Costochondritis: Rapid Evidence Review

Timothy Mott; Gregory Jones; Kimberly Roman

Costochondritis: Rapid Evidence Review

PDFComments

TIMOTHY MOTT, MD, GREGORY JONES, MD, AND KIMBERLY ROMAN, MD

Am Fam Physician. 2021;104(1):73-78

Patient information: See related handout on costochondritis.

Author disclosure: No relevant financial affiliations.

Costochondritis is a common cause of chest pain. It most commonly occurs in adults between 40 and 50 years of age, with a slight predominance in women. Although musculoskeletal and other chest wall conditions are the most common etiology for chest pain presenting to primary care, an initial differential diagnosis should include cardiovascular, psychogenic, pulmonary, gastrointestinal, and miscellaneous or unknown sources (more to less common, respectively). Additionally, physicians should remain vigilant throughout the workup because a notable portion of patients with chest wall tenderness to palpation may also have acute myocardial infarction. After a musculoskeletal or chest wall source is determined, differential diagnosis includes costochondritis, muscle trauma (including postoperative) or overuse, arthritis, fibromyalgia, neoplasm, infection, herpes zoster, Tietze syndrome, painful xyphoid syndrome, and slipping rib syndrome. The diagnosis of costochondritis is largely based on history and a physical examination that demonstrates reproduction of pain through palpation of the parasternal region of the chest wall, performance of a crowing rooster maneuver, and/or a crossed-chest adduction maneuver. Although high-quality evidence is lacking, treatment options include local application of heat, oral or topical nonsteroidal anti-inflammatory drugs, lidocaine patches, capsaicin cream, physical therapy, and acupuncture. Most patients will have complete resolution of symptoms in a few weeks' time with conservative therapy. Recalcitrant cases may respond to corticosteroid injections.

Costochondritis is a commonly encountered condition in primary care that is characterized by chest wall pain from inflammation in the costochondral joints. It most commonly occurs in adults 40 to 50 years of age. This article reviews the best available patient-oriented evidence for costochondritis.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Enlarge Print

Clinical recommendation	Evidence rating	Comments
The diagnosis of costochondritis is largely based on history and a physical examination that reproduces pain on direct palpation of the parasternal region and/or with provocation maneuvers such as the crowing rooster or crossed-chest adduction.⁴¹	C	Case series for study of diagnosis
Validated clinical prediction rules are available to assist in distinguishing chest pain caused by coronary artery disease in the primary care and emergency department setting, but they should be used to support, and not replace, clinical judgment.^1,12,43–45	A	Systematic reviews of validated clinical decision rules
Acupuncture, physical therapy, and corticosteroid injections may be considered for the treatment of costochondritis in patient with recalcitrant symptoms.^47,49,50	C	Expert opinion
Local application of heat, oral or topical nonsteroidal anti-inflammatory drugs, capsaicin cream, and lidocaine patches are first-line therapies for patients with costochondritis.^3,29–31	C	Usual practice and expert opinion

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Epidemiology

The most common age for costochondritis is middle age (between 40 and 50 years of age) with a slight predominance in women (69%) vs. men (56%).^1–3
Chest pain in adolescents presenting to an outpatient clinic is most often diagnosed with a musculoskeletal etiology (31%), with costochondritis being diagnosed 13% of the time.^3,4
Approximately 1% to 3% of all ambulatory visits in the primary care setting are for chest pain.^5–11 Of these, chest wall pain accounts for 20% to 50%.^1,5–12 Costochondritis in particular accounts for 6% to 13%.^6,10,11
In emergency departments, chest pain accounts for 9% to 10% of visits, with musculoskeletal causes accounting for 15% to 45% of noncardiac chest pain.^13–15

Diagnosis

DIFFERENTIAL DIAGNOSIS

The differential diagnosis for patients with chest pain is broad and must be carefully considered before settling on a diagnosis of costochondritis (Table 1).^1,6,16–28
Within the subset of musculoskeletal and other chest wall conditions, a number of diagnoses should be considered (Table 2).^3,29–37

TABLE 1.

Clinical Findings Associated with Select Differential Diagnoses of Chest Pain

Enlarge Print

Diagnosis	Clinical findings	LR+	LR–
Acute myocardial infarction¹⁶	Chest pain radiates to both arms	7.1	0.67
	Third heart sound on auscultation	3.2	0.88
	Hypotension	3.1	0.96
Acute thoracic aortic dissection¹⁷	Acute chest or back pain and a pulse differential in the upper extremities	5.3	NA
Chest wall pain¹	At least two of the following findings: localized muscle tension, stinging pain, pain reproducible by palpation, absence of cough	3.0	0.47
Gastroesophageal reflux disease^18,19	Burning retrosternal pain, acid regurgitation, sour or bitter taste in the mouth; one-week trial of high-dose proton pump inhibitor relieves symptoms	3.1	0.30
Heart failure²⁰	Pulmonary edema on chest radiography	11.0	0.48
	Clinical impression/judgment	9.9	0.65
	History of heart failure	5.8	0.45
	History of acute myocardial infarction	3.1	0.69
Panic disorder/anxiety state²¹	Ask a single question: In the past four weeks, have you had an anxiety attack (suddenly feeling fear or panic)?	4.2	0.09
Pericarditis^22,23	Clinical triad of pleuritic chest pain (increases with inspiration or when reclining and lessens by leaning forward), pericardial friction rub, and electrocardiographic changes (PR-interval depression, diffuse ST-segment elevation with concave downward appearance, and lack of T-wave inversion)	NA	NA
Pneumonia^24,25,28	Egophony (E to A change due to increased resonance and higher pitch of spoken words when auscultated over areas of lung consolidation)	8.6	0.96
	Clinical impression	7.7	0.54
	Dullness to percussion	4.3	0.79
	Fever	2.1	0.71
Pulmonary embolism^26,27	High pretest probability based on Wells criteria	6.8	1.80
	Moderate pretest probability based on Wells criteria	1.3*	0.70
	Low pretest probability based on Wells criteria	0.1	7.60

Note: The higher the LR is above 1, the better it rules in disease (greater than 10 is considered good). Conversely, the lower the LR is below 1, the better it rules out disease (less than 0.1 is considered good).

LR– = negative likelihood ratio; LR+ = positive likelihood ratio; NA = not available.

*—Does not change posttest probability.

Adapted with permission from McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87(3):178, with additional information from references 1 and 16–28.

TABLE 2.

Differential Diagnosis and Treatment of Chest Wall Conditions

Enlarge Print

Condition	Diagnostic considerations	Treatment principles
Arthritis of sternoclavicular, sternomanubrial, or shoulder joints	Tenderness to palpation of specific joints of the sternum; evidence of joint sclerosis visible on radiography	Analgesics, intra-articular corticosteroid injections, physiotherapy ^29,30
Costochondritis	Tenderness to palpation of costochondral junctions; reproduces patient's pain; usually multiple sites on same side of chest³¹	Simple analgesics; heat or ice; rarely, local anesthetic injections or corticosteroid injections^29,30
Destruction of costal cartilage by infections or neoplasm	Bacterial or fungal infections or metastatic neoplasms to costal cartilages; infections occur postsurgery or in intravenous drug users; chest computed tomography imaging useful to show alteration or destruction of cartilage and extension of masses to chest wall	Antibiotics or antifungal drugs; surgical resection of affected costal cartilage; treatment of neoplasm based on tissue type^32,33
Fibromyalgia	Symmetric tender points at second costochondral junctions, with characteristic tender points in the neck, back, hip, and extremities and widespread pain^29,31	Graded exercise is beneficial; cyclobenzaprine (Flexeril), antidepressants, and pregabalin (Lyrica) may be beneficial³⁴
Herpes zoster of thorax	Clusters of vesicles on red bases that follow one or two dermatomes and do not cross the midline; usually preceded by a prodrome of pain; postherpetic neuralgia is potential complication that is more common in older patients³⁵	Oral antiviral agents (e.g., acyclovir, famciclovir [Famvir], valacyclovir [Valtrex]); analgesics as needed for pain; may require narcotics or topical lidocaine patches to control pain³⁵
Painful xiphoid syndrome	Tenderness at sternoxiphoid joint or over xiphoid process with palpation³⁶	Usually self-limited unless associated with congenital deformity of xiphoid; analgesics; rarely, corticosteroid injections³⁶
Slipping rib syndrome	Tenderness and hypermobility of anterior ends of lower costal cartilages causing pain at lower anterior chest wall or upper abdomen; diagnosis by “hooking maneuver”: curving fingers under costal margin and gently pulling anteriorly—a “click” and movement is felt that reproduces patient's pain^31,37	Rest, physiotherapy, intercostal nerve blocks; if chronic and severe, surgical removal of hypermobile cartilage segment³¹
Tietze syndrome	Single tender and swollen, but nonsuppurative, costochondral junction, usually in costochondral junction of ribs two and three^31,37	Simple analgesics; usually self-limiting; rarely, corticosteroid injections^29,31
Traumatic muscle pain and overuse myalgia	History of trauma to chest or recent new onset of strenuous exercise to upper body (e.g., rowing); may be bilateral and affecting multiple costochondral areas; muscle groups may also be tender to palpation³¹	Simple analgesics; refrain from doing or reduce intensity of strenuous activities that provoke pain^29,31

Adapted with permission from Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80(6):619, with additional information from references 29–37.

SIGNS AND SYMPTOMS

The typical presentation of costochondritis is bilateral parasternal chest wall pain exacerbated by deep breaths, coughing, and stretching.
The upper (predominantly second through fifth) costochondral and/or costosternal junctions are most commonly involved.^2,3,31,38
The areas of tenderness are not generally accompanied by heat, erythema, or localized swelling.^2,3,31,38,39
Tietze syndrome presents similarly to costochondritis but includes visible edema at the involved joint(s), typically is unilateral involving the second rib, and is often incited by infection or trauma.^3,31,40
Pain reproduced by the following maneuvers has classically proven helpful: direct palpation to the involved costosternal or costochondral junction; the crowing rooster maneuver (patient neck extension simultaneously accompanied by the physician placing posterior and superior traction on the patient's arms from behind [Figure 1; also see a video showing the crowing rooster maneuver); and crossed-chest adduction of the ipsilateral arm combined with neck rotation toward the ipsilateral shoulder⁴¹ (Figure 2; also see a video showing the crossed-chest adduction maneuver).
A study of primary care patients with chest pain found that pain reproducible by palpation, no history of coronary heart disease, pain that is neither retrosternal nor oppressive, the physician not being concerned about the cause of chest pain, pain being well-localized by history or physical examination, and stabbing pain were all independent predictors of chest wall syndrome as the cause of chest pain (Table 3).⁴²

FIGURE 1.

Enlarge Print

Crowing rooster maneuvers to attempt recreating or worsening pain associated with costochondritis: (A) with patient's hands clasped behind their head; (B) with patient's arms raised to their sides. With each maneuver, patients are asked to extend their neck (look upward) while the physician gently lifts the arms superiorly and posteriorly. (See a video describing the crowing rooster maneuver.)

Crowing Rooster Maneuver

FIGURE 2.

Enlarge Print

Crossed-chest adduction maneuver to attempt recreating or worsening pain associated with costochondritis. Patient is asked to turn their head toward one shoulder. The physician brings the patient's ipsilateral arm across the chest with gentle, but continuous, pressure. This can be repeated with the opposite shoulder and arm, with the head turned to that side to assess for reproducibility of bilateral costochondral pain. (See a video describing the crossed-chest adduction maneuver.)

Crossed-Chest Adduction Maneuver

TABLE 3.

Clinical Prediction Rule for Chest Wall Syndrome as the Source of Chest Pain

Enlarge Print

Independent predictors of chest wall syndrome	Adjusted odds ratio (95% CI) for association with chest wall syndrome	Points
Independent predictors of chest wall syndrome		Points
Palpation reproduces pain	6.5 (4.6 to 9.1)	2
No history of coronary artery disease	5.1 (2.9 to 9.1)	1
Absence of physician's concern	5.0 (2.8 to 8.8)	1
Pain not retrosternal or oppressive	3.1 (2.2 to 4.3)	1
Pain well localized by history and/or physical examination	3.1 (2.2 to 4.4)	1
Pain stabbing in nature	2.1 (1.4 to 3.2)	1
		Total:___

Note: For a score of 6 or higher, the rule is 93% specific and 22% sensitive for ruling in chest wall syndrome. In the validation population, the probability of chest wall syndrome was less than 10% for patients with 0 to 1 point, between 25% and 65% for those with 2 to 4 points, and more than 70% for those with 5 or more points. The authors of the clinical prediction rules stress, however, that although more heavily weighted, the finding of pain reproduced by palpation is not pathognomonic for chest wall syndrome.

Adapted with permission from Ronga A, Vaucher P, Haasenritter J, et al. Development and validation of a clinical prediction rule for chest wall syndrome in primary care. BMC Fam Pract. 2012;13:74.

DIAGNOSTIC TESTING

Because the clinical examination lacks specificity, most patients with chest pain still need a thorough evaluation, including electrocardiography at a minimum, to rule out other more serious causes.^{1,3,6–16,43}
In one study, 12% of patients presenting to an emergency department with a chief symptom of chest pain and noted to have chest wall tenderness also had an acute myocardial infarction.²
Validated clinical prediction rules have proven useful in assisting with cardiac risk stratification of patients presenting to primary care and the emergency department with chest pain, but they should not completely replace clinical judgment.^1,12,43–45
There are no laboratory tests, imaging tests, or electrocardiography findings specifically for the diagnosis of costochondritis. If a patient relates a history of dyspnea or chest wall trauma, a chest radiograph or rib series may be indicated; in adolescent patients with low risk for coronary disease, electrocardiography may be unwarranted. Any diagnostics performed should be directed toward ruling out other possible etiologies based on each patient's unique differential diagnosis.

Treatment

No high-quality studies have examined the effectiveness of any treatment options for costochondritis. Most treatment recommendations are conservative in nature and have been traditionally accepted, perhaps because of the self-limited nature of the condition.^3,46

PHYSICAL MODALITIES

A targeted stretching program under the direction of a physical therapist demonstrated a small reduction in pain among a group of patients who had symptoms for more than one year.⁴⁷
Local application of heat is often recommended but lacks evidence from clinical trials. A period of rest from activities that exacerbate pain is often recommended.³¹

DRUG THERAPY

Nonsteroidal anti-inflammatory drugs are the most commonly prescribed medications, although no clinical trials have evaluated their effectiveness. Additionally, higher dosages and frequency of oral nonsteroidal anti-inflammatory drugs may exacerbate gastritis or reflux, further complicating the clinical diagnosis.
Capsaicin, diclofenac gel, and lidocaine patches have been recommended primarily based on experience with other inflammatory musculoskeletal conditions.⁴⁸

ALTERNATIVE MEDICINE

Acupuncture has been used for treatment, but no randomized, controlled studies for effectiveness are available.⁴⁹

OTHER TREATMENT

In one small prospective observational study, localized ultrasound-guided corticosteroid injection at the affected costochondral junction resulted in clinical and sonographic improvements among the convenience-sampled group of nine patients with Tietze syndrome, which had not improved with conservative treatment after at least three months.⁵⁰ There is inadequate evidence supporting corticosteroid injection specifically for costochondritis, so it should be considered only for patients whose symptoms do not improve with traditional therapies.

Prognosis

A large observational study found that 91% of patients with new-onset costochondritis had resolution of pain after three weeks of treatment with rest and nonsteroidal anti-inflammatory drugs.⁴⁸ After two years, the recurrence rate was approximately 4%.⁴⁸

This article updates a previous article on this topic by Proulx and Zryd.^³

Data Sources: A PubMed search was completed in Clinical Queries using the key terms costochondritis, chest pain, chest wall pain, and Tietze's syndrome. Also searched were Essential Evidence Plus, Clinical Evidence, Google Scholar, Trip Database, and the Cochrane database. Reference lists of retrieved articles were also searched. Search dates: January 2020, March 2020, and January 2021.

TIMOTHY MOTT, MD, is the program director of the South Baldwin Regional Medical Center Family Medicine Residency Program, Foley, Ala.

GREGORY JONES, MD, is the associate program director of the South Baldwin Regional Medical Center Family Medicine Residency Program.

KIMBERLY ROMAN, MD, is a faculty member of the South Baldwin Regional Medical Center Family Medicine Residency Program.

Address correspondence to Timothy Mott, MD, South Baldwin Regional Medical Center, 1613 N. McKenzie St., Foley, AL 36535 (email: timothy_mott@chs.net). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

Bösner S, Becker A, Hani MA, et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Fam Pract. 2010;27(4):363-369.
Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466-2469.
Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80(6):617–620. Accessed November 11, 2020. https://www.aafp.org/afp/2009/0915/p617.html
Pantell RH, Goodman BW. Adolescent chest pain: a prospective study. Pediatrics. 1983;71(6):881-887.
Haasenritter J, Biroga T, Keunecke C, et al. Causes of chest pain in primary care—a systematic review and meta-analysis. Croat Med J. 2015;56(5):422-430.
McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87(3):177–182. Accessed November 17, 2020. https://www.aafp.org/afp/2013/0201/p177.html
Verdon F, Herzig L, Burnand B, et al.; GMIRG. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly. 2008;138(23–24):340-347.
Verdon F, Burnand B, Herzig L, et al. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract. 2007;8:51.
Hsiao C-J, Cherry DK, Beatty PC, et al. National ambulatory medical care survey: 2007 summary. Natl Health Stat Report. 2010;27:1-32.
Hoorweg BB, Willemsen RT, Cleef LE, et al. Frequency of chest pain in primary care, diagnostic tests performed and final diagnoses. Heart. 2017;103(21):1727-1732.
Klinkman MS, Stevens D, Gorenflo DW Michigan Research Network. Episodes of care for chest pain: a preliminary report from MIRNET. J Fam Pract. 1994;38(4):345-352.
Ebell MH. Evaluation of chest pain in primary care patients. Am Fam Physician. 2011;83(5):603–605. Accessed November 17, 2020. https://www.aafp.org/afp/2011/0301/p603.html
Wertli MM, Dangma TD, Müller SE, et al. Non-cardiac chest pain patients in the emergency department: do physicians have a plan how to diagnose and treat them? A retrospective study. PLoS One. 2019;14(2):e0211615.
Cilia C, Malatino LS, Puccia G, et al. The prevalence of the cardiac origin of chest pain: the experience of a rural area of southeast Italy. Intern Emerg Med. 2010;5(5):427-432.
Bhuiya FA, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999–2008. NCHS Data Brief. 2010;43:1-8.
Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction?. JAMA. 1998;280(14):1256-1263.
von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med. 2000;160(19):2977-2982.
Zimmerman J. Validation of a brief inventory for diagnosis and monitoring of symptomatic gastro-oesophageal reflux. Scand J Gastroenterol. 2004;39(3):212-216.
Wang WH, Huang JQ, Zheng GF, et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis. Arch Intern Med. 2005;165(11):1222-1228.
Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure?. JAMA. 2005;294(15):1944-1956.
Löwe B, Gräfe K, Zipfel S, et al. Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians' diagnosis. J Psychosom Res. 2003;55(6):515-519.
Imazio M, Brucato A, Cemin R, et al.; CORP (COlchicine for Recurrent Pericarditis) Investigators. Colchicine for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med. 2011;155(7):409-414.
Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2004;25(7):587-610.
Diehr P, Wood RW, Bushyhead J, et al. Prediction of pneumonia in out-patients with acute cough—a statistical approach. J Chronic Dis. 1984;37(3):215-225.
Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278(17):1440-1445.
Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98-107.
Tamariz LJ, Eng J, Segal JB, et al. Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: a systematic review. Am J Med. 2004;117(9):676-684.
Dale AP, Marchello C, Ebell MH. Clinical gestalt to diagnose pneumonia, sinusitis, and pharyngitis: a meta-analysis. Br J Gen Pract. 2019;69(684):e444-e453.
How J, Volz G, Doe S, et al. The causes of musculoskeletal chest pain in patients admitted to hospital with suspected myocardial infarction. Eur J Intern Med. 2005;16(6):432-436.
Spalding L, Reay E, Kelly C. Cause and outcome of atypical chest pain in patients admitted to hospital. J R Soc Med. 2003;96(3):122-125.
Fam AG, Smythe HA. Musculoskeletal chest wall pain. CMAJ. 1985;133(5):379-389.
Zapatero J, López Longo J, Monteagudo I, et al. Costal chondritis in heroin addicts: a comparative study with postsurgical chondritis. Br J Dis Chest. 1988;82(4):341-346.
Chicarilli ZN, Ariyan S, Stahl RS. Costochondritis: pathogenesis, diagnosis, and management considerations. Plast Reconstr Surg. 1986;77(1):50-59.
DynaMed. Fibromyalgia (subscription required). Accessed April 9, 2020. https://www.dynamed.com/condition/fibromyalgia
DynaMed. Herpes zoster. Accessed April 9, 2020. https://www.dynamed.com/condition/herpes-zoster
Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002;32(4):235-250.
Saltzman DA, Schmitz ML, Smith SD, et al. The slipping rib syndrome in children. Paediatr Anaesth. 2001;11(6):740-743.
Wolf E, Stern S. Costosternal syndrome: its frequency and importance in differential diagnosis of coronary heart disease. Arch Intern Med. 1976;136(2):189-191.
Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil. 1992;73(2):147-149.
Tietze A. Ueber eine eigenartige Häufung von Fällen mit Dystrophie der Rippenknorpel [About a peculiar accumulation of cases with dystrophy of costal cartilage]. Berliner Klinische Wochenschrift. 1921;30:829–831. Accessed January 19, 2021. https://babel.hathitrust.org/cgi/pt?id=uc1.c2892645&view=1up&seq=125&q1=Rippenknorpel
Epstein SE, Gerber LH, Borer JS. Chest wall syndrome. A common cause of unexplained cardiac pain. JAMA. 1979;241(26):2793-2797.
Ronga A, Vaucher P, Haasenritter J, et al. Development and validation of a clinical prediction rule for chest wall syndrome in primary care. BMC Fam Pract. 2012;13:74.
Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ. 2010;182(12):1295-1300.
Harskamp RE, Laeven SC, Himmelreich JC, et al. Chest pain in general practice: a systematic review of prediction rules. BMJ Open. 2019;9(2):e027081.
Van Den Berg P, Body R. The HEART score for early rule out of acute coronary syndromes in the emergency department: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care. 2018;7(2):111-119.
Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013;40(4):863-887.
Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. 2009;31(2):169-171.
Boran M, Boran E. Tietze syndrome and idiopathic costochondritis—treatment modalities, recurrence rates, seasonality. World J Pharm Res. 2017;6(8):76-85.
Li B. 106 cases of non-suppurative costal chondritis treated by acupuncture at xuanzhong point. J Tradit Chin Med. 1998;18(3):195-196.
Kamel M, Kotob H. Ultrasonographic assessment of local steroid injection in Tietze's syndrome. Br J Rheumatol. 1997;36(5):547-550.

Bösner S, Becker A, Hani MA, et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Fam Pract. 2010;27(4):363-369.

Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466-2469.

Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80(6):617–620. Accessed November 11, 2020. https://www.aafp.org/afp/2009/0915/p617.html

Pantell RH, Goodman BW. Adolescent chest pain: a prospective study. Pediatrics. 1983;71(6):881-887.

Haasenritter J, Biroga T, Keunecke C, et al. Causes of chest pain in primary care—a systematic review and meta-analysis. Croat Med J. 2015;56(5):422-430.

McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87(3):177–182. Accessed November 17, 2020. https://www.aafp.org/afp/2013/0201/p177.html

Verdon F, Herzig L, Burnand B, et al.; GMIRG. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly. 2008;138(23–24):340-347.

Verdon F, Burnand B, Herzig L, et al. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract. 2007;8:51.

Hsiao C-J, Cherry DK, Beatty PC, et al. National ambulatory medical care survey: 2007 summary. Natl Health Stat Report. 2010;27:1-32.

Hoorweg BB, Willemsen RT, Cleef LE, et al. Frequency of chest pain in primary care, diagnostic tests performed and final diagnoses. Heart. 2017;103(21):1727-1732.

Klinkman MS, Stevens D, Gorenflo DW Michigan Research Network. Episodes of care for chest pain: a preliminary report from MIRNET. J Fam Pract. 1994;38(4):345-352.

Ebell MH. Evaluation of chest pain in primary care patients. Am Fam Physician. 2011;83(5):603–605. Accessed November 17, 2020. https://www.aafp.org/afp/2011/0301/p603.html

Wertli MM, Dangma TD, Müller SE, et al. Non-cardiac chest pain patients in the emergency department: do physicians have a plan how to diagnose and treat them? A retrospective study. PLoS One. 2019;14(2):e0211615.

Cilia C, Malatino LS, Puccia G, et al. The prevalence of the cardiac origin of chest pain: the experience of a rural area of southeast Italy. Intern Emerg Med. 2010;5(5):427-432.

Bhuiya FA, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999–2008. NCHS Data Brief. 2010;43:1-8.

Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction?. JAMA. 1998;280(14):1256-1263.

von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med. 2000;160(19):2977-2982.

Zimmerman J. Validation of a brief inventory for diagnosis and monitoring of symptomatic gastro-oesophageal reflux. Scand J Gastroenterol. 2004;39(3):212-216.

Wang WH, Huang JQ, Zheng GF, et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis. Arch Intern Med. 2005;165(11):1222-1228.

Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure?. JAMA. 2005;294(15):1944-1956.

Löwe B, Gräfe K, Zipfel S, et al. Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians' diagnosis. J Psychosom Res. 2003;55(6):515-519.

Imazio M, Brucato A, Cemin R, et al.; CORP (COlchicine for Recurrent Pericarditis) Investigators. Colchicine for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med. 2011;155(7):409-414.

Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2004;25(7):587-610.

Diehr P, Wood RW, Bushyhead J, et al. Prediction of pneumonia in out-patients with acute cough—a statistical approach. J Chronic Dis. 1984;37(3):215-225.

Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278(17):1440-1445.

Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98-107.

Tamariz LJ, Eng J, Segal JB, et al. Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: a systematic review. Am J Med. 2004;117(9):676-684.

Dale AP, Marchello C, Ebell MH. Clinical gestalt to diagnose pneumonia, sinusitis, and pharyngitis: a meta-analysis. Br J Gen Pract. 2019;69(684):e444-e453.

How J, Volz G, Doe S, et al. The causes of musculoskeletal chest pain in patients admitted to hospital with suspected myocardial infarction. Eur J Intern Med. 2005;16(6):432-436.

Spalding L, Reay E, Kelly C. Cause and outcome of atypical chest pain in patients admitted to hospital. J R Soc Med. 2003;96(3):122-125.

Fam AG, Smythe HA. Musculoskeletal chest wall pain. CMAJ. 1985;133(5):379-389.

Zapatero J, López Longo J, Monteagudo I, et al. Costal chondritis in heroin addicts: a comparative study with postsurgical chondritis. Br J Dis Chest. 1988;82(4):341-346.

Chicarilli ZN, Ariyan S, Stahl RS. Costochondritis: pathogenesis, diagnosis, and management considerations. Plast Reconstr Surg. 1986;77(1):50-59.

DynaMed. Fibromyalgia (subscription required). Accessed April 9, 2020. https://www.dynamed.com/condition/fibromyalgia

DynaMed. Herpes zoster. Accessed April 9, 2020. https://www.dynamed.com/condition/herpes-zoster

Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002;32(4):235-250.

Saltzman DA, Schmitz ML, Smith SD, et al. The slipping rib syndrome in children. Paediatr Anaesth. 2001;11(6):740-743.

Wolf E, Stern S. Costosternal syndrome: its frequency and importance in differential diagnosis of coronary heart disease. Arch Intern Med. 1976;136(2):189-191.

Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil. 1992;73(2):147-149.

Tietze A. Ueber eine eigenartige Häufung von Fällen mit Dystrophie der Rippenknorpel [About a peculiar accumulation of cases with dystrophy of costal cartilage]. Berliner Klinische Wochenschrift. 1921;30:829–831. Accessed January 19, 2021. https://babel.hathitrust.org/cgi/pt?id=uc1.c2892645&view=1up&seq=125&q1=Rippenknorpel

Epstein SE, Gerber LH, Borer JS. Chest wall syndrome. A common cause of unexplained cardiac pain. JAMA. 1979;241(26):2793-2797.

Ronga A, Vaucher P, Haasenritter J, et al. Development and validation of a clinical prediction rule for chest wall syndrome in primary care. BMC Fam Pract. 2012;13:74.

Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ. 2010;182(12):1295-1300.

Harskamp RE, Laeven SC, Himmelreich JC, et al. Chest pain in general practice: a systematic review of prediction rules. BMJ Open. 2019;9(2):e027081.

Van Den Berg P, Body R. The HEART score for early rule out of acute coronary syndromes in the emergency department: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care. 2018;7(2):111-119.

Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013;40(4):863-887.

Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. 2009;31(2):169-171.

Boran M, Boran E. Tietze syndrome and idiopathic costochondritis—treatment modalities, recurrence rates, seasonality. World J Pharm Res. 2017;6(8):76-85.

Li B. 106 cases of non-suppurative costal chondritis treated by acupuncture at xuanzhong point. J Tradit Chin Med. 1998;18(3):195-196.

Kamel M, Kotob H. Ultrasonographic assessment of local steroid injection in Tietze's syndrome. Br J Rheumatol. 1997;36(5):547-550.