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Evaluation and Treatment of Musculoskeletal Chest Pain

      Keywords

      Key points

      • Costochondritis is one of the most common causes of musculoskeletal chest pain.
      • Stretching exercises have been shown to be effective in relieving the pain in costochondritis.
      • Rib fractures, either traumatic or stress fractures, can be a source of chest pain.
      • Slipping rib syndrome may occur in children with chronic chest and abdominal pain.
      • Muscle strains may cause musculoskeletal chest pain, with intercostal muscle strains being the most common.
      • Pectoralis muscle injury needs accurate and early diagnosis for optimal functional recovery in athletes.
      • Myofascial pain and fibromyalgia are other causes of musculoskeletal chest pain.
      • Herpes zoster should be considered in elderly patients with nonspecific musculoskeletal chest pain.
      • It is important to assess all patients with chest pain for non-musculoskeletal causes of pain that could cause increased morbidity or mortality if not identified promptly.

      Introduction

      Chest pain is one of the most common reasons for seeking medical attention worldwide. In the United States alone, there are about 7.16 million visits annually to the emergency room with chest pain and most of these patients have noncardiac causes of chest pain.

      National Hospital Ambulatory Medical Care Survey: 2009 Emergency Dept Summary Tables–Table 10. 2009. Available at: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2009_ed_web_tables.pdf. Accessed February 20, 2013.

      Chest pain accounts for 1% to 3% of office visits to the primary care provider. Of these visits, 21% to 49% of patients are diagnosed with musculoskeletal chest pain, making it the most common cause of chest pain.
      • Stochkendahl M.J.
      • Christensen H.W.
      Chest pain in focal musculoskeletal disorders.
      Causes of chest pain include cardiovascular, pulmonary, musculoskeletal, gastroenterologic, and psychogenic. Pain can also radiate to the chest from the shoulders, cervical and thoracic spine, lower neck, and structures below the diaphragm (Fig. 1).
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      Figure thumbnail gr1
      Fig. 1Diverse origins and causes of chest pain.
      (From Cava JR, Sayger PL. Chest pain in children and adolescents. Pediatr Clin North Am 2004;51(6):1553–68. Philadelphia: Elsevier; with permission.)
      An important mechanism of chest pain may be referred pain from intrathoracic structures, including the heart, lungs, and esophagus.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      Pain occurs because free nerve endings that transmit pain from visceral thoracic structures, including the heart, synapse on the same spinal cord dorsal horn interneurons that receive afferent input from the skin, muscles, and joints. The convergence of visceral and somatic pain fibers on the same interneurons causes the referred visceral pain that is perceived in somatic areas remote from involved viscera.
      • Stochkendahl M.J.
      • Christensen H.W.
      Chest pain in focal musculoskeletal disorders.
      Thus, it can sometimes be difficult to delineate the precise cause of chest pain as musculoskeletal or visceral in origin.
      • Stochkendahl M.J.
      • Christensen H.W.
      Chest pain in focal musculoskeletal disorders.
      It is important to rule out visceral causes of chest pain, including cardiac, esophageal, or pulmonary causes, such as angina, myocardial infarction, malignancies, or pulmonary embolism, before definitively diagnosing musculoskeletal chest pain.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Proulx A.M.
      • Zryd T.W.
      Costochondritis: diagnosis and treatment.
      For example, anginal pain may occur along with underlying costochondritis or subacromial bursitis, which may influence the distribution of anginal pain.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      In middle-aged and elderly patients with strong, relevant risk factors for cardiac disease, it is recommended to order an electrocardiogram, echocardiogram, and even stress testing as necessary to definitively rule out cardiac causes of chest pain before treating for musculoskeletal chest pain.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Proulx A.M.
      • Zryd T.W.
      Costochondritis: diagnosis and treatment.
      Musculoskeletal chest pain includes pain related to the anterior chest wall bony and cartilaginous structures, chest wall musculature, and the thoracic spine.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      In addition, other causes of pain may include skin conditions, neoplasms, and infections of chest wall structures, metabolic causes (vitamin D deficiency),
      • Oho R.C.
      • Johnson J.D.
      Chest pain and costochondritis associated with vitamin D deficiency: a report of two cases.
      and rheumatologic disorders (Box 1).
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Muir J.
      • Yelland M.
      Skin and breast disease in the differential diagnosis of chest pain.
      The term chest wall syndrome refers to nontraumatic causes of musculoskeletal chest wall pain, which may include diagnoses such as costochondritis, atypical chest pain, and cervicothoracic angina.
      • Verdon F.
      • Burnand B.
      • Herzig L.
      • et al.
      Chest wall syndrome among primary care patients: a cohort study.
      A good history and physical examination are crucial to accurately diagnosing musculoskeletal chest pain (Box 2, Table 1).
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      Diverse causes of musculoskeletal chest pain
      • Pain related to bony and cartilaginous structures of the chest wall
        • Costochondritis
        • Tietze syndrome
        • Rib pain
          • Fractures related to trauma
          • Stress fractures
        • Slipping rib syndrome
        • Painful xiphoid syndrome
      • Pain related to muscles
        • Muscle strains
          • Pectoralis muscle strains
          • Injuries to internal oblique/external oblique muscles
          • Serratus anterior muscle injury
        • Myofascial pain
        • Fibromyalgia
        • Precordial catch syndrome
        • Epidemic myalgia
      • Pain related to thoracic spine
        • Thoracic disc herniation
      • Miscellaneous causes of chest wall pain
        • Skin-related conditions
          • Herpes zoster
          • Neoplasms
        • SAPHO syndrome
      Key points in physical examination
      • Thorough systematic examination of anterior and posterior chest wall for
        • Swelling
        • Erythema
        • Heat
        • Tenderness
      • Neurologic examination to rule out compressions of nerve roots originating in lower cervical or thoracic segments of spinal cord
        • Sensory disturbances
        • Muscular strength
        • Peripheral reflexes of upper and lower extremities
      Table 1Key points in history taking
      Data from Fam AG, Smythe HA. Musculoskeletal chest wall pain. Can Med Assoc J 1985;133:379–89.
      Pain
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      OnsetUsually acute or insidious
      LocationWell localized
      CharacterNonsqueezing, reproducible
      DurationMay become chronic
      Precipitating factorBy posture or movement
      Aggravating factor
      Relieving factor
      History of acute or repeated excessive activity
      Recent or remote trauma
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.

      Musculoskeletal chest pain related to bony and cartilaginous structures of the chest wall

      Costochondritis and Tietze Syndrome

      These are conditions characterized by pain and tenderness in costochondral junctions. The comparative characteristics between the 2 conditions are listed in Table 2.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Proulx A.M.
      • Zryd T.W.
      Costochondritis: diagnosis and treatment.
      Table 2Comparisons between costochondritis and Tietze syndrome
      CharacteristicsCostochondritisTietze Syndrome
      Signs of inflammationAbsentPresent
      SwellingAbsentPresence or absence indicate severity of problem
      Joints affectedMultiple and unilateral >90%Usually single and unilateral
      Usually second to fifth costochondral junctions involved (Fig. 2)Usually second and third costochondral junctions involved
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Semble E.L.
      • Wise C.M.
      Chest pain: a rheumatologist's perspective.
      • Kamel M.
      • Kotob H.
      Ultrasonographic assessment of local steroid injection in Tietze's syndrome.
      Prevalence
      • Proulx A.M.
      • Zryd T.W.
      Costochondritis: diagnosis and treatment.
      Relatively common (Box 3)Uncommon
      Age group affectedAll age groups, including adolescents and elderlyCommon in younger age group
      Nature of painAching, sharp, pressure likeAching, sharp, stabbing initially, later persists as dull aching
      Onset of painRepetitive physical activity provokes pain, rarely occurs at rest
      • Habib P.A.
      • Huang G.S.
      • Mendiola J.A.
      • et al.
      Anterior chest pain: musculoskeletal considerations.
      New vigorous physical activity such as excessive cough or vomiting, chest impact
      • Semble E.L.
      • Wise C.M.
      Chest pain: a rheumatologist's perspective.
      Aggravation of pain
      • Semble E.L.
      • Wise C.M.
      Chest pain: a rheumatologist's perspective.
      Movements of upper body, deep breathing, exertional activitiesMovements
      Association with other conditionsSeronegative arthropathies, angina pain
      • Freeston J.
      • Karim Z.
      • Lindsay K.
      • et al.
      Can early diagnosis and management of costochondritis reduce acute chest pain admissions?.
      No known association
      DiagnosisCrowing rooster maneuver
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      and other physical examination findings
      Physical examination, exclude rheumatoid arthritis, pyogenic arthritis
      • Stochkendahl M.J.
      • Christensen H.W.
      Chest pain in focal musculoskeletal disorders.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      Imaging studiesChest radiograph, computed tomography scan, or nuclear bone scan to rule out infections or neoplasms if clinically suspected
      • Proulx A.M.
      • Zryd T.W.
      Costochondritis: diagnosis and treatment.
      Bone scintigraphy and ultrasonography can be used for screening for other conditions
      • Kamel M.
      • Kotob H.
      Ultrasonographic assessment of local steroid injection in Tietze's syndrome.
      • Habib P.A.
      • Huang G.S.
      • Mendiola J.A.
      • et al.
      Anterior chest pain: musculoskeletal considerations.
      TreatmentReassurance, pain control, NSAIDs, application of local heat and ice compresses, manual therapy with stretching exercises.
      • Rovetta G.
      • Sessarego P.
      • Monteforte P.
      Stretching exercises for costochondritis pain.
      • Rabey M.I.
      Costochondritis: are the symptoms and signs due to neurogenic inflammation. Two cases that responded to manual therapy directed towards posterior spinal structures.
      Corticosteroid or sulfasalazine injections in refractory patients
      • Freeston J.
      • Karim Z.
      • Lindsay K.
      • et al.
      Can early diagnosis and management of costochondritis reduce acute chest pain admissions?.
      Reassurance, pain control with NSAIDs,
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Semble E.L.
      • Wise C.M.
      Chest pain: a rheumatologist's perspective.
      and application of local heat. Corticosteroid and lidocaine injections to the cartilage, or intercostal nerve block in refractory patients
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Kamel M.
      • Kotob H.
      Ultrasonographic assessment of local steroid injection in Tietze's syndrome.
      Abbreviation: NSAIDs, nonsteroidal antiinflammatory drugs.
      The possible mechanism of pain is believed to be mechanical derangement, muscular imbalance, or neurogenic inflammation .
      • Rovetta G.
      • Sessarego P.
      • Monteforte P.
      Stretching exercises for costochondritis pain.
      The pathogenesis of costochondritis is unclear. Because of its frequent association with other primary causes of chest pain, including anginal pain, it is important, especially in patients with relevant risk factors, to rule out any associated cardiac chest pain.
      • Proulx A.M.
      • Zryd T.W.
      Costochondritis: diagnosis and treatment.
      Prevalence of costochondritis
      Tabled 1
      Emergency room30% of chest pain visits were because of costochondritis
      Primary care office20% of chest pain visits were because of musculoskeletal chest pain

      Of these visits, 13% were because of costochondritis
      Figure thumbnail gr2
      Fig. 2Rib cage with costal cartilages and inflamed cartilages in costochondritis. (A) Labeling of rib cage. (B) Inflammation of coastal cartilages.
      Chest pain involving costochondral joints has also been described in association with vitamin D deficiency.
      • Oho R.C.
      • Johnson J.D.
      Chest pain and costochondritis associated with vitamin D deficiency: a report of two cases.
      The mechanism involved is believed to be defective bone mineralization caused by lack of vitamin D. This mechanism is shown by findings of rachitic rosary in children with rickets and tenderness of costochondral joints in adult patients with osteomalacia. Low vitamin D should be suspected in people with poor dietary intake of vitamin D or limited exposure to sunlight. Supplementation of vitamin D was associated with improvement of chest pain and overall quality of life. Further studies are needed to definitively associate vitamin D deficiency and costochondritis.
      • Oho R.C.
      • Johnson J.D.
      Chest pain and costochondritis associated with vitamin D deficiency: a report of two cases.

      Evaluation

      Physical examination helps in diagnosis. The “crowing rooster” maneuver reproduces the pain of costochondritis (Fig. 3).

      Treatment

      Conservative treatment is generally recommended (see Table 2). Stretching exercises have been studied recently in the treatment of costochondritis. In a retrospective open study of patients with a definitive diagnosis of costochondritis who were taking nonsteroidal antiinflammatory drugs (NSAIDs) in the last 2 to 3 months, there was statistically significant improvement in pain in the study group treated with exercises and NSAIDs, compared with the group on NSAIDs only (Fig. 4).
      • Rovetta G.
      • Sessarego P.
      • Monteforte P.
      Stretching exercises for costochondritis pain.
      Figure thumbnail gr4
      Fig. 4Stretching exercises for costochondritis.

      Rib Pain

      Rib pain can be caused by swelling, erosions, and trauma causing fractures (Figs. 5 and 6).
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Singer K.
      • Fazey P.
      Thoracic and chest pain.
      Figure thumbnail gr6
      Fig. 6Algorithm for causes of stress fractures.

      Evaluation

      There is usually a history of initial vague chest pain that increases with inspiration, with movements of the chest and upper limb movements.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Singer K.
      • Fazey P.
      Thoracic and chest pain.
      Dull, aching pain is more localized around the scapula, neck, and clavicle and may radiate to the sternum in first rib fractures.
      • Karlson K.A.
      Thoracic region pain in athletes.
      Physical examination reveals point tenderness at the site of trauma, with or without local swelling on palpation.
      • Singer K.
      • Fazey P.
      Thoracic and chest pain.
      • Karlson K.A.
      Thoracic region pain in athletes.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.
      It is important to suspect and look for trauma to underlying viscera, including lung contusions, injury to liver, spleen, kidney, or any pneumothorax or hemothorax in multiple rib fractures and also in fractures of the first 4 or last 2 ribs, because these are not commonly seen. Child abuse should always be suspected in any child presenting with rib fractures, especially in infants and toddlers, because routine causes of injury and trauma in children do not cause rib fractures (Fig. 7). Imaging studies can help in diagnosing or confirming the fracture (Box 4).
      • Karlson K.A.
      Thoracic region pain in athletes.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.
      • Sik E.C.
      • Batt M.E.
      • Heslop L.M.
      Atypical chest pain in athletes.
      • Coris E.E.
      • Higgins H.W.
      First rib stress fractures in throwing athletes.
      Figure thumbnail gr7
      Fig. 7Rib fractures in a child (arrows).
      (From Rubio EI. How do you read these images? Hone your interpretive skills. Rib fractures in a child. 2008. Available at: http://www.pediatricsconsultantlive.com/display/article/1803329/1405067. Accessed March 30, 2013; with permission.)
      Rib fracture imaging findings
      • Radiographs show a fracture line in about a half to two-thirds of fractures
      • In cases with no initial radiographic evidence of fracture, a healing callus may be seen after a few weeks on the radiograph or ultrasonogram
      • Triple phase bone scan or magnetic resonance imaging (MRI) may be used for early diagnosis.

      Treatment

      Symptomatic treatment with good pain control for at least 3 weeks is generally recommended for non–sports related injuries.
      • Singer K.
      • Fazey P.
      Thoracic and chest pain.
      Deep breathing is encouraged to prevent lung collapse, atelectasis, and lung infections. Splinting, local nerve blocks, and anesthetic injections are not routinely indicated because of poor efficacy and the associated risk of causing pneumothorax.
      • Singer K.
      • Fazey P.
      Thoracic and chest pain.
      For athletes with first rib fractures, rest is recommended until symptoms resolve, followed by a gradual return to overhead activity, with correction of technique and biomechanical modification. Full recovery may take up to a year.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.
      • Coris E.E.
      • Higgins H.W.
      First rib stress fractures in throwing athletes.
      Fractures of the fourth to eighth ribs may need pain control and rest, with gradual return to activity at 4 to 6 weeks, then full activity as tolerated at 8 to 10 weeks.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.

      Slipping Rib Syndrome

      This condition occurs when interchondral fibrous attachments between the lower ribs, usually the 9th and 10th ribs, are inadequate, or rupture and loosen, allowing costal cartilage tips to curl up and override the inner aspect of the rib above, impinging on the intercostal nerve.
      • Fu R.
      • Iqbal C.W.
      • Jaroszewski D.E.
      • et al.
      Costal cartilage excision for the treatment of pediatric slipping rib syndrome.
      • Mooney D.P.
      • Shorter N.A.
      Slipping rib syndrome in childhood.
      It is a recognized cause of chronic pain syndrome in children with recurrent pain in the lower chest and upper abdomen, but is less common compared with adults because of more flexible chests in children.
      • Mooney D.P.
      • Shorter N.A.
      Slipping rib syndrome in childhood.
      Repetitive trunk motion in athletes involved in sports such as running can cause slippage of a hypermobile rib under the superior rib, causing nerve impingement and pain.
      • Karlson K.A.
      Thoracic region pain in athletes.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.
      There may be a remote history of trauma.
      • Stochkendahl M.J.
      • Christensen H.W.
      Chest pain in focal musculoskeletal disorders.
      Pain is insidious in onset, severe, sharp, and felt in the abdominal wall or anterior costal cartilage. It may be felt as local somatic pain or as visceral pain, which may mimic biliary colic, peptic ulcer disease, and renal colic.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.
      • Mooney D.P.
      • Shorter N.A.
      Slipping rib syndrome in childhood.

      Evaluation

      Diagnosis is clinical. Examination shows increased tenderness and mobility of the anterior end of the costal cartilage, with an occasional painful click over the tip of affected cartilage. This pain can be reproduced by the hooking maneuver (Fig. 8).
      • Stochkendahl M.J.
      • Christensen H.W.
      Chest pain in focal musculoskeletal disorders.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.
      • Fu R.
      • Iqbal C.W.
      • Jaroszewski D.E.
      • et al.
      Costal cartilage excision for the treatment of pediatric slipping rib syndrome.
      • Mooney D.P.
      • Shorter N.A.
      Slipping rib syndrome in childhood.
      • Udermann B.E.
      • Cavanaugh D.G.
      • Gibson M.H.
      • et al.
      Slipping rib syndrome in a collegiate swimmer: a case report.
      • Heinz III, G.J.
      • Zavala D.C.
      Slipping rib syndrome: diagnosis using the “hooking manuever”.
      Figure thumbnail gr8
      Fig. 8Hooking maneuver for slipping rib syndrome.
      (From Waldman S. Atlas of pain management injection techniques. 3rd edition. Philadelphia: Saunders; 2013. p. 274–6, with permission; and Data from Koren W, Shahar A. Xiphodynia masking acute myocardial infarction: a diagnostic cul-de-sac. Am J Emerg Med 1998;16(2):177–8.)

      Treatment

      Reassurance, pain control with analgesics, and avoidance of movements and positions that cause the loose costal cartilage to move upwards suddenly and provoke pain are recommended.
      • Stochkendahl M.J.
      • Christensen H.W.
      Chest pain in focal musculoskeletal disorders.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.
      • Udermann B.E.
      • Cavanaugh D.G.
      • Gibson M.H.
      • et al.
      Slipping rib syndrome in a collegiate swimmer: a case report.
      Strapping and local infiltration of lidocaine and corticosteroids for intercostal nerve block may be needed, more commonly in children.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.
      • Fu R.
      • Iqbal C.W.
      • Jaroszewski D.E.
      • et al.
      Costal cartilage excision for the treatment of pediatric slipping rib syndrome.
      • Mooney D.P.
      • Shorter N.A.
      Slipping rib syndrome in childhood.
      • Udermann B.E.
      • Cavanaugh D.G.
      • Gibson M.H.
      • et al.
      Slipping rib syndrome in a collegiate swimmer: a case report.
      Subperichondrial resection of involved costal cartilages is reserved for refractory cases in children (Box 5).
      Subperichondrial resection
      • It is important to mark the point of maximum tenderness on the patient while they are awake and supine before going to the operating room
      • Affected cartilage is excised and perichondrium is preserved
      • Surgery can be performed as an outpatient procedure
      • Cryotherapy can help decrease postoperative pain
        • Mooney D.P.
        • Shorter N.A.
        Slipping rib syndrome in childhood.

      Painful Xiphoid Syndrome

      Painful xiphoid syndrome is characterized by pain and tenderness in the region of the xiphoid cartilage. Pain may be low substernal or epigastric, with radiation to the precordium or abdomen.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.

      Evaluation

      Painful xiphoid syndrome is a diagnosis of exclusion. Clinical examination by exerting pressure on xiphoid cartilage reduplicates the pain and tenderness. It is important to definitively rule out other serious causes of chest pain, such as myocardial infarction, before reaching this diagnosis.
      • Koren W.
      • Shahar A.
      Xiphodynia masking acute myocardial infarction: a diagnostic cul-de-sac.

      Treatment

      Symptomatic treatment with good pain control is generally recommended. Local injections of corticosteroids or lidocaine are recommended in refractory cases. Surgical excision of xiphoid cartilage is reserved for severe cases.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.

      Musculoskeletal chest pain related to muscles

      Muscle strains comprise one of the most common causes of musculoskeletal chest pain. They are usually acute in onset, caused by trauma or overuse.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      Gradual onset of the muscle pain has also been reported as a result of tension or anxiety in the patient.
      • Stochkendahl M.J.
      • Christensen H.W.
      Chest pain in focal musculoskeletal disorders.
      The commonly involved muscles include the intercostal muscles, pectoralis muscles, internal and external oblique muscles, and serratus anterior muscles.

      Intercostal Muscle Strains

      Intercostal muscles are the most commonly affected muscles, in almost 50% of patients,
      • Stochkendahl M.J.
      • Christensen H.W.
      Chest pain in focal musculoskeletal disorders.
      followed by the pectoralis muscle group. There may be a history of excessive exertion of untrained muscles with activities like painting a ceiling, chopping wood, or coughing, and in sports with intense upper body activity, such as rowing.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.

      Evaluation

      Diagnosis is clinical, based on a good history and physical examination. Localized pain or tenderness over the affected muscle groups is seen, which increases with stretching or contracting the involved muscles with activities such as deep inspiration and coughing.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.
      Muscle tenderness on manual palpation is the most common finding.

      Treatment

      Reassurance, local application of heat, or use of analgesics for good pain control are recommended, along with avoiding activities that cause recurrence of the pain. Local injections of lidocaine or corticosteroids are reserved for refractory cases.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Karlson K.A.
      Thoracic region pain in athletes.
      • Gregory P.L.
      • Biswas A.C.
      • Batt M.E.
      Musculoskeletal problems of the chest wall in athletes.

      Pectoralis Muscle Strains

      The pectoralis muscle is one of the most important muscles for various movements of the upper limbs and chest wall (Fig. 9).
      • Hopper M.A.
      • Tirman P.
      • Robinson P.
      Muscle injury of the chest wall and upper extremity.
      Tears to the pectoralis muscle can be caused by direct blow or indirect trauma.
      • Kretzler Jr., H.H.
      • Richardson A.B.
      Rupture of the pectoralis major muscle.
      • Wolfe S.W.
      • Wickiewicz T.L.
      • Cavanaugh J.T.
      Ruptures of the pectoralis major muscle. An anatomic and clinical analysis.
      • Bak K.
      • Cameron E.A.
      • Henderson I.J.
      Rupture of the pectoralis major: a meta-analysis of 112 cases.
      The tears can be classified by either cause or location of tear (Figs. 10 and 11). Indirect injury occurs when muscle under full tension is subjected to additional stress (eccentric muscle contraction), causing high-grade injuries in athletes in sports such as weight lifting or rugby.
      • Hanna C.M.
      • Glenny A.B.
      • Stanley S.N.
      • et al.
      Pectoralis major tears: comparison of surgical and conservative treatment.
      Non–sports injury occurs most commonly because of forced abduction with extension or external rotation during a fall or when lifting weights.
      • Hopper M.A.
      • Tirman P.
      • Robinson P.
      Muscle injury of the chest wall and upper extremity.
      • Rehman A.
      • Robinson P.
      Sonographic evaluation of injuries to pectoralis muscles.
      Figure thumbnail gr9
      Fig. 9Pectoralis muscle structure.
      (From Cava JR, Sayger PL. Chest pain in children and adolescents. Pediatr Clin North Am 2004;51(6):1553–68. Philadelphia: Elsevier; with permission.)
      Figure thumbnail gr10
      Fig. 10Algorithm for pectoralis muscle injury based on cause of injury.
      (Data from Hopper MA, Tirman P, Robinson P. Muscle injury of the chest wall and upper extremity. Semin Musculoskelet Radiol 2010;14(2):122–30.)
      Figure thumbnail gr11
      Fig. 11Algorithm for pectoralis muscle injury based on location of injury.
      (Data from Hopper MA, Tirman P, Robinson P. Muscle injury of the chest wall and upper extremity. Semin Musculoskelet Radiol 2010;14(2):122–30.)

      Evaluation

      History and physical examination can help in diagnosis, but imaging is usually advised for correct diagnosis, because clinical assessment can be misled by hematoma or muscle injury.
      • Hopper M.A.
      • Tirman P.
      • Robinson P.
      Muscle injury of the chest wall and upper extremity.
      Tears can present as sudden pain in the arm or shoulder accompanied with an audible pop, followed by swelling and ecchymosis. Inspection shows loss of the anterior axillary fold and asymmetry when compared with the other side with palpation of a defect on the side of injury. Loss of arm adduction may be a subtle but important finding in athletes such as weight lifters.
      • Hopper M.A.
      • Tirman P.
      • Robinson P.
      Muscle injury of the chest wall and upper extremity.
      Radiographs at initial assessment may show soft tissue swelling with absent pectoralis shadow. Ultrasonography and MRI are modalities of choice and help in making correct decisions about optimal management (Box 6).
      • Hopper M.A.
      • Tirman P.
      • Robinson P.
      Muscle injury of the chest wall and upper extremity.
      Ultrasonography and MRI for diagnosis of pectoralis muscle tears
      • Ultrasonography is helpful in initial rapid assessment of acute muscle injury and surrounding structures when performed by an experienced clinician
        • Rehman A.
        • Robinson P.
        Sonographic evaluation of injuries to pectoralis muscles.
      • MRI is gold standard for:
        • Accurate assessment of site and severity of injury and bony structures
        • Identifying patients who benefit most from surgery

      Treatment

      Proper documentation and determination of injury site and mechanism determine the management (Box 7).
      • Hopper M.A.
      • Tirman P.
      • Robinson P.
      Muscle injury of the chest wall and upper extremity.
      • Hanna C.M.
      • Glenny A.B.
      • Stanley S.N.
      • et al.
      Pectoralis major tears: comparison of surgical and conservative treatment.
      Treatment of pectoralis muscle tears
      • Early surgical intervention
        • Hopper M.A.
        • Tirman P.
        • Robinson P.
        Muscle injury of the chest wall and upper extremity.
        • Hanna C.M.
        • Glenny A.B.
        • Stanley S.N.
        • et al.
        Pectoralis major tears: comparison of surgical and conservative treatment.
        • Rehman A.
        • Robinson P.
        Sonographic evaluation of injuries to pectoralis muscles.
        :
        • Complete pectoralis major tendon avulsion at humeral attachment
        • Helps athletes in early return to sports
          • Optimum functional recovery
          • Good cosmetic results
      • Nonsurgical treatment
        • Hanna C.M.
        • Glenny A.B.
        • Stanley S.N.
        • et al.
        Pectoralis major tears: comparison of surgical and conservative treatment.
        :
        • Muscular or musculotendinous tears
        • Low-grade partial tears
        • Older, sedentary patients for whom loss of strength may not cause significant impairment or debility

      Injuries to Internal Oblique/External Oblique Muscles

      Injuries at the rib and costal cartilage insertion of internal and external oblique muscles are commonly referred to as side strains (Fig. 12).
      • Humphries D.
      • Jamison M.
      Clinical and magnetic resonance imaging features of cricket bowler's side strain.
      They are uncommon, mostly seen in athletes such as bowlers (cricket), javelin throwers, rowers, swimmers, or ice hockey players. The mechanism of injury is muscle lengthening followed by sudden eccentric contraction.
      • Singer K.
      • Fazey P.
      Thoracic and chest pain.
      • Hopper M.A.
      • Tirman P.
      • Robinson P.
      Muscle injury of the chest wall and upper extremity.
      • Humphries D.
      • Jamison M.
      Clinical and magnetic resonance imaging features of cricket bowler's side strain.
      • Obaid H.
      • Nealon A.
      • Connell D.
      Sonographic appearance of side strain injury.
      The injury is particularly seen in cricket fast bowlers and is seen in the nonbowling arm.
      • Singer K.
      • Fazey P.
      Thoracic and chest pain.
      Figure thumbnail gr12
      Fig. 12Insertion of external and internal oblique muscles.

      Evaluation

      Physical examination elicits pain and tenderness over the lower 4 costal cartilages, increased by resisted side flexion to the affected side.
      • Humphries D.
      • Jamison M.
      Clinical and magnetic resonance imaging features of cricket bowler's side strain.
      Diagnosis is clinical, but imaging helps in evaluating the severity of injury and in determining the course of management (Box 8, Figs. 13 and 14).
      • Hopper M.A.
      • Tirman P.
      • Robinson P.
      Muscle injury of the chest wall and upper extremity.
      Ultrasonographic findings in internal oblique muscle injury
      • Acute injury shows:
        • Hematoma
        • Fluid between muscle layers
        • Loss of normal architecture
        • Gap in the insertion of the internal oblique into costal cartilages and ribs (see Fig. 14)
      • Not sensitive to assess chronic injury and small muscle tears
        • Obaid H.
        • Nealon A.
        • Connell D.
        Sonographic appearance of side strain injury.
      Figure thumbnail gr13
      Fig. 13Ultrasonographic appearance of normal external oblique (black arrow) and internal oblique (white arrow) muscles.
      (From Obaid H, Nealon A, Connell D. Sonographic appearance of side strain injury. AJR Am J Roentgenol 2008;191(6):265. Available at: http://www.ajronline.org/doi/full/10.2214/AJR.07.3381. Accessed March 12, 2013; with permission.)
      Figure thumbnail gr14
      Fig. 14Gap in the insertion of internal oblique muscle caused by tear (arrow).
      (From Obaid H, Nealon A, Connell D. Sonographic appearance of side strain injury. AJR Am J Roentgenol 2008;191(6):265. Available at: http://www.ajronline.org/doi/full/10.2214/AJR.07.3381. Accessed March 12, 2013; with permission.)
      MRI may show hematoma, periosteal stripping, or any stress injury to the underlying rib.
      • Humphries D.
      • Jamison M.
      Clinical and magnetic resonance imaging features of cricket bowler's side strain.
      It is particularly useful in assessing acute concomitant injury to external oblique muscles. It can help in the follow-up of patients who failed to respond to conservative measures, but can be complicated by respiratory motion artifact.
      • Hopper M.A.
      • Tirman P.
      • Robinson P.
      Muscle injury of the chest wall and upper extremity.
      • Connell D.A.
      • Jhamb A.
      • James T.
      Side strain: a tear of internal oblique musculature.

      Treatment

      Conservative treatment is recommended, with rest, strengthening exercises, and return to activity gradually. A period of 4 to 6 weeks may be needed for complete return to activity, especially in fast bowlers.
      • Singer K.
      • Fazey P.
      Thoracic and chest pain.
      Reoccurrence of injury is common, especially in the first 2 years of initial injury.
      • Singer K.
      • Fazey P.
      Thoracic and chest pain.

      Serratus Anterior Muscle Injury

      Serratus anterior muscle injury is seen in athletes involved in sports such as rowing and weight lifting caused by overuse. Pain is typically located around the medial border of the scapula on the affected side and may radiate to the anterior chest.
      • Karlson K.A.
      Thoracic region pain in athletes.

      Evaluation

      Diagnosis is clinical. Physical examination shows reproducible typical pain on resisted scapular protraction.
      • Karlson K.A.
      Thoracic region pain in athletes.

      Treatment

      Improvement is seen with rest from activities that increase the pain, but may take several weeks.
      • Karlson K.A.
      Thoracic region pain in athletes.

      Myofascial Pain

      As the name implies, myofascial pain is defined as pain originating from muscles or fascia. This type of pain is described as dull and aching, with a stiff feeling. It may be caused by muscle injury or overuse.
      • Bennett R.
      Myofascial pain syndromes and their evaluation.
      Myofascial pain may be aggravated by muscle use, postural imbalance, cold, anxiety, and psychological stressors.
      • Alvarez D.J.
      • Rockwell P.G.
      Trigger points: diagnosis and management.
      What defines myofascial pain clinically is the identification of a trigger point.
      • Bennett R.
      Myofascial pain syndromes and their evaluation.
      A trigger point is “a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band” of muscle.
      • Simons D.G.
      • Travell J.G.
      • Simons L.S.
      Glossary.
      Additional clinical features of trigger points are listed in Box 9.
      • Bennett R.
      Myofascial pain syndromes and their evaluation.
      • Alvarez D.J.
      • Rockwell P.G.
      Trigger points: diagnosis and management.
      • Simons D.G.
      Understanding effective treatments of myofascial trigger points.
      Trigger points
      • Tender ropelike induration in muscle
      • May produce a twitch response, which is contraction of the muscle, when palpated or needled
      • May cause restricted range of motion or weakness in the affected muscle
      • May cause radiation of pain or parasthesias in a myotomal distribution
      • Firm pressure on a trigger point for at least 5 seconds may elicit referred pain in a myotomal distribution
      Trigger points in the pectoral major and minor muscles, intercostal muscles, anterior serratus muscles, scalenus muscles, and sternalis muscles can be a source of pain referred to the chest wall.
      • Alvarez D.J.
      • Rockwell P.G.
      Trigger points: diagnosis and management.
      • Moseley G.L.
      Pain: why and how does it hurt?.
      • Choi Y.J.
      • Choi S.U.
      • Shin H.W.
      • et al.
      Chest pain caused by trigger points in the scalenus muscle: a case report.
      For example, trigger points in the pectoral major or minor muscle may cause ipsilateral chest pain that radiates down the ulnar side of the arm. Sternalis muscle trigger points may cause a deep substernal ache.
      • Alvarez D.J.
      • Rockwell P.G.
      Trigger points: diagnosis and management.
      Myofascial trigger points are common yet often not identified or treated properly, because the initial training of so few medical providers includes adequate education in their identification and treatment.
      • Simons D.G.
      Understanding effective treatments of myofascial trigger points.

      Evaluation

      Carefully examine the chest wall and cervical muscles for active trigger points. The physical examination skills for identifying trigger points are not commonly taught in medical training, and practice is required in order to become competent at this skill. Myofascial pain may not be the sole reason for the pain, but may be a contributing factor in some cases. Therefore, evaluation for other causes of pain is important.
      • Bennett R.
      Myofascial pain syndromes and their evaluation.

      Treatment

      It is important to address postural and ergonomic factors and proper stretching and strengthening of muscles when treating myofascial pain. There are several options for local treatment of active trigger points (Box 10).
      • Bennett R.
      Myofascial pain syndromes and their evaluation.
      • Simons D.G.
      Understanding effective treatments of myofascial trigger points.
      Local treatment of trigger points
      • Ischemic pressure
      • Injection of trigger point with anesthetic solution such as lidocaine (wet needling)
      • Injection of trigger point without anesthetic (dry needling)
      • Stretching the muscle while spraying with vapocoolant
      Medications that may be helpful include NSAIDs, tricyclic antidepressant drugs, or muscle relaxants, particularly tizanidine (Zanaflex). Consider referral to a provider with experience in treating trigger points and myofascial pain. If myofascial pain is not treated appropriately and underlying predisposing factors are not addressed, it may lead to chronic pain syndromes such as fibromyalgia, through the mechanism of central sensitization.
      • Bennett R.
      Myofascial pain syndromes and their evaluation.

      Fibromyalgia

      Fibromyalgia is a distinct complex clinical syndrome that belongs to a group of clinical syndromes characterized by chronic pain, called the central sensitization syndromes.
      • Nielsen L.A.
      • Henriksson K.G.
      Pathophysiological mechanisms in chronic musculoskeletal pain (fibromyalgia): the role of central and peripheral sensitization and pain disinhibition.
      • Yunus M.B.
      Role of central sensitization in symptoms beyond muscle pain and the evaluation of a patient with widespread pain.
      • Almansa C.
      • Wang B.
      • Achem S.R.
      Noncardiac chest pain and fibromyalgia.
      The other members of this group include restless leg syndrome, functional gastrointestinal disorders, and chronic fatigue syndrome. Fibromyalgia and other central sensitivity syndromes are characterized by a range of symptoms that include chronic pain, sleep disturbances with decreased rapid eye movement sleep, other somatic symptoms, and psychological symptoms.
      • Moldofsky H.
      The significance of dysfunctions of the sleeping/waking brain to the pathogenesis and treatment of fibromyalgia syndrome.
      The current hypothesis is that these syndromes represent a spectrum of disorders that result in expression of different symptoms over time, as a result of a complex interplay of various psychological, social, and biological factors, called the biopsychosocial model.
      • Ferrari R.
      The biopsychosocial model: a tool for rheumatologists.
      According to various studies that evaluated the prevalence of fibromyalgia in patients with musculoskeletal causes of noncardiac chest pain, prevalence ranges between 2.7% and 30%.
      • Semble E.L.
      • Wise C.M.
      Chest pain: a rheumatologist's perspective.
      Both fibromyalgia and noncardiac chest pain seem to share the same pathogenesis of long-standing pain hypersensitivity, which presents as allodynia and hyperalgesia.
      • Nielsen L.A.
      • Henriksson K.G.
      Pathophysiological mechanisms in chronic musculoskeletal pain (fibromyalgia): the role of central and peripheral sensitization and pain disinhibition.
      The other accompanying somatic and visceral complaints are believed to be caused by hypothalamic-pituitary-adrenal axis abnormalities and autonomic dysfunction.
      • Crofford L.J.
      • Pillemer S.R.
      • Kalogeras K.T.
      • et al.
      Hypothalamic-pituitary-adrenal axis perturbations in patients with fibromyalgia.
      Mechanism of central sensitization with somatic or visceral hypersensitivity manifests as noncardiac chest pain in patients with fibromyalgia.
      • Hollerbach S.
      • Bulat R.
      • May A.
      • et al.
      Abnormal processing of esophageal stimuli in patients with noncardiac chest pain (NCCP).
      Fibromyalgia is characterized by chronic widespread pain, unexplained somatic symptoms, which include nonrestorative sleep, dysesthesias, cognitive difficulties, dizziness, syncope, dry mouth, and headaches, and psychological symptoms, such as anxiety or depression.
      • Clouse R.
      • Carney R.M.
      The psychological profile of non-cardiac chest pain patients.
      Another characteristic feature of fibromyalgia is the presence of specific points of tenderness at 9 symmetric body sites (Fig. 15). It is more common in women, in those 50 years or older, and in those with low educational and household income levels.
      • Wolfe F.
      • Ross K.
      • Anderson J.
      • et al.
      The prevalence and characteristics of fibromyalgia in the general population.
      Figure thumbnail gr15
      Fig. 15Tender points in fibromyalgia.
      (From Shipley M. Chronic widespread pain and fibromyalgia syndrome. Medicine 2010;38(4):202–4; with permission.)

      Evaluation

      History and physical examination are important in diagnosing fibromyalgia. The American College of Rheumatology (ACR) established diagnostic and severity criteria in 1990, which were revised in 2000 (Box 11).
      Diagnostic and severity criteria for fibromyalgia
      • ACR criteria (1990)
        • Wolfe F.
        • Smythe H.A.
        • Yunus M.B.
        • et al.
        The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee.
        : presence of chronic widespread pain and tenderness at 11 of 18 body sites
      • Chronic widespread pain is presence of pain in the upper and lower body, axial skeletal, and left and right sides for at least 3 months, without any history of lesion or trauma to explain the symptoms
      • ACR revised criteria (2000)
        • Wolfe F.
        • Clauw D.
        • Fitzcharles M.A.
        • et al.
        Clinical diagnostic and severity criteria for fibromyalgia.
        : presence of chronic widespread pain and a symptom severity scale (includes fatigue, cognitive disturbances, nonrestorative sleep, and other somatic symptoms)
      • New criteria offer greater sensitivity for diagnosis of fibromyalgia

      Treatment

      Various pharmacologic and nonpharmacologic treatments have been shown to be beneficial in fibromyalgia (Box 12).
      Treatment of fibromyalgia
      • Pharmacologic treatment: for pain control
        • Antidepressants: amitryptiline, cyclobenzaprine, fluoxetine
          • Hauser W.
          • Bernardy K.
          • Ucelyer N.
          • et al.
          Treatment of fibromyalgia syndrome with anti-depressants: a meta-analysis.
        • Opiates: tramadol
        • Central nervous system agents: gabapentin, pregabalin
      • Nonpharmacologic treatment
        • Graded aerobic exercise regimen
          • Goldenberg D.L.
          • Burckhardt C.
          • Crofford L.
          Management of fibromyalgia syndrome.
          : helps with pain, avoid overexhaustion
        • Sleep evaluation and treatment: helps with nonrestorative sleep and to correct other sleep problems, such as obstructive sleep apnea
        • Cognitive behavioral therapy: promotes and reinforces positive behaviors, helps with treatment of pain, fatigue, and other somatic symptoms
      • Treatment of other coexisting symptoms (psychological, somatic, such as gastrointestinal, etc)
      A holistic approach that addresses the various symptoms of fibromyalgia including pain, fatigue, sleep, and mood disorders has been shown to be effective and deliver the most effective results in the long-term.
      • Goldenberg D.L.
      • Burckhardt C.
      • Crofford L.
      Management of fibromyalgia syndrome.

      Precordial Catch Syndrome

      Precordial catch syndrome is an uncommon condition characterized by episodes of localized, stabbing, or sharp pain catches in the anterior chest, usually in the left parasternal area or near the cardiac apex in healthy young individuals.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Gumbiner C.H.
      Precordial catch syndrome.
      Pain occurs in a bent-over or slouched position and is increased by deep breathing. It is relieved by shallow respirations and by correcting posture. Local tenderness is absent. The cause is believed to be intercostal muscle spasm caused by postural defects.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.

      Evaluation

      Precordial catch syndrome is a diagnosis of exclusion.

      Treatment

      Reassurance, correcting postural defects, and good pain control are generally recommended.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      • Gumbiner C.H.
      Precordial catch syndrome.

      Epidemic Myalgia

      Epidemic myalgia is also called devil’s grip, caused by acute viral illness with pain in the chest wall and epigastrium.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.
      The usual causes are the group B coxsackie viruses, which usually affect intercostal and upper abdominal wall muscles, and rarely the pleura. A prodrome of 1 to 10 days is followed by severe, sharp pain in the lateral chest wall in adults or the upper abdomen in children. Pain is increased by breathing, coughing, and other thoracic movements and lasts 3 to 7 days, with frequent recurrences.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.

      Evaluation

      Diagnosis is usually clinical, with good history and physical examination, with local tenderness of involved muscle groups. Isolation of the virus from the throat or feces or showing increasing titer levels of type-specific neutralizing antibodies can confirm the diagnosis.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.

      Treatment

      Symptomatic treatment with good pain control is recommended.
      • Fam A.G.
      • Smythe H.A.
      Musculoskeletal chest wall pain.

      Musculoskeletal chest pain related to thoracic spine

      Acute Thoracic Disc Herniation in Athletes

      Thoracic disc herniation does not have a typical clinical presentation and most commonly presents as a nonspecific, often acute-onset, midline pain in the thoracic area. It can be unilateral or bilateral. It can be intermittent or constant and may be increased by coughing and straining.
      • Baranto A.
      • Borjesson M.
      • Danielsson B.
      • et al.
      Acute chest pain in a top soccer player due to thoracic disc herniation.
      Radicular distribution of pain depends on the thoracic spinal segment involved and may be followed by sensory and motor disturbances caused by spinal cord compression. The usual cause is believed to be degeneration, although acute trauma has to be considered in young patients, especially in athletes.
      • Baranto A.
      • Borjesson M.
      • Danielsson B.
      • et al.
      Acute chest pain in a top soccer player due to thoracic disc herniation.

      Evaluation

      MRI is the imaging of choice and shows thoracic disc herniation.
      • Baranto A.
      • Borjesson M.
      • Danielsson B.
      • et al.
      Acute chest pain in a top soccer player due to thoracic disc herniation.

      Treatment

      Conservative management is successful in most patients. Selective spinal root or intercostal nerve blockade and epidural steroid injections are used. If there is no improvement in symptoms after 2 to 3 months, or if there is progression of symptoms with new neurologic deficits, operative treatment is recommended, with a success rate of about 80%.
      • Baranto A.
      • Borjesson M.
      • Danielsson B.
      • et al.
      Acute chest pain in a top soccer player due to thoracic disc herniation.
      Long-term prognosis is considered to be good, but recurrences of pain and other symptoms are not uncommon. It is important to explain the possibility of recurrent pain to patients, especially young athletes, because it can cause them to prematurely end their sporting careers.
      • Baranto A.
      • Borjesson M.
      • Danielsson B.
      • et al.
      Acute chest pain in a top soccer player due to thoracic disc herniation.

      Miscellaneous causes of musculoskeletal chest pain

      Herpes Zoster of the Chest Wall

      Herpes zoster is caused by the reactivation of the latent varicella zoster virus, which has been dormant in dorsal root ganglion of the spinal cord since the initial chicken pox infection.
      • Johnson R.W.
      Herpes zoster and postherpetic neuralgia: a review of the effects of vaccination.
      About 50% of elderly patients older than 80 years are believed to develop this infection over their lifetime.
      • Johnson R.W.
      Herpes zoster and postherpetic neuralgia: a review of the effects of vaccination.
      It presents as a vesicular eruption of the skin, and is dermatomally distributed. The rash is usually unilateral and confined to a single dermatome, but involvement of multiple, bilateral dermatomes is seen. Severe pain is a hallmark of herpes zoster and often precedes, accompanies, and follows resolution of rash (Box 13).
      • Johnson R.W.
      Zoster associated pain: what is known, who is at risk and how can it be managed?.
      Characteristics of pain in herpes zoster
      • Preherpetic neuralgia: prodromal pain that precedes the development of skin eruption (usually by 4 days)
        • Johnson R.W.
        Zoster associated pain: what is known, who is at risk and how can it be managed?.
        • Gilden D.H.
        • Dueland A.N.
        • Cohrs R.
        • et al.
        Preherpetic neuralgia.
        • Leads to diagnostic confusion depending on the dermatomes affected
        • Fever, malaise, and skin tenderness over affected area may accompany the pain
      • Postherpetic neuralgia: pain that persists or is recurrent more than 1 month after the onset of initial herpes zoster infection
        • Jung B.F.
        • Johnson R.W.
        • Griffin D.R.
        • et al.
        Risk factors for postherpetic neuralgia in a patient with herpes zoster.
        • More common in elderly women with history of severe prodromal pain and severe skin rash
        • Pain is debilitating and resistant to treatment
          • Jung B.F.
          • Johnson R.W.
          • Griffin D.R.
          • et al.
          Risk factors for postherpetic neuralgia in a patient with herpes zoster.
          • Zareba G.
          Pregabalin: a new agent for the treatment of neuropathic pain.
      • Zoster sine eruption: prodromal pain is not followed by skin eruption
        • Leads to diagnostic difficulties
          • Barrett A.P.
          • Katelaris C.H.
          • Morris J.G.
          • et al.
          Zoster sine herpete of the trigeminal nerve.
          • Schuchmann J.A.
          • McAllister R.K.
          • Armstrong C.S.
          • et al.
          Zoster sine herpete with thoracic motor paralysis temporally associated with thoracic epidural steroid injection.
      Involvement of thoracic dermatomes, especially in elderly patients, can cause diagnostic confusion with cardiac and pulmonary causes of pain, particularly before development of the rash.
      • Goh C.L.
      • Khoo L.
      A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic.
      • Franken R.A.
      • Franken M.
      Pseudo-myocardial infarction during an episode of herpes zoster.
      Rash usually involves thoracic dermatomes with grouped vesicles and pustules present on erythematous base. Infection typically resolves completely in 4 weeks. Scarring and depigmentation in the area of the rash may be seen.
      • Muir J.
      • Yelland M.
      Skin and breast disease in the differential diagnosis of chest pain.

      Evaluation

      Diagnosis during the prodromal phase before appearance of skin lesions is difficult.
      • Muir J.
      • Yelland M.
      Skin and breast disease in the differential diagnosis of chest pain.
      • Morgan R.
      • King D.
      Characteristics of patients with shingles admitted to a district general hospital.
      A history of varicella zoster in the past and hyperesthesia and skin tenderness on physical examination that follows a dermatomal distribution are clues to the diagnosis.
      • Muir J.
      • Yelland M.
      Skin and breast disease in the differential diagnosis of chest pain.
      • Morgan R.
      • King D.
      Characteristics of patients with shingles admitted to a district general hospital.
      A dermatomally distributed skin rash with grouped vesicles and pustules on an erythematous base is diagnostic (Fig. 16). Clinical diagnosis can be confirmed by Tzanck smear (swabs from the base of the vesicles show varicella zoster virus DNA on polymerase chain reaction testing).
      Figure thumbnail gr16
      Fig. 16Dermatomal distribution of herpes zoster skin rash.
      (From Swartz MH. Textbook of physical diagnosis: history of examination. Philadelphia: Saunders; 2009. p. 137–95; with permission.)

      Treatment

      Pain control and antivirals are mainstays of treatment (Box 14).
      Treatment of herpes zoster

      SAPHO Syndrome

      SAPHO syndrome is a chronic disease that is characterized by association of synovitis, acne, pustulosis, hyperostosis, and osteitis.
      • Chamot A.M.
      • Benhamou C.L.
      • Kahn M.F.
      • et al.
      Acne-pustulosis-hyperostosis-osteitis syndrome. Result of a national survey. 85 cases.
      It usually presents with cutaneous manifestations (neutrophilic eruptions, such as palmoplantar pustulosis and hidradenitis suppurativa) and aseptic inflammatory bone lesions with associated findings that include hyperostosis and arthritis of adjacent joints (osteoarthropathy).
      • Zigang Z.
      • Ying L.
      • Yuanyuan L.
      • et al.
      Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome with review of the relevant published work.
      SAPHO syndrome has a predilection to affect the bony structures of the anterior chest, including the sternum and medial end of clavicle. Anterior chest pain is one of the most common symptoms.
      • Zigang Z.
      • Ying L.
      • Yuanyuan L.
      • et al.
      Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome with review of the relevant published work.
      The pathogenesis of SAPHO syndrome is unclear. One of the proposed mechanisms is a possible autoimmune response triggered by a microorganism producing sterile inflammation in the joints and bones.
      • Zigang Z.
      • Ying L.
      • Yuanyuan L.
      • et al.
      Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome with review of the relevant published work.
      • Grossman M.E.
      • Rudin D.
      • Scher R.
      SAPHO syndrome: report of three cases and of the literature.
      • Earwaker J.W.
      • Cotton A.
      SAPHO: syndrome or concept? Imaging findings.
      Propionibacterium acnes is the most commonly cultured microorganism in skin and bone specimens obtained from patients with SAPHO syndrome.
      • Hurtado-Nedelec M.
      • Chollet-Martin S.
      • Nicaise-Roland P.
      • et al.
      Characterization of the immune response in the synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome.
      Genetic factors and stress are other important factors that are correlated with the syndrome.
      • Zigang Z.
      • Ying L.
      • Yuanyuan L.
      • et al.
      Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome with review of the relevant published work.
      • Grossman M.E.
      • Rudin D.
      • Scher R.
      SAPHO syndrome: report of three cases and of the literature.
      • Earwaker J.W.
      • Cotton A.
      SAPHO: syndrome or concept? Imaging findings.

      Evaluation

      Although there are no validated criteria, standard diagnostic criteria agreed on by most clinicians and researchers can be used in diagnosis (Box 15).
      • Schuster T.
      • Bielek J.
      • Dietz H.G.
      • et al.
      Chronic recurrent multifocal osteomyelitis (CRMO).
      Standard diagnostic criteria for SAPHO syndrome
      • Local bone pain with gradual onset
      • Multifocal lesions involving long tubular bones and spine
      • Failure to culture an infectious microorganism
      • Neutrophilic skin eruptions (palmoplantar pustulosis, nonpalmoplantar pustulosis, psoriasis vulgaris, or severe acne)
      • Protracted course for several years, with exacerbations and improvement with antiinflammatory drugs
      Laboratory findings are nonspecific and include mild leukocytosis, mild anemia, and an increased erythrocyte sedimentation rate. Serum levels of complement C3 and C4 may be increased or normal and serum IgA levels are usually increased.
      • Zigang Z.
      • Ying L.
      • Yuanyuan L.
      • et al.
      Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome with review of the relevant published work.

      Treatment

      Symptomatic relief with NSAIDs and analgesics are the mainstay of therapy. Corticosteroids, sulfasalazine, and isotretinoin have been used in some cases. Use of tumor necrosis factor inhibitors (such as infliximab and etanercept) and immunomodulators (such as leflunomide and methotrexate) have been proposed in some studies.
      • Zigang Z.
      • Ying L.
      • Yuanyuan L.
      • et al.
      Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome with review of the relevant published work.
      • Hurtado-Nedelec M.
      • Chollet-Martin S.
      • Nicaise-Roland P.
      • et al.
      Characterization of the immune response in the synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome.
      • Gupta A.K.
      • Skinner A.R.
      A review of the use of infliximab to manage cutaneous dermatoses.
      • Robert I.
      • Matthias L.
      • Costakis G.
      • et al.
      Mechanism of action for leflunomide in rheumatoid arthritis.

      Summary

      Musculoskeletal chest pain can be a cause of significant morbidity and anxiety for a patient. Better understanding of the various causes of musculoskeletal chest pain can help prevent unnecessary testing and anxiety for patients and ensure timely treatment.

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