Introduction

Tietze syndrome is considered a rare, inflammatory disorder indicated by chest pain, localised tenderness and swelling. It usually affects the rib cage's second or third costal cartilage or costochondral joints.¹ 

The exact cause of this condition is unknown, although some studies suggest that microtraumas to the front chest wall may play a part in its development. Tietze syndrome can also occur more often in disorders like psoriatic arthritis, and other possible causes include vehicular accidents, falls, and illnesses contributing to coughing, like laryngitis. Impact to the chest, trauma, vomiting, prolonged, excessive coughing, bacterial or viral infections, as well as surgery to the thoracic area, may happen before the disorder develops in some cases. A recent study also implied that Tietze syndrome can develop following a recent asymptomatic COVID-19 infection.¹   

Prevalence and gender differences

The exact epidemiology of Tietze syndrome is unknown, but it impacts those younger than 40 years more than those over 40 years. Notably, it affects both persons assigned male at birth (AMAB) and persons assigned female at birth (AFAB) at equal rates.¹  

Recognising any gender-specific differences in Tietze Syndrome is crucial for tailoring diagnosis, treatment, and overall patient care.

Pathophysiology

Tietze syndrome has a localised, painful, swollen mass showing no redness or presence of pus. It is primarily linked to the cartilage of the upper ribs only, mainly the second or third rib, and approximately 70% of patients experience the condition confined to one side. Tietze syndrome may also affect the sternoclavicular and xiphisternal joints.¹

The associated symptoms are typically self-limiting, so they resolve on their own. However, recurrences are possible.¹

Symptoms and clinical presentation in women

The symptoms of Tietze syndrome are due to the cartilage being irritated and inflamed. They can occur suddenly or develop over time. These include:^1,2

• Localised swelling
• Localised, acute chest pain – described as dull and aching when resting but sharp and radiating to the neck, arms and shoulders upon moving
• Tenderness
• Raised area near the upper sternum
• Firm mass that is firm to the touch 
• Discolouration and erythema are uncommon 
• Warmth in the affected area 

Unfortunately, the current literature does not indicate gender-specific signs and symptoms for women.  

Risk factors and triggers in women

The main risk factors relating to Tietze syndrome are the presence or previous history of a condition which affects the cartilage of the rib cage with irritation, weakness and/or inflammation. Examples are as follows:²

• Autoimmune diseases 
• Rheumatic diseases 
• Hereditary connective tissue diseases
• Chronic coughing and/or vomiting
• Chronic chest infections
• Degenerative or inflammatory arthritis
• Recent surgery in the chest area 

For women, it is possible that several factors could influence and lead to Tietze syndrome. These include:

1. Hormonal influences 

Progesterone and estrogen are the primary female hormones that are essential in the regulation of female sexual reproduction. These hormones regularly fluctuate during certain times and events in a person’s assigned female at birth (AFAB) life, such as during the menstrual cycle. In regards to pain sensitivity and inflammation, it has been reported that fluctuations in the levels of estrogen and progesterone can lead to lower pain thresholds in persons assigned female at birth (AFAB).³

2. Prevalence of autoimmune conditions 

Persons assigned female at birth (AFAB) are more likely to be affected by autoimmune diseases, as approximately 78% of individuals with autoimmune diseases are AFAB. This is due to a robust immune response and increased antibody production.⁴

3. Pregnancy changes affecting the ribcage and cartilage

During pregnancy, it is normal for the ribcage to change and undergo stress. Firstly, the growing baby and its movement, including kicking, put extra pressure on the ribs, leading to pain. This can also happen due to an increase in breast size. Hormones, specifically relaxin and progesterone, may cause the rib cage to move as they cause the muscles and ligaments to become softer and stretchy during pregnancy. The rib cage will expand to accommodate the baby, and this can result in cartilage inflammation.⁵

Diagnostic considerations

Differential diagnosis

The symptoms of Tietze syndrome are similar to an array of other medical conditions, so a broad differential diagnosis is required. Other pathologies with these symptoms to rule out are:¹ 

• Costochondritis – inflammation in the cartilage where the ribs join the sternum⁶ 
• Acute coronary syndrome
• Hypertensive crisis
• Inflammatory processes or infections of the lungs and pleura 
• Malignancies
• Chest trauma-associated fractures
• Rheumatoid or pyogenic arthritis
• Gastroesophageal reflux disease
• Psychogenic disorders
• Rib fractures 
• Conditions such as lupus and fibromyalgia

Evaluation

Upon presentation with acute chest pain, the healthcare provider will perform an electrocardiogram (EKG) to determine if it is a heart attack. Afterwards, other symptoms can be noted, and a physical examination of the chest can be done. Lab results tend to be non-specific, but it's possible to see elevated inflammatory markers such as the erythrocyte sedimentation rate (ESR) or plasma protein (C-reactive protein/CRP).^1,2 

A biopsy of the affected cartilage early on could provide a diagnosis. However, an ultrasound is the most effective diagnostic tool as it efficiently confirms any swelling at the inflammation site. Look for inflammation and signs of injury inside your chest. Nuclear magnetic resonance (NMR)  is another imaging diagnostic test that detects inflammation-related alterations in the neighbouring fat tissue and bone marrow. Radiographs are commonly utilised, and computed tomography (CT scan) may demonstrate a slight localised swelling or mild scarring of the symptomatic joint.²  

Treatment and management approaches

Management is based on treating the symptoms presented to improve the patient’s daily life. First-line treatment involves rest and anti-inflammatory and analgesic medications such as NSAIDs and pain relievers. If this does not help enough, a targeted injection of local anaesthetic, steroid such as cortisone, or a combination of both can be given at the site of maximum swelling, and the site can be observed using a sonogram. Warming pads have been known to help some patients.^1,2 

Lifestyle changes, such as reducing vigorous activities while experiencing symptoms, may be necessary. In extreme, prolonged cases, medical personnel may decide on surgery, resection of the cartilage.^1,2 

FAQs 

What triggers Tietze syndrome?

Tietze Syndrome is caused by inflammation of the costal cartilage, often without a clear cause, but some common triggers include:

• Repetitive chest movements (e.g., heavy lifting, frequent coughing, intense exercise)
• Trauma or injury to the chest area
• Respiratory infections (viral or bacterial)
• Post-surgical effects (especially after chest or heart surgery)
• Autoimmune disorders that increase inflammation
• Poor posture or excessive strain on the ribcage

What are the symptoms of Tietze's syndrome in the NHS?

The NHS does not distinguish Tietze Syndrome separately from costochondritis, but its symptoms include:

• Swelling of the costal cartilage, usually at the second or third rib
• Sharp, localised chest pain that may radiate to the arms or shoulders
• Pain that worsens with movement, deep breathing, or coughing
• Tenderness in the affected area when touched
• Symptoms may last weeks to months and can come and go

What is the difference between costochondritis and Tietze syndrome?

How to calm down costochondritis flare-ups?

To relieve pain and inflammation during a flare-up:

1. Heat/cold therapy
2. Take anti-inflammatory medication (e.g., ibuprofen, naproxen)
3. Practice deep breathing exercises 
4. Improve posture (avoid slouching, use ergonomic seating)
5. Reduce physical strain, so limit activities that worsen pain
6. Use gentle stretching exercises (to release tension in the chest)
7. Try alternative therapies, namely acupuncture, massage

Summary

Tietze syndrome is a rare inflammatory condition characterised by localised chest pain, tenderness, and swelling, primarily affecting the second or third costal cartilage. While its exact cause remains unknown, contributing factors may include chest trauma, repetitive strain, chronic coughing, infections, or underlying autoimmune disorders. Recent research has also linked the syndrome to asymptomatic COVID-19 infections. Though its epidemiology is unclear, it tends to affect individuals under 40 at equal rates across genders, though gender-specific factors may influence its manifestation and severity.

Several unique risk factors could contribute to the development of Tietze syndrome in women. Hormonal fluctuations, particularly in estrogen and progesterone levels, may lower pain thresholds and increase inflammation, making women more susceptible to symptoms. Additionally, women are disproportionately affected by autoimmune diseases, which may further exacerbate cartilage inflammation. Pregnancy-related rib cage expansion, changes in breast size, and hormonal shifts can also contribute to increased stress on the cartilage, potentially triggering or worsening the condition.

The primary symptoms include acute, localised chest pain that may radiate to the shoulders, arms, or neck and a firm, swollen mass near the sternum. Unlike costochondritis, which does not involve swelling, Tietze syndrome presents with noticeable enlargement of the affected cartilage. Although its symptoms can resolve independently, flare-ups and recurrences are common. Diagnosing the condition requires ruling out other severe conditions such as heart disease, infections, and autoimmune disorders. Imaging techniques like ultrasound, MRI, and CT scans can help confirm the presence of inflammation and swelling.

Management primarily focuses on symptom relief. First-line treatments include NSAIDs, pain relievers, and rest. In more severe cases, corticosteroid injections or local anaesthetics may reduce inflammation and pain. Lifestyle modifications, such as improving posture, reducing strenuous activities, and using heat or cold therapy, can help alleviate symptoms. Surgery is rarely required but may be considered in extreme cases. Due to the overlap of symptoms with other conditions, increasing awareness of Tietze syndrome, particularly in women, is essential for improving diagnosis and treatment outcomes.

There is a need for further research on Tietze syndrome to gain more insights and determine any gender-specific differences, including associations with hormones, etc. This could then allow for personalised therapy for persons assigned female at birth (AFAB).