Introduction

Tietze syndrome is a rare inflammatory condition causing pain and swelling in the cartilage of the rib cage. The pain can be sudden and significant but is usually not serious and self-limiting.

Given the clinical presentation of sudden chest pain, Tietze syndrome can mimic other more serious conditions such as those affecting the heart or lungs. Therefore, healthcare professionals play a very important role in its diagnosis. Tietze syndrome is diagnosed through a process of elimination, where life-threatening or more common diseases must be excluded in their clinical assessment and evaluation.¹ 

Background

What is Tietze syndrome?

Tietze syndrome is a relatively uncommon condition characterised by localised painful swelling in the cartilage and ribs at the front chest wall. The pain is typically restricted to the cartilage of the upper 10 ribs, where they connect to the breastbone, also known as the costochondral joints, and is described as a dull ache at rest, while a sharp and stabbing pain on movement.¹

It is a self-resolving, non-life threatening condition, where the exact cause remains unclear, but most commonly thought to be due to multiple micro-injuries to the chest wall. Treatment typically consists of pain relief, such as non-steroidal anti-inflammatory drugs. As its symptoms mimic other more serious conditions, people presenting with it require thorough medical evaluation and exclusion of other conditions during diagnosis.^2,3

Diagnosing Tietze syndrome

Given the non-specific symptoms, Tietze syndrome is diagnosed through the elimination of other similar, or more life-threatening conditions, such as musculoskeletal, heart, or lung conditions.

On physical examination, a clinician will typically feel a firm, tender swelling over the cartilage of the affected rib. Blood tests will not show any findings specific to Tietze Syndrome. Therefore, while there are no clear laboratory or clinical findings of Tietze syndrome, clinicians will typically perform imaging and blood tests to rule out other potential causes of the pain, and Tietze Syndrome will be diagnosed through this process of elimination.¹

Differential diagnoses of Tietze syndrome

Given the general presentation of sudden chest pain, a broad differential of conditions can resemble the presentation of Tietze Syndrome, which must be ruled out. These include heart, lung, infectious, cancerous or autoimmune diseases. A comprehensive clinical workup is frequently carried out, and once all other causes are eliminated, a diagnosis of Tietze Syndrome is given, and a person can be managed in primary care as an outpatient.¹

Musculoskeletal causes

Costochondritis

Tietze Syndrome is frequently misdiagnosed as costochondritis, a more common condition affecting people of all ages. Like Tietze Syndrome, people complain of sudden, sharp, aching pain at the front of the chest at the joints connecting the ribs to the breastbone.

Tietze’s Syndrome usually affects one rib while costochondritis involves multiple ribs, however there will be no visible swelling in costochondritis.^1,3,5,6 

Rib fractures

Bruised or broken ribs can cause pain in the chest area, particularly in movement, breathing or coughing. There will be associated swelling tenderness and bruising over the site of injury.

Fibromyalgia

A common chronic pain syndrome affecting the muscles and bones. It is widespread throughout the body, not limited to the front of the chest. People complain of tenderness throughout on tough, and general tiredness and difficulty sleeping.⁶ 

Heart causes

Acute Coronary Syndrome (ACS)

Acute coronary syndrome covers a range of serious conditions including heart attack and unstable angina, where there is reduced blood flow to the heart. A person will typically complain of aching or pressure on the chest that spreads to other parts of the body, including the shoulders, arms, and neck. Other symptoms could include nausea, shortness of breath, sweating or indigestion.

This is one of the key differentials a clinician must rule out when a person is presenting with chest pain. A person is more likely to be suffering from one of these if they have existing risk factors such as age, family history and lifestyle factors such as obesity, smoking, high blood pressure and diabetes.⁷ 

Pericarditis

This is an inflammation of the pericardium, a fluid sac lining which surrounds the heart, causing chest pain. The chest pain is usually stabbing and spreads to the shoulders or arms, feeling worse on breathing or lying on your left side. People usually feel better when they lean forward.

It is not usually a serious condition and usually follows a viral infection such as the flu, so is typically treated with painkillers and antibiotics depending on what is causing it.⁸

Aortic dissection

This is a life-threatening condition, where the aorta tears. The aorta is the main blood vessel that carries oxygenated blood away from your heart to the rest of your body. This will disrupt or completely stop blood flow to parts of the body. People complain of sudden, severe pain in the chest, upper back and belly, which is usually triggered by some form of heavy exertion, however, it can occur in any circumstance. Other symptoms include shortness of breath, fainting, dizziness, confusion, low blood pressure, sweating and even symptoms of stroke.

Aortic dissection requires immediate care, and if not treated promptly can lead to stroke, heart attack, damage to organs or even death.⁹

Lung causes

Pulmonary embolism

This is when a person has a blood clot which blocks a blood vessel in the lungs. Symptoms include sudden shortness of breath, pain when breathing in and may also cough up blood. There may also be pain, swelling and redness in one of the calves of the leg due to a blood clot in this location.

This is life-threatening if not treated quickly, and people will be given blood thinning medication to stop it from getting bigger and prevent new clots.¹⁰

Pneumothorax

A pneumothorax occurs when air leaks from outside the lung into the chest wall, leading to a collection of air in that space. The air applies pressure on the lung causing it to collapse. It can be caused by blunt chest injury, certain medical procedures or in people with underlying lung conditions.

People complain of sudden chest pain with shortness of breath. Depending on the size of the collection of air, treatment can include inserting a tube to remove it, or it can heal on its own.¹¹ 

Pleurisy

This is inflammation of the lining surrounding the lungs, causing sharp chest pain when breathing in. Symptoms are usually worse on coughing or movement and may spread to the shoulders. It resolves spontaneously after a few days but usually requires some pain relief. It can be caused by a bacterial infection, in which case you may need antibiotics.¹²

Gastrointestinal causes

Gastroesophageal Reflux Disease (GERD)

A condition where acid from the stomach flows back up into the oesophagus, the tube which connects the stomach to the mouth. This is called acid reflux and can irritate the lining of the oesophagus causing a heartburn pain sensation in the chest. The pain is in the upper belly, usually worse when lying down, after eating or at night. People can also have trouble swallowing.¹³ 

Oesophageal spasm

These are painful contractions of the muscles of the oesophagus. People feel sudden squeezing chest pain, which can be minor or severe and can last minutes to hours. They may experience difficulty swallowing and feel an object stuck in the throat.¹⁴ 

Peptic ulcer disease

These are open sores in the lining of the stomach or small intestine, causing a burning painful sensation and indigestion that come and go, often after eating. People may also experience a loss of appetite, bloating, excessive burping and nausea. In severe cases, they may have blood in their stool, or vomit, where the sore has begun to bleed and can cause a hole in the stomach.¹⁵ 

Joint and autoimmune disorders

Spondyloarthritis and rheumatic disease 

These are several long-term inflammatory disorders including psoriatic arthritis, reactive arthritic, ankylosing spondylitis and rheumatoid arthritis, where people complain of pain, stiffness and swelling of the joints. People may have these symptoms in the anterior chest wall, at the joints commonly affected by Tietze Syndrome. However, these disorders affect other areas of the body too and are not self-resolving, requiring more comprehensive treatment.¹⁶

Lupus pleuritis

Systemic Lupus Erythematosus (SLE) is an autoimmune disorder in which the body mistakenly attacks various parts of the body, including the joints and skin. A person can experience pain and discomfort in their ribs, chest or back if the immune system attacks the pleura surrounding the lungs. This causes inflammation of the pleura, resulting in sharp chest pain when breathing, and can cause coughing, shortness of breath, fever and tenderness.¹⁷ 

Infectious causes

Osteomyelitis of the rib

This is a rare painful infection of the rib bones, usually due to some other cause such as tuberculosis. In addition to tenderness over the site, a person will have swelling, redness and fever.¹⁸ 

Cancer of the chest wall 

Primary or metastatic rib tumours 

These are growths or masses that can develop in the ribs or surrounding tissues, which can present similarly, with pain and swelling over the cartilage in the front of the chest. These need to be ruled out through scans.¹⁹

Summary

Tietze Syndrome is a rare, self-limiting, non-serious condition, that mimics a lot of more long-term, complicated or serious conditions in its presentation of swelling and chest pain. It is easily managed in primary care with pain relief. However, clinicians must undertake a thorough evaluation, looking at medical history, examination and appropriate tests, such as scans or electrocardiograms. These are essential to diagnose Tietze Syndrome by ruling out more serious potential causes and ensuring accurate diagnosis and treatment.