Causes of Pain

Chest pain can have many causes and does not necessary have anything to do with Tietze. It can for example be caused by  a hearth condition . It is important to check this first because hart condition can be life threatening in the short term. That's why doctors often start with an electrocardiogram (ECG) and a x-ray of the chest and a number of blood tests.  If they still find the symptoms suspicious even though the  tests results are normal, they might yet send  the patient to a hospital for observation, because  these normal tests cannot exclude the possibility of a heart attack.

Mechanism of respiration

When we inhale the external intercostal muscles (between the ribs) and diaphragm contract to expand the chest cavity. The intercostal muscles move the rib cage upwards and out. (fig. 1)

    afbeelding 1. Inademen

When we exhale, the external intercostal muscles relax and therefore also the tension on the ribs relax. (fig.2)

afbeelding 2. Uitademen

 

Tietze and costochondritis

To make movement of the ribcage possible for inhaling and exhaling, the ribs are connected to the sternum with flexible cartilage. When a sudden sharp pain on the ribcage near the connection of a rib to the sternum can be felt and when pressure on the sternum or the rib causes even more pain, it could be an indication that this might be Tietze syndrome. This is  a barely understood inflammation  of the cartilage connection between ribs and sternum.

It is not a life threatening condition however it can cause severe pain, even more when coughing or sneezing. With Tietze, no abnormalities will be found in the blood. If the same kind of pain is felt at other cartilage connection than the sternum/rib, it is most likely costochondritis.

If pain only occurs near the sternum and is there a swelling near the sternum, it could be an indication for Tietze Syndrome. Is the pain on other parts of the ribs, it could be an indication for costochondritis.

 

Sternum

The sternum is a flat bone, 15-20 cm long, located in the middle front side of the chest and consists of three parts.

  • The manibrium
  • The body
  • xiphoid process

On both sides of the sternum there are seven notches for the connection of the cartilage of the upper seven ribs. The top of the sternum has also two sideway notches for connection to the collar bones. The sternum is a complex joint as it also is the place where other muscles, nerve system (plexus Solaris) and tendons are connected. The Xiphoid Process is a swordlike extension  that mostly is made of cartilage.

With Tietze it must be noted that the first manifestations of the swelling will be located at the lower part of the sternum. The sternum is diagnostically important, because the pain  that occur with many diseases, like Angina Pectoris, Hart attack, embolic lung, gastric ulcer or pancreatitis, will be felt near the sternum.

 

afbeelding 3

Gliding Joint

is a common type of joint formed between bones that meet at flat or nearly flat articular surfaces. Gliding joints allow the bones to glide past one another in any direction along the plane of the joint – up and down, left and right, and diagonally. When two bones are exposed to forces, for example shocks or movements like walking, lifting or pushing, they glide past each other and friction will occur. The  friction surface of every joint is covered with cartilage that acts as a buffer. This cartilage is constantly renewed.

afbeelding 4    

 

 

Cartilage

Cartilage is more flexible and tougher than the calcium rich bones and plays an important role in the functioning and movements of the joints The most bones in the body start as cartilage that solidifies (ossified) during the growing process. At the outer ends of the bones, where they connect with other bones the cartilage does not ossify, but becomes a flexible connection. The contraction and relaxation of the chest during inhalation and exhalation is possible because of the flexible cartilage between ribs and sternum.

Cartilage is composed of a dense network of collagen fibres embedded in a firm, gelatinous ground substance that has the consistency of plastic; this structure gives the tissue tensile strength, enabling it to bear weight while retaining greater flexibility than bone. Cartilage cells, called chondrocytes, occur at scattered sites through the cartilage and receive nutrition by diffusion through the gel; cartilage contains no blood vessels or nerves, unlike bone.

There are three types of cartilage:

  • Hyaline cartilage: This is a low-friction, wear-resistant tissue present within joints that is designed to bear and distribute weight. It is a strong, rubbery, flexible tissue but has a poor regenerative capacity.
  • Elastic cartilage:  this cartilage is more flexible that hyaline cartilage and is present in the ear, larynx and epiglottis.
  • Fibro cartilage: This is a tough and inflexible form of cartilage found in the knee and between vertebrae.

Articular cartilage

Articular cartilage is the hyaline cartilage that covers the ends of bones. It has a smooth, slippery surface, which allows the bones of the joints to slide over each other without rubbing. This slick surface is designed to minimize pressure and friction as you move. When the cartilage wears off (Artrose) of gets infected (Tietze)  movements of the joints become difficult or painful.

Simular disorders

Pain in the chest can be caused by a wedged nerve in the back, a gastric ulcer, gall stones etc. or a contusion of ribs or a broken rib. If local pain can be felt on the chest without swelling or pain on the ribs, and the patient can exactly  point the location of the pain and can arouse it, it is most likely plain muscle pain. It is always reassuring if a patient feels  pain when the doctor presses on a rib. After all, the hearth is sheltered beneath a bony cage and won't hurt when the doctor presses on someone's chest. If the local pain suddenly appears combined with redness, fever, overall tiredness and weight loss, the pain may be the result of some form of Rheuma.

Disorders with similar symptoms

ANGINA PECTORIS (Hart disorders) Very often someone a person with Tietze resembling symptoms ends up at the cardiologist., mostly because the pain has a tightening and pressing character.  It feels like a heart attack. Examination very often reveals that it is not Angina Pectoris.

OSTEOARTHRITIS This is one of the most common type of disease of the Joints. Pain and stiffness  occurs frequently and  sometimes the joint completely freezes.  With this disease the cartilage of the joint slowly disintegrate over time, the bone structure changes and sometimes a bone infection may occur. 

OESOPHAGUS Pain in the chest can be caused by an inflammation or burning of the oesophagus from hot food and drinks or from reflux of gastric acids.

STOMACH PAIN The pain can radiate to chest and shoulder and therefore might indicate Tietze, but examination by a doctor will reveal it is not Tietze.

BOWEL PAIN Constipation, polyps or nervousness of the intestines can result in pain in the chest area. Examination will reveal the real cause. 

OSTEOPOROSIS decalcification of the bones will occur in later age and can cause pain in the chest area. 

PSYCHOSOMATIC CHESTPAIN  Unexplained  (imagined) chest pain that can occur in stressful situations and will disappear as sudden as they appear. Like for example the pain suddenly disappears when "a doctor looks at it".

FYBROMYALGIA (Soft tissue Rheuma)  Fibromyalgia syndrome is a common and chronic disorder characterized by widespread pain, diffuse tenderness, sleep deprivation and a number of other symptoms. Although fibromyalgia is often considered an arthritis-related condition, it is not truly a form of arthritis (a disease of the joints) because it does not cause inflammation or damage to the joints, muscles, or other tissues. Like arthritis, however, fibromyalgia can cause significant pain and fatigue, and it can interfere with a

person’s ability to carry on daily activities. Also like arthritis, fibromyalgia is considered a rheumatic condition, a medical condition that impairs the joints and/or soft tissues and causes chronic pain. Fibromyalgia affects approx. 2 out of 100 people, mostly women but men and children can be affected too. Symptoms look very much like Tietze when they occur in the chest area. Diagnosis is difficult as x-rays and blood tests don't show anything abnormal. Patients very often end up at rheumatologist or chronic pain clinics. The causes of fibromyalgia are unknown, but there are probably a number of factors involved. Many people associate the development of fibromyalgia with a physically or emotionally stressful or traumatic event, such as an automobile accident. Some connect it to repetitive injuries. Others link it to an illness. For others, fibromyalgia seems to occur spontaneously. Because of its character, fibromyalgia can have a negative effect on the quality of life.