Introduction

Tietze Syndrome (TS) is a rare inflammatory disease that affects the joints. It is known as a benign arthropathy, meaning that is a localised condition that mainly affects the costochondral joints that are located between the ribs and rib cage.¹ Costochondritis is another inflammatory condition affecting the costochondral joints, which is similar to TS regarding its symptoms and overall presentation however this disease is more prevalent in people over 40 years of age, which is not the case in TS instances. As well as this, TS leads to swelling at the costochondral joint, which is uncommon in costochondritis instances. Finally, TS differs from costochondritis as this condition is typically unilateral (affects the second rib, or in some cases the third rib), whereas costochondritis affects multiple ribs.² Athletes appear to be more susceptible to TS as risk factors include

repetitive arm movements and trauma to the chest wall and trunk areas. As TS affects those who are younger in age, this disease leads to worse performance in sports due to the pain and discomfort associated with this condition.³ At the time of writing there is a shortage of research concerning TS and athletic performance. This article aims to explore how sports and physical performance are impacted by this disease through analysing causes and impacts on performance as well as exploring treatment and prevention strategies 

Causes and risk factors in athletes

There are many reasons as to why athletes are more susceptible to TS when compared to the average population. Repetitive stress and overuse injuries are very common amongst athletes, where the same part of the body is overused, thus resulting in micro traumas within these areas. Joints such as the costochondral joint, particularly the soft tissues of these joints, can be injured for a long period of time.⁴ Many fractures that occur due to training affect the ribs and chest area. Intercostal muscles are tender in TS instances, and this can be due to the posture of athletes and the movements that have to take place. Chest pain can occur due to a multitude of reasons, including issues with the thorax, the heart and lungs amongst other areas, thus athletes are increasingly likely to have trauma within the chest area. Overuse also leads to this.⁵ As aforementioned, issues regarding posture occur due to the position of the spine during sports and the cumulative damage can lead to injury in many cases. This is also exacerbated due to muscle and biomechanical imbalances that can occur during training or playing certain sports. There is a positive feedback loop in which injuries lead to more potential imbalances, leading to long-term damage and injury.⁶ Many athletes may have previous inflammatory conditions such as bronchoconstriction (contraction of the bronchus muscles), leading to airway issues and breathing difficulties. Inflammatory conditions that occur prior to TS lead to worse symptoms and effects.⁷

Symptoms and diagnosis

There are many symptoms and methods which are used to detect and diagnose TS. Symptoms include swelling in the costal cartilages and tenderness in these regions which can occur for years.8 Chest pain is characteristic of this illness. As well as this, breathing is very difficult, leading to pain when there is no clear rhythm.9 Physical activity also leads to periods of intense pain; therefore, people with TS are often not able to exercise adequately as it is too difficult to do so.¹⁰ There are a few different diagnostic methods including physical examinations.

The distinguishing factor in TS when compared to similar diseases is swelling of the costochondral junction (second or third).¹¹ Medical imaging techniques are also used for diagnostic purposes. These include magnetic resonance imaging (MRI), ultrasound, and computed tomography (CT) scans, which can visualise swelling of the aforementioned joints as well as calcification within the cartilage and joints.12 There is an issue surrounding diagnosis as differential diagnosis may occur, and symptoms may lead to a different diagnosis other than TS. This is due to cardiac and pulmonary issues presenting with similar symptoms such as chest pain and breathing difficulties and as mentioned previously, costochronditis is very similar in its presentation when compared to TS.¹³ It is of utmost importance that patients are examined and diagnosed properly to establish whether they have TS.

Impact on sports and physical performance

Tietze syndrome does negatively impact performance within sports and leads to physical limitations in the majority of instances. Firstly, upper body movements are compromised meaning that athletes are unable to perform to their usual standard in sports.¹ As well as this, the swelling associated with TS leads to severe chest pain meaning that athletes would find it difficult to continue intense exercises and sports for prolonged periods of time.¹⁴ The anxiety associated with TS is overlooked in a large number of cases. Athletes with this condition are psychologically affected due to the anxiety surrounding chest pain which can lead to depression. This anxiety tends to be worse in women as the pain occurs near breast tissue which can also be indicative of a tumour.¹⁵ If this condition is not treated, long-term complications may develop. This includes developing chest wall syndrome which is typically preceded by costochondritis.¹⁶

Treatment and management strategies

Managing and treating this condition is possible due to a few different strategies. Taking rest periods have been shown to reduce pain over time. Training is possible following these periods as a decrease in activity and rest during intense pain is crucial for recovery.¹⁷ Heat and ice therapy on the affected areas are known to reduce the swelling and inflammation associated with TS, with utilising ice packs in short bursts four times a day being shown to improve patient outcomes.¹⁸ Treatments such as glucocorticoids and non-steroidal anti-inflammatory drugs (NSAIDs) are used to reduce inflammation in TS instances. Although surgeries are possible many studies have suggested that these medications are better for the patients.¹⁹ Physical therapy has also proven useful with stretching and strength-building exercises leading to patients recovering over time.²⁰ As aforementioned, many athletes with TS have poor posture therefore postural correction exercises to reduce and correct these abnormalities are useful physical therapy measures to manage this condition.²¹ Finally, there are alternative therapies such as cupping, acupuncture, and massage techniques which are used to reduce pain in those suffering from TS and have shown to be mostly effective.²²

Preventive measures for athletes

Athletes can use certain techniques to reduce the risk of TS. Firstly, using proper warm-up routines and cool-down exercises prior to intense physical activity reduces the risk of injury resulting from overexertion. Athletes should do this regardless of whether they are at high risk of TS or not.²³ Strengthening muscles in the core and chest regions by using exercise methods such as push-ups will reduce the risk of injuries and TS.³ Athletes overtraining are at higher risk for TS thus avoiding this and allowing adequate recovery for the muscles used during exercise is crucial to prevent serious injury.²⁴ It is important that athletes with chest pain seek medical attention early so that they can be assessed and use the aforementioned techniques to prevent TS development. Early detection is a large contributor to differing patient outcomes in athletes with chest pain.²⁵

Summary

In summary, Tietze syndrome is caused by overuse injuries and repeated stress to joints and muscles in the chest region. Chest trauma is more likely in athletes who undergo intense training and exercise. As athletes may have a poor posture when undergoing physical activity, they are more susceptible to TS when compared to the general population. This condition greatly inhibits athletes in performing in their sport as upper body movements and overall athletic ability are reduced, which in some cases can lead to long-term complications. This condition is diagnosed through different imaging techniques and correct diagnosis is key due to TS sharing similar symptoms to other medical conditions, particularly costochondritis. Treatments such as NSAIDs and corticosteroids reduce inflammation in the affected areas and there are physical therapy methods that have proven useful, but it is important to increase awareness of this condition.

Many athletes do not understand the signs of TS, therefore leading to further overuse injuries and a higher risk of TS thus understanding will allow earlier management of this disease. The need for a holistic approach cannot be underestimated as there are a wide variety of techniques that can be useful in preventing this disease and treating it. Ensuring that athletes warm-up adequately and allow time to recover is important and alternative therapies have shown success in treating this condition. It is likely that with increased awareness and understanding of this condition, TS will be less prevalent amongst athletes and that those affected will have better outcomes in the near future.