Symptoms of costochondritis sometimes begin following sudden, unguarded, or explosive movements, like coughing or sneezing.  Patients will often report a history that includes twisting, reaching, pushing, or pulling.

Costovertebral joint dysfunction presents clinically as localized pain, 3-4 cm lateral to the spine with possible radiation of symptoms along the associated rib.  Radiating complaints may include hyperalgesia or paresthesia.

Presenting complaints of costovertebral joint dysfunction range from focal and burning to sharp, stabbing, and radiating.  Patients will sometimes describe concurrent costovertebral and costosternal pain as if they were “shot by an arrow.” Patients with costovertebral joint dysfunction often report variable periods of improvement.

Patients may experience pain and stiffness following activity, especially upon arising the next morning.  Symptoms may increase when lying down. Symptoms may increase when taking a deep breath.

The pain is often provoked by:

breathing,

coughing,

sneezing,

twisting, or

bending.

Reaching, pushing, or pulling requires scapular muscle activation and may provoke symptoms where the scapular stabilizers attach.  Costovertebral joint dysfunction of the upper thoracic region may be provoked by “pump handle” movements, like reaching or carrying loads on the shoulder, while mid and lower costovertebral problems are provoked by “bucket handle” motions of bending, lateral flexion, and rotation.

Undiagnosed rib dysfunction or costochondritis often causes unnecessary worry about more sinister causes, but failure to diagnose a threatening origin has much greater consequences. Pain and mechanical dysfunction in the costovertebral region is common and may become a “biased” diagnosis for manual medicine providers. Not all costovertebral pain is of primary mechanical origin and sometimes presents concurrently with a more ominous diagnosis.

Clinicians should be astute in performing a review of systems (particularly cardiac, pulmonary, GI, and renal), as viscerosomatic referral is a common source of thoracic complaints.  Cardiac complaints often include a sensation of “pressure” or “squeezing” in the substernal region that may or may not radiate to the left arm and jaw and is provoked by exertion. Fracture may be suspected in patients with a history of trauma, particularly in older patients.

Imagin studies are not generally warranted in the initial workup of simple costovertebral pain. Radiographs may be necessary in cases of “significant trauma”, suspicion of fracture or instability, age over 50, lack of improvement with conservative care, or neuromotor deficits.

The presence of red flags, including unexplained weight loss, history of cancer, corticosteroid use, osteoporosis, fever, or drug/alcohol abuse also warrants further investigation. However costochondritis can not be visualized on x-ray and even rib fractures may not be visible even if present.