Tietze syndrome

Tietze syndrome is a benign, non-suppurative inflammatory condition affecting the anterior chest wall — typically presenting as painful, tender swelling at the costochondral, sternocostal, or sternoclavicular junctions. Though frequently confused with costochondritis, Tietze syndrome is distinct in its association with focal swelling, often of the second or third rib cartilage. Most cases are unilateral and localised, with symptom onset that may be acute or insidious.

First described by German surgeon Alexander Tietze in 1921, the condition remains relatively rare and is frequently misdiagnosed, especially in emergency settings where musculoskeletal chest pain accounts for up to 50% of non-cardiac presentations. The primary clinical concern is differentiation from life-threatening causes of chest pain such as acute coronary syndromes or pulmonary embolism.

Aetiology and Pathogenesis: The precise aetiology remains uncertain. Proposed mechanisms include:

• Microtrauma to the chest wall (e.g., repetitive coughing, vomiting, physical strain)
• Associations with respiratory tract infections, psoriatic arthritis, or viral illness (including post-COVID-19 cases)
• Rarely, linked to thoracic surgery or minor trauma

Histologically, affected cartilage may show peripheral hypertrophy, increased vascularity, and mucopolysaccharide clefts, occasionally with calcification.

Clinical Presentation

• Chest pain: dull, sharp, or aching; may radiate to shoulder/arm
• Tender swelling: firm, often spindle-shaped over costal cartilage (typically rib 2 or 3)
• Symptoms worsened by:
  • Coughing, sneezing
  • Deep inspiration
  • Movement of the ipsilateral arm or trunk

Symptoms are usually unilateral and self-limiting, though may last weeks to months. Unlike costochondritis, visible swelling is common and diagnostic.

Examination

• Localised tenderness and swelling over the upper costochondral junctions
• No systemic signs (fever, malaise)
• No abnormalities on cardiopulmonary auscultation
• NOTE: Chest wall tenderness reproducible on palpation, differentiating from visceral pain

Differential Diagnosis: Tietze syndrome should be distinguished from:

• Costochondritis (no swelling; usually multiple joints)
• Myocardial infarction, angina
• Pleurisy, pulmonary embolism, aortic dissection
• Rib fractures, neoplasms, slipping rib syndrome
• Intercostal neuralgia, rheumatic disorders (e.g., RA, AS)

Investigations: Tietze syndrome is a clinical diagnosis of exclusion. Investigations are aimed at ruling out serious pathology.

• ECG, troponin, CXR — rule out cardiac/pulmonary causes
• Ultrasound or MRI may demonstrate:
  • Costal cartilage thickening
  • Bone marrow oedema
  • Increased signal intensity on T2/STIR
• Bone scintigraphy (rarely used) may show focal uptake
• Routine bloods typically normal

Management

• Reassurance is central: benign, self-limited course
• First-line:
  • NSAIDs, heat therapy
  • Activity modification
• Second-line (refractory cases):
  • Local corticosteroid injection
  • Lidocaine for diagnostic/therapeutic relief
  • Rarely, surgical excision (if persistent swelling causes distress)

Symptoms usually resolve within a few weeks, but swelling can linger for months.

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History of Tietze syndrome

1921 – Alexander Tietze (1864-1927) described the condition based on cases of painful, non-suppurative costochondral swelling. The publication established a distinct clinical entity from infectious or suppurative arthritis of the chest wall in Über eine eigenartige Häufung von Fällen mit Dystrophie der Rippenknorpel. The original description differentiated the condition from chest wall infections and malignancy.

In discussing the aetiology Tietze tentatively suggested that the condition represented a dystrophic change in the cartilage analogous to the bone disease of nutritional origin which was prevalent in Germany in the early 1920’s

1921 – Fröhlich reported an additional case on November 14, 1921 at the Breslauer Chirurgischen Gesellschaft and published in the Berliner klinische Wochenschrift. The case was reviewed by Tietze and Hermann Küttner (1870–1932)

1923 – Dr H. Harttung reported a detailed case study of a 24-year-old male labourer presenting with painful swelling of the left 1st–4th costal cartilages, closely mirroring Tietze’s earlier description. He confirmed the absence of tuberculosis, performed cartilage biopsy. Histology (via Prof Winkler) revealed Calcification, atrophic changes, and fibrous transformation consistent with degenerative processes linked to nutritional deficits

1937 – Satani and Fujii reported a series of nine cases of Tietze disease in under‑nourished women. Radiographs: in one case atrophy of rib cartilage; in another, rib shortening and cartilage calcification; in all the others radiology normal. Biopsies: fibrosis, ossification, atrophy, no granulation tissue or pus.

1942 – A. Morton Gill, R. Arden Jones and Leo Pollak reported on “Tietze’s Disease: (non‑suppurative non‑specific swellings of rib cartilage)” in the British Medical Journal. This article added five new cases of the condition originally described by Alexander Tietze, and for the first time highlighted a consistent association with recent respiratory tract infection rather than overt malnutrition or tuberculosis.

An account is given of a syndrome first described by Tietze in which non-suppurative non-specific swellings appear affecting rib cartilage, and 5 cases are added to the 16 already recorded. The association with respiratory tract infections has not previously been noted.

Gill, Jones and Pollack 1942

This shifted the etiological emphasis away from nutritional dystrophy (as originally proposed by Tietze) and toward post‑infectious/respiratory‑triggered cartilage changes, expanding the conceptual framework and influencing subsequent classification of the syndrome.

1945 – Aubrey Kent Geddes (1898–1968) reported 22 cases of non-suppurative, non-specific swelling of the rib cartilages seen in Canadian soldiers stationed in England during WWII. He published “Tietze’s Syndrome” in the Canadian Medical Association Journal, and emphasised:

• Seasonal clustering in autumn and winter
• A consistent antecedent of upper respiratory tract infection
• No clear link to malnutrition
• Histopathology showed fibrocartilage metaplasia, calcification, early bone formation, and perichondrial thickening

A condition receiving very little attention in the literature but which … is by no means rare in the Canadian Army

1954 – Benson and Zavala proposed the term “costochondral syndrome” to replace “costochondritis” due to absence of inflammation. In their JAMA paper on the Importance of the costochondral syndrome in evaluation of chest pain they evaluated 62 cases and highlighted frequent misdiagnosis as cardiac pain and the emotional distress associated. They stressed importance of posture, respiratory strain, and chest wall trauma.

Over the past several years we have seen many patients whose chest pains definitely originated in the costochondral junctions… most physicians are unaware of the frequency of the condition.

Benson, Zavala 1954

1955 – Wehrmacher and Kayser discussed Tietze syndrome in wider differential of anterior chest pain and reinforced radiologic and clinical criteria.

2000s–Present

• Modern classification distinguishes between:
  • Tietze Syndrome: Localized swelling + pain, usually upper costochondral junctions, benign.
  • Costochondritis: Pain without swelling, more diffuse, typically multiple joints.
• Causes: include microtrauma, infection, strain, and possibly autoimmune conditions.
• Imaging (e.g., ultrasound, MRI) used to rule out serious causes (neoplasia, infections).
• Management: Reassurance, NSAIDs, physical therapy, sometimes corticosteroid injections.

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Associated Persons

• Alexander Tietze (1864-1927)
• Aubrey Kent Geddes (1898–1968)

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Alternative names

• Costochondral junction syndrome
• Chondropathia tuberosa
• Tietze-Syndrom
• Tietze’s Disease, Tietze’s Disease

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Eponymic chest pain syndromes

• Bornholm disease
• Tietze syndrome
• Syndrôme de Huchard or Texidor Twinge
• Da Costa syndrome
  

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References

Historical articles

• Tietze A. Über eine eigenartige Häufung von Fällen mit Dystrophie der Rippenknorpel. [About a peculiar accumulation of cases with dystrophy of costal cartilage] Berliner klinische Wochenschrift. 1921; 58(2): 829-831
• Frohlich. Rippenknorpelerkrankung: Breslauer Chirurgischen Gesellschaft. In: Berliner klinische Wochenschrift. 1921; 58(2): 1544-1545
• Harttung H. Über eine eigenartige Rippenknorpelerkrankung. Zentralblatt für Chirurgie 1923; 50(9): 333-336.
• Davies-Colley R. Some Affections of Ribs, Guy’s Hospital Gazette. 1927; 41: 290-293
• Satani H, Fujii S. Über 9 Fälle von Tietze’scher Krankheit, Mitteilungen aus der Medizinischen Akademie zu Kioto. 1937; 21: 1716

Eponymous terms review

• Gill AM, Arden R, Pollak L. Tietze’s Disease. Br Med J. 1942 Aug 8;2(4257):155-6.
• Geddes AK. Tietze’s Syndrome. Can Med Assoc J. 1945 Dec;53(6):571-3.
• Benson EH, Zavala DC. Importance of the costochondral syndrome in evaluation of chest pain: report of sixty-two cases. J Am Med Assoc. 1954 Nov 27;156(13):1244-6.
• Wehrmacher WH. Significance of Tietze’s Syndrome in Differential Diagnosis of Chest Pain. JAMA 1955; 157: 505-507
• Frey GH. Tietze’s syndrome; a new entity in the differential diagnosis of anterior chest wall swelling. AMA Arch Surg. 1956 Dec;73(6):951-4.
• Kayser HL. Tietze’s syndrome. A review of literature. Am J Med. 1956 Dec; 21(6): 982-9.
• Landon J, Malpas JS. Tietze’s Syndrome. Ann Rheum Dis. 1959 Sep; 18(3): 249–254.
• Cameron HU, Fornasier VL. Tietze’s disease. J. clin. Path., 1974, 27, 960-962
• Grodin L, Farina G. Tietze’s Syndrome in the emergency department: A rare etiology of atraumatic chest pain. Case Reports in Clinical Medicine, 2013; 2: 208-210.
• Rokicki W, Rokicki M, Rydel M. What do we know about Tietze’s syndrome? Kardiochir Torakochirurgia Pol. 2018 Sep;15(3):180-182. 
• Mott T, Jones G, Roman K. Costochondritis: Rapid Evidence Review. Am Fam Physician. 2021 Jul 1;104(1):73-78.
• Rosenberg M, Sina RE, Conermann T. Tietze Syndrome. 2024