Atypical Chest Wall Pain

Introduction

The initial evaluation for chest pain must rule out potentially life-threatening cardiac and pulmonary causes. However, the majority of chest pain cases are actually noncardiac in origin and typically involve the chest wall. ^,

A retrospective study of over 1300 emergency department visits for noncardiac chest pain found that 45% of the cases were musculoskeletal in origin. Another prospective trial of 130 consecutive emergency department admissions found 30% had chest wall tenderness. Chest wall pain is even more common in the outpatient setting, with up to 47% of cases categorized as noncardiac in nature. In addition, 45% of patients who proceeded with a negative coronary angiography were found to have chest wall pain present.

Chest wall pain is defined as pain along the xiphoid, costosternal junction, or sternum. Chest wall pain may be an isolated musculoskeletal pain syndrome or can present as a result of rheumatic and nonrheumatic systemic causes, which makes early recognition essential for providing appropriate management. ^, The majority of chest wall pain syndromes are self-limiting in nature and amenable to conservative management.

Etiology and Pathogenesis

The causes and pathophysiology of chest wall pain are poorly understood. It is commonly believed that chest wall pain is largely due to inflammation of the costal cartilages and sternal articulations, with costosternal and lower rib syndromes being the most common causes. For patients with radicular symptoms along with a dermatomal distribution, it may be secondary to thoracic disc herniation or osteophyte compression, both of which can cause nerve root impingement or irritation, although these are relatively rare occurrences in the thoracic spine. ^,

Persistent chest wall pain is also seen following surgical procedures. The incidence of postmastectomy pain syndrome (PMPS) is 20%–72% following breast cancer-related procedures and is due to direct nerve injury during surgery or nerve entrapment from postoperative scar formation. ^, The anterior and lateral cutaneous branches of the intercostal nerves originating from the T3–6 nerve roots innervate the skin overlying the breast. Moreover, the most commonly injured nerve during axillary dissection is the intercostobrachial nerve, which is the lateral branch of the second intercostal nerve that innervates the upper lateral breast quadrant.

Similarly, postthoracotomy pain syndrome (PTPS) occurs in approximately 30%–50% of patients who undergo thoracotomy procedures and presents as persistent pain along the thoracotomy scar. PTPS is thought to be a result of injury to the intercostal nerves during surgical incision, rib retraction, and insertion of the surgical trocars.

Clinical Features

There are a variety of chest wall pain syndromes that present similarly with a few distinguishing characteristics ( Table 21.1 ).

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Costochondritis :
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  Costochondritis is one of the most common causes of chest wall pain, with 30% of chest pain complaints in the emergency department being attributed to this diagnosis. Patients complain of pain that worsens with upper body movement and deep breathing. Most commonly with an unknown cause, pain is typically diffuse and reproducible with palpation of the costosternal joints of the chest. The upper costochondral or costosternal junctions are most frequently involved. ^,^,
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Lower Rib Pain Syndrome
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  This condition occurs when the inferior ribs are displaced due to hypermobility of the false rib costal cartilages and is also known as “rib-tip” syndrome, “slipping rib,” or “clicking rib” syndrome. Pain is localized to the lower chest or upper abdomen along the costal margin. Pain is often reproducible on palpation. It may occur at any age, though it is more commonly seen in younger female athletes.
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Sternalis Syndrome
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  Patients present with tenderness directly over the sternum with pain radiating bilaterally. This syndrome does not typically present with a diffuse distribution of pain and is thought to be due to myofascial pain.
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Tietze’s Syndrome
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  Patients present with pain along the costosternal, costochondral, or sternoclavicular joints that worsens with upper body movements. There is often nonsuppurative, localized swelling or edema present and most commonly occurs near the second and third ribs. Swelling or edema is a distinguishing feature of Tietze Syndrome and is found to be self-limiting and benign. This is often due to infectious, neoplastic, or rheumatologic processes.
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Xiphoidalgia
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  Often times a result of chest wall trauma, this rare condition presents with localized tenderness over the xiphoid. Typically, symptoms will present after a large meal, with chest movement, or lifting heavy objects.
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Posterior Chest Wall Pain
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  Posterior chest pain typically arises from structures in the thoracic spine, including the intervertebral discs, facet joints, and costovertebral joints. Although pain is often localized either unilaterally or bilaterally to the posterior chest, patients may present with pain that radiates in a band-like, dermatomal distribution to the anterior chest with associated numbness and tingling.
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Postmastectomy Pain Syndrome
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  Patients present with burning, electric shock-like, and stabbing pains with associated neuropathic symptoms (numbness, paresthesia) at the surgical site, chest wall, axilla, or ipsilateral arm. Also a misnomer, symptoms often occur after breast cancer-related surgeries but can also be seen following radiation therapy or chemotherapy without signs of infection or recurrent disease. ^,
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Post-Thoracotomy Pain Syndrome
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  Much like PMPS, patients present with intense sharp pains with associated neuropathic symptoms along a previous thoracotomy incision.
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Other rheumatologic causes
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  Rheumatic and psoriatic arthritis as well as fibromyalgia are possible etiologies that should be considered, though isolated chest pain is rarely the presenting symptom.

Table 21.1

Chest Wall Pain Syndromes.

Syndrome	Location of Pain
Costochondritis	Upper costochondral or costosternal junctions
Lower rib pain syndrome	Lower chest or upper abdomen along the costal margin
Sternalis syndrome	Directly over the sternum with pain radiating bilaterally
Tietze’s syndrome	Along the costosternal, costochondral, or sternoclavicular joints
Xiphoidalgia	Localized tenderness over the xiphoid
Posterior chest wall pain	Dermatomal distribution radiating from the thoracic spine
Postmastectomy pain syndrome (PMPS)	May involve the surgical site, chest wall, axilla, or ipsilateral arm with neuropathic pain symptoms such as numbness, tingling, burning, allodynia, hyperalgesia
Postthoracotomy pain syndrome (PTPS)	Pain along previous thoracotomy incision with associated neuropathic pain symptoms