Major causes of musculoskeletal chest pain

Christopher M Wise, MD

Jan 27, 2000

Chest pain is one of the more common symptoms requiring medical attention in the outpatient setting. Cardiac and pulmonary problems are usually the focus of the initial diagnostic evaluation. After these areas are excluded, other conditions affecting the structures in and around the thoracic cage enter into the differential diagnosis, including diseases of the esophagus, upper abdomen, and head and neck. Conditions affecting the musculoskeletal structures of the chest wall are frequently listed as potential causes of atypical or noncardiac chest pain [1,2].

This card will review the major causes of musculoskeletal chest pain. The evaluation of such patients is discussed separately. (See "Clinical evaluation of musculoskeletal chest pain").

PREVALENCE — The proportion of patients with chest pain having a musculoskeletal source varies with the clinical setting (show table 1).

Emergency room — In the emergency room, approximately 10 to 15 percent of adults and 20 to 25 percent of children presenting with chest pain have a musculoskeletal cause [3,4]. In one large retrospective study, for example, 11 percent of adults presenting with chest pain were felt to have a musculoskeletal cause [3]. The incidence rose to 26 percent in those patients considered at low suspicion for myocardial infarction, making this the most common category of noncardiac chest pain in this setting.

In a prospective emergency room study of 122 consecutive patients, 36 (30 percent) were felt to have chest wall tenderness due to costochondritis [5]. In 17, the tenderness reproduced their pain. Two of these patients had acute myocardial infarction (6 percent), indicating that chest wall tenderness does not exclude the presence of serious coronary disease.

Nonemergent settings — The prevalence of musculoskeletal chest pain in the nonemergent, ambulatory care setting appears to be even greater. In a recent review of 399 episodes of chest pain evaluated in primary care practice settings, 36 percent were categorized as musculoskeletal in origin, making this the most common diagnostic category [6].

Musculoskeletal pain also may be present in some of the 30 percent of patients undergoing coronary arteriography who have negative findings [7]. Prospective studies of such patients have shown that 13 to 20 percent have chest wall tenderness that reproduces their pain, suggesting a musculoskeletal etiology [8,9,10,11]. Another 50 to 60 percent have chest wall tenderness that does not reproduce their pain, and is probably clinically unimportant [10,11]. Once again, however, findings suggestive of a musculoskeletal source of pain do not preclude coexisting pain due to coronary disease [8,10].

ISOLATED MUSCULOSKELETAL CHEST PAIN SYNDROMES — There are a number of chest wall syndromes with chest pain associated with musculoskeletal inflammation (show table 2).

Tietze's syndrome — Tietze's syndrome has been defined as a benign, painful, nonsuppurative localized swelling of the costosternal, sternoclavicular, or costochondral joints, most often involving the area of the second and third ribs [12]. Only one area is usually involved, and young adults are more commonly affected.

Tietze's syndrome is rare, and should be differentiated from more diffuse forms of myofascial chest pain (costochondritis) in which no areas of localized swelling are detected on examination. The cause of Tietze's syndrome is unknown, but antecedent upper respiratory infections and excessive coughing have been described in some patients. The relationship between Tietze's syndrome and the anterior chest wall involvement of the seronegative spondyloarthropathies and the more recently described sternocostoclavicular hyperostosis is uncertain, but a recent review has raised questions regarding the existence of Tietze's syndrome as a specific entity [13].

Treatment with nonsteroidal antiinflammatory drugs or local steroid injections may improve the acute symptoms. The pain usually subsides within a few weeks, with some residual swelling persisting for longer periods of time.

Costosternal syndromes (costochondritis) — A majority of patients with musculoskeletal chest wall syndromes have a more diffuse pain syndrome, in which multiple areas of tenderness are found that reproduce the described pain. The upper costal cartilages at the costochondral or costosternal junctions are most frequently involved [1,8,14,15].The areas of tenderness are not accompanied by heat, erythema, or localized swelling.

A variety of diagnostic terms have been used in this group of patients, including costochondritis, costosternal syndrome, and anterior chest wall syndrome. The diagnosis is based solely upon the ability to reproduce pain by palpation of tender areas. In some studies, certain maneuvers, such as the "crowing rooster" and horizontal arm flexion maneuvers, have also been found to be useful. (See "Clinical evaluation of musculoskeletal chest pain").

Although the costosternal syndrome is a frequent diagnosis in patients with noncardiac chest pain, the causes, natural history, and treatment of this condition are poorly documented. Most cases follow a self-limited course with occasional exacerbations. The coexistence of fibromyalgia should be considered in patients with persistent symptoms (see below).

Treatment is nonspecific. Most patients recover spontaneously but antiinflammatory agents, antidepressants, muscle relaxants, and physical measures have been used in selected cases.

Sternalis syndrome — The sternalis syndrome is a rarely described condition in which localized tenderness is found directly over the body of the sternum or overlying sternalis muscle, and palpation often causes radiation of pain bilaterally [16]. This syndrome is generally self-limited, and less likely to cause persistent pain than the more diffuse costosternal syndrome. It should be differentiated from arthritis of the manubriosternal joint, which can sometimes be involved in various types of systemic arthritis.

Xiphoidalgia — Xiphoidalgia (xiphoidynia) is another relatively rare syndrome that is characterized by localized discomfort and tenderness over the xiphoid process of the sternum [17,18]. Symptoms are often aggravated by eating a heavy meal or bending or twisting movements; they may also be associated with resumption of heavy work or a recent cough, suggesting a traumatic cause in some patients. Analgesics or local injection of an anesthetic-steroid combination are frequently curative [17,18].

Spontaneous sternoclavicular subluxation — Spontaneous, atraumatic, subluxation of the sternoclavicular joint, not associated with any systemic process, has been described in small numbers of patients [19]. This syndrome occurs almost exclusively in women in the 40 to 60 year age group, most often in the dominant hand associated with moderate to heavy repetitive tasks. The subluxation is typically in a cranial and/or anterior direction. Sclerosis of the medial clavicle is often seen radiographically. Supportive, nonoperative therapy is usually recommended.

Lower rib pain syndromes — A variety of names have been given to pain syndromes involving the lower ribs, including rib-tip syndrome, slipping rib, twelfth rib, and clicking rib. This condition is characterized by pain in the lower chest or upper abdomen, a tender spot on the costal margin, and reproduction of the pain by pressing on the spot [20]. In some reports, hypermobility of the anterior end of a costal cartilage has been implicated, possibly related to indirect trauma due to lifting or twisting [21].

In addition to direct palpation, another useful diagnostic test is the "hooking maneuver", in which the examiner's curled fingers are hooked under the ribs at the costal margin and the ribs are gently pulled forward [22].

Painful lower rib syndromes have been found in three to five percent of patients referred to some gastroenterology practices. A majority of patients with this condition are women, with a mean age in the mid-40s. The pain persists in 70 percent of patients followed for an average of four years from diagnosis. One-third of patients undergo further evaluations for other causes of pain, even after a definitive diagnosis is made. Reassurance and mild analgesics are useful in most patients, with local anesthetic injections, and rarely, rib resection used in a few reported cases.

Posterior chest wall pain syndromes — There are several causes of posterior chest wall pain. Thoracic disc herniations are rare and difficult to diagnose, but should be considered in patients with unilateral dermatomal pain. This condition is most common in patients in their 40s, two-thirds of whom have "band-like" chest pain [23]. Surgical decompression was required in only 27 percent of patients in one recent series, as a majority of those treated with conservative measures returned to normal activities.

Costovertebral joint dysfunction is another uncommon condition causing posterior chest wall pain. Patients usually present with pain that is made worse with coughing or deep breathing, and often undergo evaluation for an intrapulmonary processes, most often pulmonary embolism [24]. On physical examination, pain is often reproduced by palpation in the area of the costovertebral junctions or directly over the affected rib, and local hyperalgesia may be caused by skin pinching. In some cases, degenerative changes are seen in the affected joints. Intercostal nerve block or facet joint injection has been used in patients who do not respond to conservative measures.

The costovertebral joints may be diffusely involved in ankylosing spondylitis, but the chest pain associated with this condition is usually more diffuse, and associated with other features of the disease, including limited chest expansion on physical examination (see below).

RHEUMATIC DISEASES CAUSING MUSCULOSKELETAL CHEST WALL PAIN — Involvement of thoracic joints in rheumatic diseases can be associated with musculoskeletal chest wall pain (show table 3).

Rheumatoid arthritis — Diffuse chest wall pain, as in costochondritis or costosternal syndrome, is not part of rheumatoid arthritis. However, there may be symptomatic involvement of the sternoclavicular joint in up to seven percent of patients with established, generalized rheumatoid arthritis, and radiographic changes may be apparent in 30 percent [25,26]. Establishing the diagnosis is usually not difficult, except in the rare case in which involvement of the sternoclavicular joint is the initial manifestation of the disease [27]. (See "Biologic markers in the diagnosis and assessment of outcome in rheumatoid arthritis").

Ankylosing spondylitis — Pain in the thoracic spine and around the chest wall, resulting from inflammatory disease of the costovertebral, costotransverse, and thoracic apophyseal joints, is common in ankylosing spondylitis [28]. Patients with this condition usually present with symptoms in the lower back or buttocks and some element of morning stiffness; however, about three percent of patients present with pain in the dorsal spine, and two percent with pain around the chest [29]. Involvement of these joints often results in limitation of chest expansion. This finding is frequent and typical enough to be included in commonly used criteria for the diagnosis of this disease [30], and is felt to be the most sensitive of the clinical elements used in these criteria [31]. (See "Clinical manifestations and diagnosis of ankylosing spondylitis").

Symptoms in the anterior chest wall occur in five to 25 percent of patients with ankylosing spondylitis. Radiographic evidence of anterior chest involvement is more common, with 18 percent having sternoclavicular and 51 percent manubriosternal involvement [32].

Psoriatic arthritis — Approximately five to ten percent of patients with typical psoriasis develop arthritis, which may be axial or peripheral in distribution. Some patients with psoriatic arthritis have a spondylitis similar to that seen in ankylosing spondylitis. Anterior chest wall involvement is uncommonly reported, and some confusion exists regarding the relationship of this finding to sternocostoclavicular hyperostosis. As in other disorders, anterior chest wall symptoms (one percent) are less common than radiologic evidence of disease in the manubriosternal and sternoclavicular joint (10 to 25 percent) [32]. (See "Clinical manifestations and diagnosis of psoriatic arthritis").

Sternocostoclavicular hyperostosis (SAPHO syndrome) — Sternocostoclavicular hyperostosis is a relatively recently described syndrome characterized by a unique arthropathy that frequently involves the anterior chest wall and is associated with a spectrum of neutrophilic skin lesions [32,33,34,35]. Clinical descriptions of this syndrome have appeared most frequently in the Japanese and European literature under a variety of different names, including acne-associated spondyloarthropathy, chronic recurrent multifocal osteomyelitis, and pustulotic arthroosteitis). The acronym SAPHO syndrome has been proposed as a unifying term to include the various features common to these closely related disorders: synovitis; acne; pustulosis; hyperostosis; and osteomyelitis.

  •  The skin lesions associated with the SAPHO syndrome include palmoplantar pustulosis, acne conglobata, acne fulminans, hidradenitis suppurativa, and dissecting cellulitis of the scalp, all of which are characterized pathologically by neutrophilic pseudoabscesses. (See "Neutrophilic dermatoses").

  •  Various patterns of asymmetric peripheral and axial arthritis have been described in association with these skin lesions, many resembling the seronegative spondyloarthropathies. However, no consistent association with HLA-B27 has been demonstrated. (See "HLA-B27 and the pathogenesis of Reiter's syndrome and ankylosing spondylitis").

  •  The anterior chest wall is the most frequent area of involvement, particularly in patients with palmoplantar pustulosis [36]. Affected patients may present with pain, tenderness, and swelling of the sternum and its articulations, and some patients have restricted mobility. Enlargement and sclerosis of one or both medial clavicles may be seen radiographically, sometimes progressing to involvement of the lateral aspects. Osteolytic lesions may be visible within sclerotic areas. Similar involvement may be seen in the sternum, particularly the manubrium, and the anterior segments of the ribs. In some cases, the condition progresses to total or partial fusion and ossification involving the ribs, sternum, medial clavicles, and adjacent ligaments. Outside the chest wall, similar findings have been described in the mandible, peripheral long bones, and vertebral bodies.

  •  Patients who present with bone lesions alone often develop other manifestations over time. In one study of 15 patients followed for more than a decade, 12 eventually suffered from extraosseous features, including sacroiliitis, psoriasis, and palmoplantar pustulosis [37].

The histopathology of the bony lesions in this syndrome resemble a sterile osteomyelitis. Although the etiology of the SAPHO syndrome is unknown, occult disseminated infection by a low virulence organism, such as Propionibacterium acnes, has been implicated in some studies [38].

Treatment of this condition is usually nonspecific and conservative. Antibiotics have not been useful, but nonsteroidal antiinflammatory drugs, colchicine, corticosteroids, sulfasalazine, methotrexate, and retinoids have all been reported to be effective in some patients. A recent report demonstrated dramatic relief of acute exacerbations in a few patients treated with intramuscular calcitonin [39]. How this might occur is not known.

Fibromyalgia — Fibromyalgia is a common chronic musculoskeletal pain syndrome, characterized by diffuse musculoskeletal pain, fatigue, sleep disturbance and multiple periarticular tender points found on physical examination [40]. The most common areas of reported pain in patients with this condition are the low back, neck, shoulders, and hips. (See "Clinical manifestations and diagnosis of fibromyalgia").

Chest pain occurs with a frequency that has ranged from eight to 71 percent [41,42]. However, 85 percent of patients with fibromyalgia have tenderness over the second anterior costochondral junctions (over 60 percent characterized as moderate or greater), making this one of the most common sites of tenderness in fibromyalgia [40].

In the emergency room setting, only three percent of all patients, and eight percent of those with chest wall tenderness, appear to have fibromyalgia [5]. Similar frequencies have been reported in patients evaluated after negative coronary angiography [11].

Infectious arthritis of the chest wall — Infection of the ribs and joints of the chest wall is uncommon. When infectious arthritis does occur, it usually affects the sternoclavicular joint. In one review of patients with sternoclavicular infections, a history of intravenous drug abuse or rheumatoid arthritis were the most commonly associated conditions [43]. The most common causative organism was Pseudomonas aeruginosa in patients with a history of drug abuse, while Staphylococcus aureus and various streptococcal species predominated in those without such a history. The risk of developing an abscess in the surrounding area was about 20 percent, and such spread has been associated with mediastinitis [44].

Relapsing polychondritis — This rare condition, characterized by inflammatory lesions of cartilage, classically presents with inflammation of the ears, nasal cartilage, and respiratory tract. Associated problems in some patients include a nonerosive synovitis, ocular inflammation, and inner ear dysfunction. Inflammation of the costochondral and manubriosternal areas may occur in up to one-quarter of patients, with rare reports of destructive lesions resulting in flail chest [45].

NONRHEUMATIC SYSTEMIC CAUSES OF CHEST WALL PAIN — Several systemic disorders are characterized by bony involvement that can lead to chest wall pain.

Stress fractures — Stress or insufficiency fractures of the ribs should be considered in patients with chest pain and risk factors for osteoporosis or osteomalacia, including rheumatoid arthritis treated chronically with corticosteroids [46], renal failure, and vitamin D deficiency, especially in the elderly. (See "Causes of hypophosphatemia", section on vitamin D deficiency).

Neoplasms — Primary or secondary neoplasms infrequently involve the chest wall, usually as mass lesions. Lung or breast carcinoma, for example, may involve the chest wall by direct extension or metastases, while other neoplasms occasionally cause hematogenous metastases. Primary neoplasms of the chest wall are rare, and include various sarcomas, malignant fibrous histiocytoma, and multiple myeloma [47].

Sickle cell disease — The acute chest syndrome described as a part of sickle cell crisis has usually been attributed to pulmonary infarction. However, one report, using technetium bone scans, found that rib infarctions may contribute in many cases [48]. There may also be an association of rib involvement with the abdominal pain and distension that is part of some crises [49].