Chest Wall Pain

Zar Baqai, MD

Jon Zhou, MD

FAST FACTS

Chest pain is a common presenting symptom in primary care.
There are noncardiac causes of chest pain.
Accurate assessment is essential to ensure appropriate management.
Assessment is largely based on history and physical examination.

INTRODUCTION

The chief complaint of “chest pain” is one of the most common, high-risk presentations encountered in the medical field.¹ Owing to the potential for a life-threatening condition, it is imperative to diagnose and treat patients with acute myocardial infarction, thoracic aortic dissection, or pulmonary embolism. However, in the primary care setting, studies show that more benign conditions such as musculoskeletal chest wall pain account for nearly half of all chest pain complaints.²^,³ The purpose of this chapter is to aid primary care physicians in both recognizing and managing various types of chest wall pain.

HISTORY

There are 3 general categories of musculoskeletal chest pain: isolated musculoskeletal pain syndromes, rheumatic disease-related pain, and systemic nonrheumatologic conditions. The history and physical examination are essential in making an accurate diagnosis, especially in isolated musculoskeletal pain syndromes such as costochondritis where no confirmatory laboratory test or imaging study currently exists. A large study by Bosner et al. found that 4 determinants were particularly useful in diagnosing musculoskeletal chest pain: localized muscle tension, stinging pain, pain reproducible by palpation, and absence of cough. The presence of 2 out of 4 determinants leads to a greater than 60% sensitivity and specificity for the diagnosis of musculoskeletal chest pain.²

A thorough history including pain location, quality, severity, onset, setting, aggravating/alleviating factors, and associated symptoms should be completed. Past medical history may disclose systemic conditions including osteoporosis, chronic renal disease, or cancer, which may be related to the pain complaint. The family history will aid in identifying individuals with genetic predisposition to diseases including rheumatologic conditions. The social history may indicate whether there has been a change in physical activity or if work or recreational activities that are frequent and repetitive are implicated. Travel history helps determine exposure to infections, for example, those caused by tick-borne diseases in endemic areas leading to the complaint of musculoskeletal chest wall and joint pain.

Inspection and palpation are essential physical examination elements in patients complaining of musculoskeletal chest pain. Visual inspection of the location of pain is essential to evaluate for obvious infection, trauma, scarring, tumor, erythema, and swelling. Examining areas that are tender to palpation helps narrow the diagnosis. Specifically, the costochondral junctions, clavicular articulations, manubrium, sternum, xiphoid, and ribs should be palpated. Positive findings on palpation of the costal margins and techniques such as the “hooking maneuver” can aid in the diagnosis of painful rib syndrome otherwise known as slipping rib syndrome⁴ (see Figure 17-1). All patients should have an examination of the spine, hips, and pelvic girdle evaluating for tenderness, flexion and extension, stiffness, and rotation. Patients with restriction to flexion
of the lumbar spine, tenderness in the sacroiliac joint, and morning stiffness may have ankylosing spondylitis, which is associated with tenderness in the sternum and sternoclavicular joints. The presence of uveitis or dactylitis would further support this diagnosis. A thorough examination of more distal joints should be performed as well to evaluate for other types of rheumatologic disease (Table 17-1).

FIGURE 17-1 Hooking maneuver.

TABLE 17-1 Musculoskeletal Chest Wall Pain

CAUSES	SYMPTOMS	PHYSICAL EXAM	LABS/IMAGING
Costochondritis	Pain at costochondral joint	Tender to palpation	NA
Lower rib pain syndrome/slipping Rib syndrome	Pain at costal margin	Tender to palpation	NA
Post-thoracotomy pain	Incisional pain/neuropathy	Tender to palpation	NA
Sternalis syndrome	Pain over sternum	Tender to palpation	NA
Xiphoidalgia	Pain over xiphoid	Tender to palpation	NA
Fibromyalgia	Fatigue, diffuse pain, waking unrefreshed	Trigger points	NA
Rheumatoid arthritis	Joint pain, morning stiffness	Tender, swollen, deformed joints	RF, anti-CCP, ESR, CRP, and X-ray/US showing inflammation and arthritis
Ankylosing spondylitis	Joint pain, back pain, stiffness	Joint tenderness, dactylitis	HLA-B27, pelvic X-ray, and MRI SI joint
Systemic lupus erythematosus	Can affect the kidneys, lungs, heart, brain, bone marrow, muscles, joints	Malar rash, joint involvement	ANA, ESR, CRP, anti-ds-DNA, anti-Sm, proteinuria, CBC, creatinine, anti-phospholipid ab, C3, C4
Insufficiency or stress fractures	Localized pain	Tender to palpation/swelling	X-ray (inexpensive, higher propensity for false negative than MRI) MRI (expensive, more accurate than X-ray)
Malignancy	Systemic, vary based on types	Tumor, swelling	CT chest
Tietze syndrome	Pain and swelling at costosternal, costochondral, or sternoclavicular joints, younger patients, usually second or third ribs	Tenderness, swelling	NA