View source for Tietze syndrome

{{Short description|Inflammation, tenderness, and pain of the chest wall with swelling present}}
{{distinguish|Tietz syndrome}}
{{good article}}
{{cs1 config|name-list-style=vanc}}
{{Infobox medical condition
| name          = Tietze syndrome
| image         = Gray315.png
| caption       = [[Sternocostal joints|Sternocostal]] and [[interchondral joints|interchondral]] joints
| pronounce     = 
| field         = [[Family medicine]], [[general practitioners]], [[internal medicine]], [[rheumatology]], [[orthopedics]]
| synonyms      = 
| symptoms      = [[Chest pain]], [[edema|swelling]] and [[tenderness (medicine)|tenderness]] of the chest
| complications = 
| onset         = 
| duration      = 
| types         = 
| causes        = 
| risks         = 
| diagnosis     = [[Physical examination]], [[Diagnosis of exclusion|the ruling out of other conditions]], [[radiology|radiologic]] imaging
| differential  = [[Angina|Angina pectoris]], [[myocardial infarction]], [[pleurisy]], [[pneumothorax]], [[pulmonary embolism]], [[neoplasm]], [[aortic dissection]], [[pneumonia]], [[rib fracture]], [[costochondritis]], [[slipping rib syndrome]], intercostal [[neuralgia]], [[rheumatism|rheumatic disorders]]
| prevention    = 
| treatment     = [[Analgesics]], [[Nonsteroidal anti-inflammatory drugs|NSAIDs]], [[manual therapy]], [[heat therapy]], [[nerve blocks]], [[surgery|surgical intervention]]
| medication    = 
| prognosis     = 
| frequency     = 
| deaths        = 
}}

'''Tietze syndrome''' is a benign [[inflammation]] of one or more of the [[costal cartilage]]s. It was first described in 1921 by German surgeon [[Alexander Tietze]] and was subsequently named after him. The condition is characterized by [[Tenderness (medicine)|tenderness]] and painful [[Edema|swelling]] of the anterior (front) [[chest wall]] at the [[Costochondral joint|costochondral]] (rib to cartilage), [[Sternocostal joints|sternocostal]] (cartilage to sternum), or [[Sternoclavicular joint|sternoclavicular]] (clavicle to sternum) junctions. Tietze syndrome affects the [[true rib]]s and has a predilection for the 2nd and 3rd ribs, commonly affecting only a single joint.

In environments such as the emergency department, an estimated 20-50% of non-cardiac chest pain is due to a musculoskeletal cause.<ref name="sawada">{{cite journal | vauthors = Sawada K, Ihoriya H, Yamada T, Yumoto T, Tsukahara K, Osako T, Naito H, Nakao A | display-authors = 6 | title = A patient presenting painful chest wall swelling: Tietze syndrome | journal = World Journal of Emergency Medicine | volume = 10 | issue = 2 | pages = 122–4 | date = 2019 | pmid = 30687451 | pmc = 6340818 | doi = 10.5847/wjem.j.1920-8642.2019.02.011 }}</ref> Despite [[Musculoskeletal disorder|musculoskeletal conditions]] such as Tietze syndrome being a common reason for visits to the emergency room, they are frequently misdiagnosed as [[angina pectoris]], [[pleurisy]], and other serious [[cardiopulmonary]] conditions due to similar presentation. Though Tietze syndrome can be misdiagnosed, life-threatening conditions with similar symptoms such as [[myocardial infarction]] (heart attack) should be ruled out prior to diagnosis of other conditions.

Tietze syndrome is often confused with [[costochondritis]]. Tietze syndrome is differentiated from costochondritis by swelling of the costal cartilages, which does not appear in costochondritis. Additionally, costochondritis affects the 2nd to 5th ribs while Tietze syndrome typically affects the 2nd or 3rd rib.

==Presentation==
Tietze syndrome typically presents unilaterally at a single joint of the anterior chest wall, with 70% of patients having tenderness and swelling on only one side, usually at the 2nd or 3rd rib.<ref name="rokicki">{{cite journal|vauthors=Rokicki W, Rokicki M, Rydel M|date=September 2018|title=What do we know about Tietze's syndrome?|journal=Kardiochirurgia i Torakochirurgia Polska = Polish Journal of Cardio-Thoracic Surgery|volume=15|issue=3|pages=180–2|doi=10.5114/kitp.2018.78443|pmc=6180027|pmid=30310397}}</ref><ref name="kayser">{{cite journal|vauthors=Kayser HL|date=December 1956|title=Tietze's syndrome; a review of the literature|journal=The American Journal of Medicine|volume=21|issue=6|pages=982–9|doi=10.1016/0002-9343(56)90111-5|pmid=13372573}}</ref> Research has described the condition to be both [[Acute (medicine)|sudden]]<ref name="Geddes">{{cite journal | vauthors = Geddes AK | title = Tietze's Syndrome | journal = Canadian Medical Association Journal | volume = 53 | issue = 6 | pages = 571–3 | date = December 1945 | pmid = 20323631 | pmc = 1582475 }}</ref> and gradual, varying by the individual.<ref name="stochkendahl">{{cite journal|vauthors=Stochkendahl MJ, Christensen HW|date=March 2010|title=Chest pain in focal musculoskeletal disorders|journal=The Medical Clinics of North America|volume=94|issue=2|pages=259–73|doi=10.1016/j.mcna.2010.01.007|pmid=20380955}}</ref><ref name="levey">{{Cite journal|vauthors=Levey GS, Calabro JJ|date=June 1962|title=Tietze's syndrome: Report of two cases and review of the literature|journal=Arthritis & Rheumatism|language=en|volume=5|issue=3|pages=261–9|doi=10.1002/art.1780050306|doi-access=free}}</ref> Pain and swelling from Tietze syndrome are typically chronic and intermittent and can last from a few days to several weeks.<ref name="levey" />

The most common symptom of Tietze syndrome is pain, primarily in the [[Chest pain|chest]], but can also [[Radicular pain|radiate]] to the [[Shoulder pain|shoulder]] and arm.<ref name="rokicki" /><ref name="levey" /> The pain has been described as aching, gripping, neuralgic, sharp, dull, and even described as "gas pains".<ref name="kayser" /> The symptoms of Tietze syndrome have been reported to be exacerbated by sneezing, coughing, deep inhalation, and overall [[Exertion#Physiological|physical exertion]].<ref name="stochkendahl" /><ref name="aim">{{cite journal|vauthors=Bernreiter M|date=July 1956|title=Tietze's syndrome|journal=Annals of Internal Medicine|volume=45|issue=1|pages=132–4|doi=10.7326/0003-4819-45-1-132|pmid=13340574}}</ref> Tenderness and swelling of the affected joint are important symptoms of Tietze syndrome and differentiate the condition from [[costochondritis]].<ref name="wangseok">{{cite journal|vauthors=Do W, Baik J, Kim ES, Lee EA, Yoo B, Kim HK|date=April 2018|title=Atypical Tietze's Syndrome Misdiagnosed as Atypical Chest Pain: Letter to the Editor|journal=Pain Medicine|volume=19|issue=4|pages=813–5|doi=10.1093/pm/pnx213|pmid=29025153|doi-access=free}}</ref><ref name="jurik">{{cite journal|vauthors=Jurik AG, Graudal H|date=January 1988|title=Sternocostal joint swelling--clinical Tietze's syndrome. Report of sixteen cases and review of the literature|journal=Scandinavian Journal of Rheumatology|volume=17|issue=1|pages=33–42|doi=10.3109/03009748809098757|pmid=3285453}}</ref> It has also been suggested that discomfort can be further aggravated due to restricted shoulder and chest movement.<ref name="kennedy">{{cite journal | vauthors = Kennedy AC | title = Tietze's syndrome; an unusual cause of chest wall swelling | journal = Scottish Medical Journal | volume = 2 | issue = 9 | pages = 363–5 | date = September 1957 | pmid = 13467305 | doi = 10.1177/003693305700200904 | s2cid = 7942778 }}</ref>

==Cause==
The true [[Cause (medicine)|etiology]] of Tietze syndrome has not been established, though several theories have been proposed. One popular theory is based on observations that many patients begin developing symptoms following a [[Respiratory tract infection|respiratory infection]] and [[Cough#Differential diagnosis|dry cough]], with one study finding 51 out of 65 patients contracted Tietze syndrome after either a cough or respiratory infection.<ref name="kayser" /><ref name="landon">{{cite journal | vauthors = Landon J, Malpas JS | title = Tietze's syndrome | journal = Annals of the Rheumatic Diseases | volume = 18 | issue = 3 | pages = 249–54 | date = September 1959 | pmid = 14413814 | pmc = 1007107 | doi = 10.1136/ard.18.3.249 }}</ref><ref name="motulsky">{{cite journal | vauthors = Motulsky A, Rohn RJ | title = Tietze's syndrome; cause of chest pain and chest wall swelling | journal = Journal of the American Medical Association | volume = 152 | issue = 6 | pages = 504–6 | date = June 1953 | pmid = 13044558 | doi = 10.1001/jama.1953.03690060020007 }}</ref> Thus, it has been hypothesized that the repetitive mild [[Injury|trauma]] of a severe cough from a respiratory infection may produce small tears in the [[Costal cartilage|ligament]] called [[microtrauma]],<ref name="levey" /><ref name="Kim">{{Cite journal| vauthors = Kim DC, Kim SY, Kim BM |date=2020|title=Dynamic Contrast-Enhanced MR Imaging of Tietze's Syndrome: a Case Report |journal=Investigative Magnetic Resonance Imaging |volume=24|issue=1|pages=55|doi=10.13104/imri.2020.24.1.55 |s2cid=216159576 |doi-access=free }}</ref> causing Tietze syndrome.<ref name="motulsky" /><ref name="wehrmacher">{{cite journal | vauthors = Wehrmacher WH | title = Significance of Tietze's syndrome in differential diagnosis of chest pain | journal = Journal of the American Medical Association | volume = 157 | issue = 6 | pages = 505–7 | date = February 1955 | pmid = 13221462 | doi = 10.1001/jama.1955.02950230019009 }}</ref> However, this theory is disputed as it does not account for symptoms such as the onset of attacks while at rest as well as the fact that swelling sometimes develops before a cough.<ref name="landon" /><ref name="Kim" /><ref name="ishibashi">{{cite journal | vauthors = Ishibashi A, Nishiyama Y, Endo M, Kawaji W, Kato T | title = Orthopedic symptoms in pustular bacterid (pustulosis palmaris et plantaris): Tietze's syndrome and arthritis of manubriosternal joint due to focal infection | journal = The Journal of Dermatology | volume = 4 | issue = 2 | pages = 53–9 | date = April 1977 | pmid = 15461326 | doi = 10.1111/j.1346-8138.1977.tb01011.x | s2cid = 13298760 }}</ref> The respiratory infection has also been observed accompanying [[rheumatoid arthritis]]<ref name="levey" /><ref name="motulsky" /> which, coupled with [[leukocytosis]],<ref name="rokicki" /><ref name="karabudak">{{cite journal | vauthors = Karabudak O, Nalbant S, Ulusoy RE, Dogan B, Harmanyeri Y | title = Generalized nonspecific pustular lesions in Tietze's syndrome | journal = Journal of Clinical Rheumatology | volume = 13 | issue = 5 | pages = 300–1 | date = October 2007 | pmid = 17921807 | doi = 10.1097/RHU.0b013e3181581e1b }}</ref> [[neutrophilia]],<ref name="motulsky" /> [[c-reactive protein]] (CRP),<ref name="karabudak" /> and elevated [[erythrocyte sedimentation rate]] (ESR),<ref name="jurik" /><ref name="motulsky" /> suggest an [[Infection|infectious]] and [[rheumatoid]] factor, though the evidence is conflicting.<ref name="ishibashi" /> Many theories such as [[malnutrition]],<ref name="tietze">{{cite journal|author=Tietze A|year=1921|title=Über eine eigenartige Häufung von Fällen mit Dystrophie der Rippenknorpel|trans-title=About a strange accumulation of cases with dystrophy of the costal cartilage|journal=Berliner klinische Wochenschrift|language=German|volume=58|pages=829–31}}</ref><ref name=":0">{{Cite journal|last=McSweeny|first=AJ|date=September 1958|title=Treatment of Tietze Disease with Prednisolone|url=http://archinte.jamanetwork.com/article.aspx?doi=10.1001/archinte.1958.00030010459018|journal=Archives of Internal Medicine|language=en|volume=102|issue=3|pages=459–461|doi=10.1001/archinte.1958.00030010459018|pmid=13570735 |issn=0003-9926|url-access=subscription}}</ref> [[Chest injury|chest trauma]],<ref name="kennedy" /> and [[tuberculosis]],<ref name="tietze" /> were thought to be among the potential causes but have since been disproven or left unsupported.<ref name="Geddes" /><ref name="motulsky" /><ref name="wehrmacher" />

==Diagnosis==
[[Medical diagnosis|Diagnosis]] for Tietze syndrome is primarily a clinical one, though some studies suggest the use of [[Radiology|radiologic]] imaging.<ref name="sawada" /><ref name="martino">{{cite journal | vauthors = Martino F, D'Amore M, Angelelli G, Macarini L, Cantatore FP | title = Echographic study of Tietze's syndrome | journal = Clinical Rheumatology | volume = 10 | issue = 1 | pages = 2–4 | date = March 1991 | pmid = 2065502 | doi = 10.1007/BF02208023 | s2cid = 40467215 }}</ref> [[Musculoskeletal disorder|Musculoskeletal conditions]] are estimated to account for 20-50% of non-[[cardiac]] related chest pain in the emergency department.<ref name="sawada" /> Ruling out other conditions, especially potentially life-threatening ones such as [[myocardial infarction]] (heart attack) and [[angina|angina pectoris]], is extremely important as they can present similarly to Tietze syndrome.<ref name="wangseok" /> These can usually be ruled out with diagnostic tools such as an [[electrocardiogram]] and a physical examination showing reproducible [[Thoracic wall|chest wall]] tenderness, .<ref name="sawada" /><ref name="levey" /> After eliminating other possible conditions, physical examination is considered the most accurate tool in diagnosing Tietze syndrome. Physical examination consists of gentle pressure to the chest wall with a single finger to identify the location of the discomfort.<ref name="rokicki" /> [[Edema|Swelling]] and [[Tenderness (medicine)|tenderness]] upon [[palpation]] at one or more of the [[Costochondral joint|costochondral]], [[Sternocostal joints|sternocostal]], or [[Sternoclavicular joint|sternoclavicular]] joints, is a distinctive trait of Tietze syndrome and is considered a positive diagnosis when found.<ref name="rokicki" /><ref name="kayser" />

There are some [[Pathology|pathological]] features that can be observed with Tietze syndrome, including degeneration of the [[costal cartilage]], increase in [[Blood vessel|vascularity]], and [[Hypertrophy|hypertrophic]] changes (enlarged cells).<ref name="cameron">{{cite journal | vauthors = Cameron HU, Fornasier VL | title = Tietze's disease | journal = Journal of Clinical Pathology | volume = 27 | issue = 12 | pages = 960–2 | date = December 1974 | pmid = 4141710 | pmc = 475563 | doi = 10.1136/jcp.27.12.960 }}</ref> However, these features can only be identified from a [[biopsy]].<ref name="wangseok" /> Some studies have begun exploring and defining the use of radiographic imaging for diagnosing Tietze syndrome. This includes [[computed tomography]] (CT),<ref name="edelstein">{{cite journal | vauthors = Edelstein G, Levitt RG, Slaker DP, Murphy WA | title = Computed tomography of Tietze syndrome | journal = Journal of Computer Assisted Tomography | volume = 8 | issue = 1 | pages = 20–3 | date = February 1984 | pmid = 6690519 | doi = 10.1097/00004728-198402000-00004 | s2cid = 7068641 }}</ref> [[magnetic resonance imaging]] (MRI),<ref name="volterrani">{{cite journal | vauthors = Volterrani L, Mazzei MA, Giordano N, Nuti R, Galeazzi M, Fioravanti A | title = Magnetic resonance imaging in Tietze's syndrome | journal = Clinical and Experimental Rheumatology | volume = 26 | issue = 5 | pages = 848–53 | date = September 2008 | pmid = 19032818 }}</ref> [[bone scintigraphy]],<ref name="ikehira">{{Cite journal | vauthors = Ikehira H, Kinjo M, Nagase Y, Aoki T, Ito H | journal = The British Journal of Radiology | title = Acute pan-costochondritis demonstrated by gallium scintigraphy. | volume = 72 | issue = 854 | pages = 210–11 | date = February 1999 | pmid = 10365077 | doi = 10.1259/bjr.72.854.10365077 | issn = 0007-1285 | url = http://www.birpublications.org/doi/10.1259/bjr.72.854.10365077 | access-date = 2021-08-12 | archive-date = 2023-01-17 | archive-url = https://web.archive.org/web/20230117153542/https://www.birpublications.org/doi/10.1259/bjr.72.854.10365077 | url-status = dead | url-access = subscription }}</ref> and [[Medical ultrasound|ultrasound]],<ref name="kamel">{{cite journal | vauthors = Kamel M, Kotob H | title = Ultrasonographic assessment of local steroid injection in Tietze's syndrome | journal = British Journal of Rheumatology | volume = 36 | issue = 5 | pages = 547–50 | date = May 1997 | pmid = 9189056 | doi = 10.1093/rheumatology/36.5.547 | doi-access = free }}</ref> though these are only case studies and the methods described have yet to be thoroughly investigated.<ref name="volterrani" /> Methods such as plain [[Radiography|radiographs]], better known as an x-ray, are helpful in the exclusion of other conditions, but not in the diagnosis of Tietze syndrome.<ref name="levey" /><ref name="wangseok" /> Some researchers believe that ultrasound is superior to other available imaging methods, as it can visualize the increased volume, swelling, and structural changes of the [[costal cartilage]].<ref name="rokicki" /><ref name="wangseok" />

===Differential diagnosis===
The symptoms of Tietze syndrome can display as a wide variety of conditions, making it difficult to diagnose, especially to physicians unaware of the condition.<ref name="kennedy" /> Due to its presentation, Tietze syndrome can be misdiagnosed as a number of conditions, including [[myocardial infarction]] (heart attack), [[Angina Pectoris|angina pectoris]], and [[neoplasm]]s.<ref name="levey" /><ref name="wangseok" /><ref name="kennedy" />

[[Costochondritis]] is most commonly confused with Tietze syndrome, as they have similar symptoms and can both affect the costochondral and sternocostal joints. Costochondritis is considered a more common condition and is not associated with any swelling to the affected joints, which is the defining distinction between the two.<ref name="rokicki" /><ref name="stochkendahl" /> Tietze syndrome commonly affects the 2nd or 3rd rib and typically occurs among a younger age group,<ref name="rokicki" /> while costochondritis affects the 2nd to 5th ribs and has been found to occur in older individuals, usually over the age of 40. In addition, [[ultrasound]] can diagnose Tietze syndrome, whereas costochondritis relies heavily on physical examination and [[medical history]].<ref name="wangseok" />

Another condition that can be confused for Tietze syndrome and costochondritis is [[slipping rib syndrome]] (SRS). All three conditions are associated with chest pain as well as inflammation of the costal cartilage.<ref name="fares">{{Cite journal| vauthors = Fares MY, Dimassi Z, Baytown H, Musharrafieh U |title = Slipping Rib Syndrome: Solving the Mystery of the Shooting Pain | journal = The American Journal of the Medical Sciences | volume = 357 | issue = 2 |pages = 168–73 | date = February 2019 | pmid = 30509726 | doi = 10.1016/j.amjms.2018.10.007 |s2cid = 54554663 | url = https://linkinghub.elsevier.com/retrieve/pii/S0002962918303884| url-access = subscription }}</ref> Unlike both costochondritis and Tietze syndrome, which affect some of the [[true rib]]s (1st to 7th), SRS affects the [[false ribs]] (8th to 10th). SRS is characterized by the partial dislocation, or [[subluxation]], of the joints between the costal cartilages.<ref name ="turcios">{{Cite journal|last=Turcios|first=NL|date= March 2017 |title=Slipping Rib Syndrome: An elusive diagnosis|url=https://linkinghub.elsevier.com/retrieve/pii/S1526054216300094|journal=Paediatric Respiratory Reviews|language=en|volume=22|pages=44–6|doi=10.1016/j.prrv.2016.05.003|pmid=27245407 |url-access=subscription}}</ref> This causes [[inflammation]], irritated [[intercostal nerves]], and straining of the [[intercostal muscles]]. SRS can cause abdominal and back pain, which costochondritis does not.<ref name="mcmahon">{{Cite journal|last=McMahon|first=LE|date = June 2018|title=Slipping Rib Syndrome: A review of evaluation, diagnosis and treatment|url=https://linkinghub.elsevier.com/retrieve/pii/S1055858618300349|journal=Seminars in Pediatric Surgery|language=en|volume=27|issue=3|pages=183–8|doi=10.1053/j.sempedsurg.2018.05.009|pmid=30078490 |s2cid=51920821 |url-access=subscription}}</ref> Tietze syndrome and SRS can both present with [[Radicular pain|radiating pain]] to the [[Shoulder problem|shoulder]] and arm, and both conditions can be diagnosed with [[ultrasound]], though SRS requires a more complex [[Slipping rib syndrome#Diagnosis|dynamic ultrasound]].<ref name="van tassel">{{Cite journal | vauthors = Van Tassel D, McMahon LE, Riemann M, Wong K, Barnes CE | title = Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome | journal = Skeletal Radiology | volume = 48|issue = 5| pages = 741–51| date = May 2019 | pmid = 30612161 | doi = 10.1007/s00256-018-3133-z | s2cid = 57448080 | issn = 0364-2348| url = http://link.springer.com/10.1007/s00256-018-3133-z| url-access = subscription }}</ref>

The vast differential diagnosis also includes:
* [[Pleural disease]]s including [[pleurisy]], [[pneumonia]], [[pulmonary embolism]], and [[pneumothorax]].<ref name="wangseok" /><ref name="levey" />
* [[Rheumatism|Rheumatic disorders]] such as [[rheumatoid arthritis]], [[ankylosing spondylitis]], and [[rheumatic fever]].<ref name="jurik" />
* [[Arthritis]] of the [[costal cartilage]]s, including [[rheumatoid arthritis]], [[septic arthritis]] (pyogenic), [[monoarthritis]], and [[psoriatic arthritis]].<ref name="sawada" /><ref name="levey" /><ref name="Kim" />
* [[Neoplasm]]s, both [[Benign tumor|benign]] and [[Cancer|malignant]] (cancerous), including [[chondroma]], [[osteochondroma]], [[multiple myeloma]], [[osteosarcoma]], [[Hodgkin lymphoma]], and [[carcinoma]].<ref name="kayser" /><ref name="landon" />
* [[Nerve pain]], specifically intercostal [[neuritis]] and intercostal [[Peripheral neuropathy|neuropathy]].<ref name="wangseok" /><ref name="wehrmacher" />
*[[Aortic dissection]], a serious condition involving a tear in the body's largest [[artery]].<ref name="gologorsky" />

==Treatment==
Tietze syndrome is considered to be a [[Self-limiting (biology)|self-limiting]] condition that usually resolves within a few months with rest.<ref name="kayser" /> [[Pain management|Management]] for Tietze syndrome usually consists of [[analgesic]]s and [[nonsteroidal anti-inflammatory drug]]s (NSAIDs) such as [[ibuprofen]], [[aspirin]], [[acetaminophen]] (paracetamol), and [[naproxen]].<ref name="gologorsky">{{Cite journal| vauthors = Gologorsky R, Hornik B, Velotta J | title = Surgical Management of Medically Refractory Tietze Syndrome | journal = The Annals of Thoracic Surgery | volume = 104 | issue = 6 | pages = e443–45 | date = December 2017 | pmid = 29153814 | doi = 10.1016/j.athoracsur.2017.07.035 | issn = 0003-4975 | url = https://www.annalsthoracicsurgery.org/article/S0003-4975(17)31075-5/fulltext| doi-access = free | url-access = subscription }}</ref> Other methods of management include [[manual therapy]] and [[Heat therapy|local heat application]].<ref name="sawada" /><ref name="wehrmacher" /> These are intended to relieve pain and are not expected to treat or cure Tietze syndrome as the condition is expected to resolve on its own.

=== Intercostal nerve block ===
A [[nerve block]] can be utilized in cases where symptom management is not satisfactory in relieving pain.<ref name="rokicki" /><ref name="stochkendahl" /> This is usually a [[local anesthetic nerve block|nerve-blocking injection]] that consists of a combination of [[steroid]]s such as [[hydrocortisone]], and [[anesthetic]]s such as [[lidocaine]] and [[procaine]], which is typically administered under [[ultrasound]] guidance.<ref name="levey" /><ref name="wangseok" /> One study used a combination of [[triamcinolone hexacetonide]] and 2% [[lidocaine]] in 9 patients and after a week, found an average 82% decrease in size of the affected [[costal cartilage]] when assessing with ultrasound as well as a significant improvement of symptoms clinically.<ref name="kamel" /> However, the long-term effectiveness of the injection is disputed, with multiple researchers describing recurrence of symptoms and repetitive injections.<ref name="levey" /><ref name="gologorsky" />

=== Surgical intervention ===
In [[Refractory disease|refractory]] cases of Tietze syndrome, where the condition is resistant to other [[Conservative management|conservative treatment]] options, [[surgery]] is considered.<ref name="rokicki" /><ref name="kayser" /> Surgery is uncommon for cases of Tietze syndrome, as many describe Tietze syndrome as manageable under less invasive options.<ref name="kennedy" /> The use of surgery in this context refers to the [[Rib removal|resection]] of the affected [[costal cartilage]]s and some of the surrounding areas.<ref name="rokicki" /> Some surgeons have resected cartilage matching the symptoms of Tietze syndrome under the assumption the cartilage was [[tuberculosis|tubercular]].<ref name="Geddes" /> One study describes a case in which surgeons resected a large amount of cartilage, including minutely [[Hypertrophy|hypertrophied]] tissue, as a previous resection failed to relieve symptoms which is believed to be due to improperly resected [[Resection margin|margins]].<ref name="gologorsky" /> There is limited literature on surgical treatment of this disease,<ref name="garrell">{{Cite journal | vauthors = Garrell M, Meltzer S | title = Tietze's Syndrome: A Case Report | journal = Diseases of the Chest | volume = 36 | issue = 5 | pages = 560–61| date = November 1959| pmid = 13826637 | doi=10.1378/chest.36.5.560 | url = https://linkinghub.elsevier.com/retrieve/pii/S0096021715335378| url-access = subscription }}</ref> and overall research on the treatment of severe, [[Chronic condition|chronic]] forms of Tietze syndrome.<ref name="gologorsky" />

==History==
Tietze syndrome was named after and first described in 1921 by German surgeon [[Alexander Tietze]].<ref name="tietze" /> Tietze first cited 4 cases in Germany of painful swelling where he originally believed the condition was as a result of tuberculosis or wartime malnutrition.<ref name=":0" />

== References ==
{{reflist}}

== External links ==
{{Medical resources
|   DiseasesDB     = 13112 
|   ICD10          = {{ICD10|M|94|0|m|91}} 
|   ICD9           = {{ICD9|733.6}}
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|   MedlinePlus    =
|   eMedicineSubj  =
|   eMedicineTopic =
|   MeshID         = D013991
|GARDNum=10100
|NORD=
}}
{{Osteochondropathy}}

[[Category:Syndromes with musculoskeletal abnormalities]]
[[Category:Musculoskeletal disorders]]