Young describes in her blog, Rheumatoid Arthritis Warrior. This is especially the case if you don’t understand the cause or haven’t experienced it before. But there’s a good chance that the cause behind the pain isn’t serious.

Diagnosing Costochondritis

X-rays don’t show soft tissue well and there’s not a blood test for it, so costochondritis is typically diagnosed by a doctor through a physical exam. Older adults experiencing these symptoms may need to get an EKG to rule out the possibility of cardiac problems.

The Costochondritis–Rheumatoid Arthritis Connection

Costochondritis isn’t directly related to RA, but inflammation from RA can be a reason for damage to the rib cartilage. “Costochondritis also happens in people with rheumatic diseases because their joints aren’t working properly, so they can move the wrong way and tweak their bodies even further,” says Gewanter. “It’s a biomechanical issue, and it can become a house of cards.”

While the chest pain may be related to an inflammatory disease, such as rheumatoid arthritis or ankylosing spondylitis, it can also be partially caused by noninflammatory conditions, such as fibromyalgia.

It’s Not the Same as Tietze’s Syndrome

Costochondritis is often confused with Tietze’s syndrome, a similar but less common disorder that typically involves swelling of the second or third rib that can last for months. According to the American Family Physican review, Tietze’s syndrome typically affects people who are younger than 40, while costochondritis is more common in people older than that. Local swelling is typically present with Tietze’s, while it is not with costochondritis. Tietze’s syndrome can subside without treatment, but over-the-counter pain medication may be used.

How to Treat Costochondritis

Treatment typically takes the form of oral pain relievers — typically either Tylenol (acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil or Motrin (ibuprofen). The American Family Physician report notes that heating pads can help, as can minimizing activities that provoke your symptoms. Cough suppressants can also help reduce discomfort, and sometimes physical therapy is used to help diminish soreness. “But there really is no great way to treat it, outside of time,” says Gewanter. There’s also no real way of knowing how long the pain will last, and it can go away on its own without any treatment.

The Rib Lesions of Rheumatoid Arthritis

Although the synovial membrane is the most frequent site of the rheumatoid lesion, in recent years there has been considerable interest in the extra-articular and visceral manifestations of this generalized collagen disease. While the corneal complications (21) have been recognized since 1926 (19), there is now more evidence to implicate rheumatoid arthritis in lesions of the heart valves (4), pericardium (7), lung (11), and pleura (9). Because of their proximity to pannus formation, the articular ends of the tubular bones are the most frequent site of lytic changes. Extra-articular osseous alterations, however, have been demonstrated in the vertebral bodies (1), the pelvis (8), and the skull (16). In our experience the ribs may also be involved by rheumatoid arthritis in their extra-articular portions. Since these costal changes have not been adequately described in the literature, the findings in 8 cases demonstrating rheumatoid rib erosions will be presented.

Review of the Literature

The authors reviewed the medical literature from 1930 through 1962. In this period over 50 articles were published dealing with the roentgen manifestations of rheumatoid arthritis, but no author mentioned the erosions in the nonarticular portions of the ribs. Martel (12), however, did describe one patient with bone absorption at the “posterior ends of the ribs,” evidently at the costovertebral articulations. In addition, an article by Noetzli and Steinbach (13) on hyperparathyroidism referred to rib changes in rheumatoid arthritis, suggesting a possible relationship to steroid therapy. Neither article contained roentgenograms of the affected ribs.

Clinical Material

In the 8 patients with rib changes the average age was fifty-five years, with a range of thirty-six to sixty-nine. There were 5 women and 3 men. The average duration of arthritic symptoms was twenty years, with a minimum of fourteen and a maximum of thirty-two. None had complaints referable to the ribs. Their symptoms were due to peripheral joint involvement and consisted of pain, swelling, and stiffness. The physical findings included limitation of joint motion, flexion deformities, muscle atrophy, and ulnar deviation of the fingers. The erythrocyte sedimentation rate was elevated in all patients. A laboratory test for rheumatoid arthritis was carried out in 5 (sheep-cell agglutination or latex fixation) and was positive in all. Five of the 8 patients had received oral steroids at some time in the clinical course of their disease; 1 of the 5, however, had had only one month of corticoids. Two of the 8 patients had been given a limited number of intra-articular steroid injections. One patient had never received cortisone.

Roentgen Findings

In 7 of the 8 patients the rheumatoid rib lesions were visualized as either localized areas of flattening or erosions. The maximum length of the segmental flattening was 6 cm. The maximum length of the cup-like erosions was 9 mm., with a maximum depth of 4 mm. These changes were all confined to the superior borders of the posterior aspects of the third, fourth, and fifth ribs. The third rib was involved 11 times, the fourth rib 6 times, and the fifth rib twice. The lesions were bilateral in 7 of the 8 cases. The 1 patient (Case VIII) with unilateral lesions had involvement of both the third and fourth ribs. The most extensive costal lesions were seen in Case III. Here the posterior portion of the right third rib was destroyed almost completely for a distance of 6 cm. Three small lytic areas were also present in the left third and fourth ribs.

Differential Diagnosis

Segmental flattening of the superior aspect of a posterior rib (13) is occasionally observed as an anatomic variant, and this may mimic the rheumatoid lesion. A notch-like erosive change, however, has not been regarded as a normal finding.

About the author

Leave a Reply

Your email address will not be published. Required fields are marked *