Chest wall pain is caused by problems affecting the muscles, bones or nerves of the chest wall. Although it is critical to exclude non musculoskeletal causes particularly those requiring urgent intervention, that is as far as the physician takes the diagnosis. Once the serious causes have been ruled out, physicians often consider their job to be done.
But for patients having this “chest wall pain syndrome” although they are relieved to find out they don’t have the above-mentioned pathology, they are still in pain, and will be still interested in an actual diagnosis and appropriate treatment.
Musculoskeletal causes of chest wall pain can be grouped into 3 categories:
1) Isolated musculoskeletal pain
More common
- Costocondritis
- Lower rib pain syndrome
- Pain from thoracoc spine/joints
- Sternalis syndrome
Less common
- Stress fracture
- Tietze’s syndrome
- Xiphoidalgia
- Sternoclavicular subluxation
2) Rheumatic diseases
More common
- Fibromyalgia
- Rheumathoid arthritis
- Spondyloarthritis
- Psoriatic arthritis
Less common
- Sternoclavicular hyperostosis
- Systemic lupus erythematosus
- Septic arthritis of chest wall
- Relapsing polychondritis
3) Non rheumatic systemic causes
- Osteoporotic fracture
- Neoplasm
- Pathological fracture
- Bone pain
Costochondritis or costochondral syndrome is the most common cause of isolated chest wall pain. Typically, it involves areas of tenderness over the costochondral or costosternal junctions of 2nd to 5th ribs. Palpation reproduces the pain. It differs from the rarer Tietze’s disease which only involves one area with associated painful and localized swelling.
Lower rib pain syndromes or slipping/clicking rib presents with lower chest or upper abdominal pain. There is tender spot on the costal margin. This is possibly due to subluxation of costal cartilage, impinging on the intercostal nerve.
Disorder of thoracic spine from structures including the vertebra, intervertebral discs and facet, costotransverse and costovertebral joints may result in anterior or posterior chest wall pain.
Sternalis syndrome presents with localized anterior chest wall pain and tenderness over the sternum. Palpation causes pain to radiate bilaterally. This condition may be underdiagnosed. The cause is unknown but it is usually self-limiting.
Chest pain resulting from rheumatic causes tend to associated with other problems. Low back pain raises possibility of spondyloarthropathy, involvement of multiple synovial joints the possibility of rheumatoid arthritis, skin lesion may suggest psoriatic arthritis, sleep disturbance and fatigue, with widespread pain and trigger points suggest fibromyalgia.
In patients with chest pain resulting from non-rheumatic systemic causes, they may present with fractures of the spine or ribs. They will have osteoporosis risk factors including chronic steroid use especially from consumption of unregulated supplements. If the pain is very severe or patient has night pain, neoplasm with pathological fracture or bone pain should be considered.
Treatment options for isolated musculoskeletal chest wall pain
Treatment begins with reassurance and explanation of the condition to patients. Temporary avoidance of aggravating activities. Stretching exercise, application of heat for muscle spasm or ice for swelling may help to relieve the pain. Analgesia such as paracetamol or nonsteroidal anti-inflammatory agents (oral or local) can be tried.
Patients can be considered for formal physiotherapy if symptoms persist. This includes biomechanical assessment and relevant stretching and strengthening exercise, mobilization and soft tissue therapy.
In patients who have failed conservative therapy, injection of local an anaesthetic /corticosteroid agent is an option,
Uncommonly isolated musculoskeletal chest wall pain can lead to chronic pain. Treatment options may include anticonvulsants, antidepressants, behavioral therapy and physical therapy. Where possible, opioids should be avoided. In severe chronic chest wall pain, it is important to consider a missed diagnosis of malignancy, infection or fracture. For persistent symptoms, the possibility of fibromyalgia should always be considered.
Key Points
- Musculoskeletal conditions are the most common cause of chest pain presenting in general practice
- It is critical to exclude serious conditions such as cardiovascular disease before making diagnosis of isolated musculoskeletal pain.
- Reproducing the patient’s pain by palpation or movement is the key diagnostic feature for isolated musculoskeletal chest pain
- Specific Investigations will be needed if rheumatic or systemic diseases are suspected
