Chest wall pain

Background
  • Major cause of chest pain
  • Diagnosis of chest wall pain is given to a vast majority (10-50%) of all ED visits for chest pain

Types
  • Costochondritis
    • Inflammation of costal cartilages or sternal articulations
    • No localized swelling
  • Tietze's syndrome
    • Benign, painful, localized swelling of costosternal, sternoclavciular, or costochondral joints
    • Associated with excessive coughing
  • Xiphodynia
    • Inflammation of xiphoid process
  • Precordial catch syndrome
    • 1-2 minute lancinating pain near the cardiac apex
    • Associated with poor posture and inactivity
  • Sternalis syndrome
    • Tenderness directly over body of sternum or sternalis muscle
  • Lower rib pain syndromes (Rib tip syndrome, slipping rib)
    • Tenderness over costal margin
    • Can be associated with abdominal pain

Clinical Features
  • Varying types of pain: sharp, dull, pleuritic
  • Can be worsened by inspiration or coughing
  • Not typically associated with cardiac disease, erythema, or swelling (except Tietze's syndrome)
  • Positive crowing roster maneuver or horizontal arm flexion

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Evaluation
  • Clinical diagnosis
  • EKG if ruling out ACS
  • Consider CXR based on symptoms and risk factors

Management[1]
  • Nonpharmacologic
    • Advise patient to avoid activity that lead to injury
    • Stretching
    • Hot or cold packs
  • Pharmacologic
  • Approximately 50% of patients will continue to have chest pain for 6-12 months with moderate limitation of activities [2]

Disposition
  • Discharge
  • Follow up in 4-6 weeks

References
  1. Phillips, K and Schur, P. (2018). Treatment of musculoskeletal chest pain. In P.L. Romain (Ed.), UpToDate. Retrieved August 20, 2018 from https://www.uptodate.com/contents/treatment-of-musculoskeletal-chest-pain
  2. Zaruba RA, Wilson E. IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES. Int J Sports Phys Ther 2017; 12:458.

Mahler S. Chapter 48: Chest Pain. In: Tintinalli J. Tintinalli's Emergency Medicine. A comprehensive study guide. 8th ed. 2016: 328.

Wise, C. (2017). Major causes of musculoskeletal chest pain in adults. In P. L. Romain (Ed.), UpToDate. Retrieved August 20, 2018, from https://www.uptodate.com/contents/major-causes-of-musculoskeletal-chest-pain-in-adults

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