Chest Wall pain

• Most common cause of chest pain in GP
• Divide into –
  • Musculoskeletal pain
  • Rheumatic diseases
  • Non- rheumatic systemic causes

Musculoskeletal causes of chest wall pain

Isolated musculoskeletal pain More common – Costochondritis – Lower rib pain syndromes – Pain from thoracic spine/costovertebral joints – Sternalis syndrome Less common – Stress fractures – Tietze’s syndrome – Xiphoidalgia – Spontaneous sternoclavicular subluxation Rheumatic diseases More common – Fibromyalgia – Rheumatoid arthritis – Axial spondyloarthritis (including ankylosing spondylitis) – Psoriatic arthritis Less common -Sternoclavicular hyperostosis – Systemic lupus erythematosus – Septic arthritis of the chest wall – Relapsing polychondritis Non-rheumatic systemic causes Osteoporotic fracture Neoplasms  Pathological fracture Bone pain Sickle cell disease (rare)

• Costochondritis
  • Multiple areas of tenderness, no swelling 0 over the costochondral or costosternal juntions, palpation reproduces pain

• Tietze’s disease
  • one area with painful, localised swelling

• Lower rib pain syndrome
  • Painful rib syndrome, rib tip, slippine rib, twelfth rib
  • Lower chest/upper abdo pain
  • Tender spot on costal margin – pain reproducible by palpation

• Posterior chest pain – may arise from thoracic spine
  • Intervertebral discs
  • Facet (zygapophyseal) joints
  • Costotransverse, costovertebral joints

• Sternalis syndrome – localizes tenderness body of the sternum/sternalis muscle
• Reproducing pain by palpation or movement is key diagnostic feature for isolated MSK pain

• Treatment options for MSK
  • Avoid aggravating
  • Stretching
  • Heat for muscle spasm, ice for swelling
  • Simple analgesia
  • Consideration physio if persists

• Consider
  • Low back pain – ?spondyloarthropathy
  • Multiple joints – ?RA
  • Rashes – ?psoriasis
  • Sleep disturbance, fatigue, widespread pain – ?fibro

Key features of common causes of musculoskeletal chest wall pain

Condition	Key features
Isolated musculoskeletal chest wall pain
Costochondritis	Tenderness in multiple areas over the costochondral or costosternal junctions; palpation reproduces the pain No associated swelling; mostly affects 2nd to 5th ribs
Lower rib pain syndrome	Pain in the lower chest or upper abdomen with a tender spot on the costal margin; pain reproduced by pressing on the spot
Sternalis syndrome	Localised tenderness over the body of the sternum or sternalis muscle; palpation often causes radiation of pain bilaterally
Thoracic costovertebral joint dysfunction	Localised pain approximately 3–4 cm from the midline and possibly referred pain ranging from the posterior midline to the lateral chest wall, and anterior chest painMovement of the rib provokes pain at the costovertebral joint and reproduces referred pain
Rheumatic causes
Fibromyalgia	Widespread musculoskeletal pain and tenderness, poor quality, unrefreshing sleep, fatigue and cognitive disturbances, not accounted for by another conditionDiagnosed by American College of Rheumatology criteria
Rheumatoid arthritis	Swelling and/or tenderness of multiple small and/or large synovial joints, positive for rheumatoid factor and/or anti-citrullinated protein antibody, and abnormal C-reactive protein or erythrocyte sedimentation rateDiagnosed by American College of Rheumatology criteria
Axial spondyloarthropathy (including ankylosing spondylitis)	Back pain for 3 months or longer with onset under 45 years of age, together with either:imaging features of sacroiliitis on MRI or X-ray, and one other feature of SpA*HLA-B27 and two other features of SpA*
Psoriatic arthritis	Inflammatory articular disease (joint, spine, or entheseal) with three out of five of the following: 1) evidence of current psoriasis, past history or a family history of psoriasis, 2) current psoriatic nail changes, 3) negative for rheumatoid factor, 4) current or a history of dactylitis, 5) radiographic evidence of juxta-articular new bone formation on plain radiographs of the hand or foot
Non-rheumatic systemic causes
Osteoporotic fracture	Acute back pain, loss of height or kyphosis for thoracic spine fractures, acute localised pain for rib fractures Corticosteroid use and other osteoporosis risk factors for both.
Neoplasm with pathological fracture or bone pain	Severe and/or night pain, and associated non-musculoskeletal symptoms
*SpA, spondyloarthritis: features are inflammatory low back pain, arthritis, enthesitis, uveitis, dactylitis, psoriasis, inflammatory bowel disease, good response to non-steroidal anti-inflammatory drugs, family history of SpA, HLA-B27, elevated C-reactive protein