(Kiosk 2) The Cost of Missed Costovertebral Joint Dysfunction

Case Diagnosis: Costovertebral Joint Dysfunction

Case Description: Patient is a 34-year-old male with a history of anxiety who presented with 2.5 years of left sided chest wall pain, initially diagnosed by cardiology as pericarditis via EKG secondary to Covid-19 Vaccine, and treated with colchicine for 6 weeks without relief. Echocardiogram and cardiac MRI were normal. He was referred to rheumatology and diagnosed with costochondritis via physical exam. He was provided standard treatment, including a Medrol Dosepak and NSAIDs without relief. He also completed 1 month of exercise-based physical therapy without improvement. He presented to our outpatient musculoskeletal clinic reporting intermittent episodic pain, lasting 2-3 months with 1-2 weeks of relief in between. Pain was located diffusely at the costochondral and sternocostal junctions of the middle ribs, left greater than right, with a migratory pattern. On examination, observation revealed mild thoracolumbar dextroscoliosis. Pain was reproduced with right greater than left thoracic rotation active range of motion testing. He reported concordant pain with T4-T6 accessory motion testing as well as with testing of left ribs 4-6; hypomobility was noted in these segments. He was diagnosed with costovertebral dysfunction and referred to physical therapy.

Discussion: This case report first highlights the importance of a comprehensive musculoskeletal physical exam in proper diagnosis of atypical chest pain, and secondarily thoracic spine and rib dysfunction as a cause of persistent chest pain in a patient mistakenly diagnosed with pericarditis and costochondritis.

Setting: Outpatient Musculoskeletal Clinic

Assessment/Results: Patient was seen by physical therapy for 6 sessions over 5 weeks. Treatment included joint mobilization to costovertebral and facet joints at posterior aspect of ribs 4-6 followed by thoracic rotation mobility exercises and scapular stabilization. By the sixth session, thoracic rotation demonstrated mild discomfort to the right. ODI improved from 20% to 10% disability.

Conclusion: Consider mechanical dysfunction as a musculoskeletal etiology of persistent chest wall pain.