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Rib-vertebral articulation syndrome.
Last reviewed: 04.07.2025
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The costovertebral joint is a true joint that can be affected by osteoarthritis, rheumatoid arthritis, psoriatic arthritis, Reiter's syndrome, and especially ankylosing spondylitis. The joint is often injured by acceleration-deceleration injuries and blunt chest trauma, and subluxation or displacement of the joint may occur with severe injuries.
Overuse can lead to acute inflammation of the costovertebral joint, which can be very debilitating. The joint can also be affected by a tumor from a primary site, such as a lung tumor, and by metastatic disease. Pain originating from the costovertebral joint can mimic pain of pulmonary or cardiac origin.
Symptoms of the costovertebral joint
On physical examination, patients attempt to immobilize the affected joint or joints and avoid flexion, extension, and lateral bending of the spine; they may also attempt to retract the scapulae in an attempt to relieve pain. The costovertebral joint may be tender to palpation and hot and swollen when acutely inflamed. Patients may complain of a clicking sensation when moving this joint. Because ankylosing spondylitis often involves both the costovertebral and sacroiliac joints, many patients may develop a hunched posture, which should alert clinicians to the possibility of this disorder as a cause of costovertebral joint pain.
Survey
Plain radiography and CT are indicated in all patients with pain thought to originate at the costovertebral joint to exclude occult bone pathology, including tumor. In the presence of trauma, radionuclide bone scans may be useful to detect occult rib or sternum fractures. Laboratory tests for collagen vascular diseases and other joint diseases, including ankylosing spondylitis, are indicated in patients with costovertebral joint pain, especially if other joints are intact. Because of the frequent involvement of the costovertebral joint in ankylosing spondylitis, HLA B-27 testing should be considered. Additional tests, such as complete blood count, prostate-specific antigen, erythrocyte sedimentation rate, and antinuclear antibodies, may also be performed if clinically indicated. MRI is indicated if joint instability or tumor is suspected or to further elucidate the cause of pain.
Differential diagnosis
As stated previously, costovertebral joint syndrome pain is often mistaken for pulmonary or cardiac pain, leading to emergency department visits and unnecessary pulmonary or cardiac support. If trauma is present, costovertebral joint syndrome may coexist with broken ribs or a spinal or sternum fracture, which may be missed on plain radiography and may require radionuclide bone scanning for more definitive identification.
Neuropathic chest wall pain may be confused with or coexist with costovertebral joint syndrome. Examples of such neuropathic pain are diabetic neuropathy and acute herpes zoster affecting the thoracic nerves. Diseases of the mediastinal structures are possible and difficult to diagnose. Pathological processes that lead to inflammation of the pleura, such as pulmonary thrombus, infection, Bornholm disease, can also complicate diagnosis and treatment.
Complications and diagnostic errors
Since many pathological processes can imitate pain from the costovertebral joint, the doctor must exclude diseases of the lungs, heart, and structures of the spine and mediastinum. Failure to do so can lead to serious consequences.
The main complication of the injection technique is pneumothorax, if the needle is positioned too laterally or enters deeply into the pleural cavity. Infection, quite rarely, can occur if asepsis is violated. Trauma to the mediastinal structures is also possible. The incidence of these complications can be significantly reduced by strictly observing the correct positioning of the needle.
Patients with pain originating from the costovertebral joint may be convinced that they are suffering from pneumonia or myocardial infarction. They need to be reassured.
[ Treatment of the costovertebral joint
Initial treatment for pain and dysfunction in costovertebral joint syndrome is NSAIDs (eg, diclofenac or lornoxicam). Local application of heat and cold may be effective. Application of an elastic rib wrap may provide pain relief and protect the costovertebral joint from further trauma. For patients who do not respond to these treatments, the next step is injection of local anesthetics and steroids into the costovertebral joint. Gentle exercise is indicated for a few days after the steroid injection. Excessive exercise should be avoided, as it worsens symptoms. Simple analgesics and NSAIDs may be used concurrently with the injections.