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Costochondritis is one of the most common causes of musculoskeletal chest pain.
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Stretching exercises have been shown to be effective in relieving the pain in costochondritis.
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Rib fractures, either traumatic or stress fractures, can be a source of chest pain.
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Slipping rib syndrome may occur in children with chronic chest and abdominal pain.
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Muscle strains may cause musculoskeletal chest pain, with intercostal muscle strains being the most common.
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Pectoralis muscle injury needs accurate and early diagnosis for optimal functional recovery in athletes.
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Myofascial pain and fibromyalgia are other causes of musculoskeletal chest pain.
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Herpes zoster should be considered in elderly patients with nonspecific musculoskeletal chest pain.
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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.
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.
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).
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.
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.
For example, anginal pain may occur along with underlying costochondritis or subacromial bursitis, which may influence the distribution of anginal 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.
Musculoskeletal chest pain includes pain related to the anterior chest wall bony and cartilaginous structures, chest wall musculature, and the thoracic spine.
In addition, other causes of pain may include skin conditions, neoplasms, and infections of chest wall structures, metabolic causes (vitamin D deficiency),
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.
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.
Costochondritis: are the symptoms and signs due to neurogenic inflammation. Two cases that responded to manual therapy directed towards posterior spinal structures.
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.
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.
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).
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).
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.
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.
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.
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.
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.
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.
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.
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).
(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.)
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.
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.
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.
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.
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,
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.
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.
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.
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.
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.
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.
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).
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.
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.)
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.)
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
Fibromyalgia is a distinct complex clinical syndrome that belongs to a group of clinical syndromes characterized by chronic pain, called the central sensitization syndromes.
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.
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.
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%.
Both fibromyalgia and noncardiac chest pain seem to share the same pathogenesis of long-standing pain hypersensitivity, which presents as allodynia and hyperalgesia.
The other accompanying somatic and visceral complaints are believed to be caused by hypothalamic-pituitary-adrenal axis abnormalities and autonomic dysfunction.
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.
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.
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).
: 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
: 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).
Sleep evaluation and treatment: helps with nonrestorative sleep and to correct other sleep problems, such as obstructive sleep apnea
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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.
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.
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.
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.
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.
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.
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.
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%.
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.
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.
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).
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.
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.
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.
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).
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.)
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).
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.
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.
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.
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.
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.
Costochondritis: are the symptoms and signs due to neurogenic inflammation. Two cases that responded to manual therapy directed towards posterior spinal structures.
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