Introduction

Musculoskeletal chest pain is one of the most common causes of non-cardiac chest pain. It comprises a significant proportion of primary care attendances for chest pain and constitutes a significant number of Emergency Department attendances for the same complaint.

It has a number of aetiologies including costochondritis, chest trauma and rib fractures, chest muscle pain, and radiculopathies.

Typically, it is characterised by a sharp-type chest pain which is worsened by movement or inspiration. Pain may also be elicited on palpation.

Most causes are benign, but it is crucial to rule out more serious causes (such as acute coronary syndrome, pulmonary embolism, pneumothorax, etc.) as they can present very similarly but be fatal if missed.

Epidemiology

  • Incidence: 1000.00 cases per 100,000 person-years
  • Peak incidence: 50-60 years
  • Sex ratio: 1:1
Condition Relative
incidence
Gastro-oesophageal reflux disease5.00
Musculoskeletal chest pain1
Pneumonia0.50
Acute coronary syndrome0.20
Acute pericarditis0.10
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Aetiology

Musculoskeletal chest pain has a number of different causes:
  • Costochondritis
  • Lower rib pain syndromes
  • Rib fractures/chest trauma
  • Fibromyalgia
  • Primary or secondary bone metastases in the rib
  • Inflammatory arthritides - generally there will be other joint involvement
  • Tietze syndrome
  • Spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction)

Pathophysiology

The pathophysiology of musculoskeletal chest pain varies depending on the underlying cause.

Rib fractures
  • The chest wall consists of 24 ribs - any one of these ribs can be fractured.
  • The chest wall has a large nerve supply and the movement of the ribs (and fracture) with inspiration increases this pain.

Costochondritis and Tietze Syndrome
  • The ribs articulate with costal cartilage at the costochondral joints
  • These joints become inflamed in costochondritis causing pain.
  • Tietze syndrome is caused by painful swelling of these articulations.

Lower rib pain syndrome
  • The pathophysiology is not well understood
  • It may arise from disruption of the interchondral fibrous attachments of the anterior ribs
  • This allows intermittent subluxation of the costal cartilage and impingement and irritation of intercostal nerves.

Spinal disorders causing chest pain
  • The chest wall and surrounding skin and musculature are supplied by nerve roots from both cervical and thoracic vertebrae.
  • In the case of some spinal disorders, impingement or damage to these nerves can present with chest pain.

Clinical features

Overview

Musculoskeletal chest pain is frequently sharp and often nagging. Often, the pain is localized but can radiate. Pain is generally worsened by movement, changes in position, and deep inspiration.

The following suggest the underlying cause for chest pain is not musculoskeletal:
  • Central crushing chest pain and tearing chest pain (these may be red flags for cardiac ischaemia and aortic dissection)
  • Dyspnoea
  • Fever
  • Diaphoresis
  • Syncope and collapse

Costochondritis

Chest pain in costochondritis is typically sharp and worse on inspiration and movement.
  • The patient may have a recent history of cough, vomiting, over-exercising, or similar.
  • There is generally localised tenderness to palpation.
    • This is commonly in multiple areas.
    • Most frequently in the upper costal cartilages.
  • The pain may be chronic (~50% of patients with costochondritis still have pain 6-12months after symptom onset).

Lower rib pain syndrome

Lower rib pain syndrome generally causes lower chest pain/upper abdominal pain with an identifiably tender spot on the costal margin.
  • Pain may be reproduced during examination by pressing on this spot.
  • Pain is also reproduced using the 'hooking manoeuvre'
    • Hooking manoeuvre = the examine hooks fingers under the patient's ribs and pulls gently forward.
    • It may be difficult to perform the manoeuvre in patient with this syndrome due to exquisite sensitivity in the subcostal margins

Rib fractures

Traumatic fractures:
  • History of trauma to the ribs.
  • This may be severe trauma, minor to moderate (generally blunt) trauma, or repetitive minor trauma (stress fractures).
  • There is usually tenderness over the affected rib(s), and potentially bruising.
  • The pain may be elicited by deep inspiration and movement.
  • Bony crepitus may be present.
Stress fractures
  • In stress fractures the pain is typically gradual onset
  • Pain is typically related to activity.

Fibromyalgia

Chest pain in fibromyalgia is typically sharp and worse on inspiration and movement.
  • There is often tenderness to palpation.
    • Most commonly of the second anterior costochondral junctions.
    • Typically affecting more than one rib.
  • Other symptoms of fibromyalgia typically present (e.g. pain in other areas, symptoms of depression and anxiety, cognitive impairment, etc.).

Primary/secondary bone cancer in the ribs

  • Often a dull, aching pain that is frequently worse at night.
  • May be poorly localised.

Inflammatory arthritides

  • Chest pain may present like costochondritis.
  • Ankylosing spondylitis in particular can cause chest wall pain.

Tietze's syndrome

Pain in Tietze's syndrome is typically sharp and worse on inspiration and movement.
  • The patient may have a recent history of cough, vomiting, over-exercising, or similar.
  • There is fusiform swelling of the costal cartilage at the costochondral junction that is tender on palpation.
    • This is typically unilateral.
    • It commonly only affects a single joint.

Spinal disorders

Spinal disorders tend to cause dull aching chest pain which is typically aggravated by specific neck movements.
  • Pain may also radiate down the arm, into the head, or into the shoulder or across scapulae (non-segmental distribution).
  • Patient may have pain in the spine and may have paraesthesia.

Investigations

Overview

For most causes of musculoskeletal chest pain, there are no definitive investigations. Diagnosis often relies on clinical examination and ruling out of other causes (cardiac, pulmonary and abdominal).

Bedside

ECG is a particularly useful bedside test. It helps to rule out some cardiac causes of chest pain, particularly STEMI.

Other pathologies that may be visualised on an ECG include:
  • Pericarditis
  • Heart failure
  • Arrhythmias

It is important to note that pulmonary embolism may or may not have ECG changes, and a clean ECG does not rule out other acute coronary syndromes (NSTEMI or angina).

Bloods

Bloods are predominantly used to rule out non-musculoskeletal causes of chest pain.

Examples of bloods that may be useful to perform include:
  • 'Rule out' bloods (e.g. troponin and D-dimer) - may be appropriate if there is reasonable suspicion of MI or pulmonary embolism
  • CRP/ESR - while non-specific, they may show evidence of inflammation or infection which may aid diagnosis

Other bloods are typically most appropriate in older patients or patients with other symptoms that may suggest an underlying visceral cause to chest pain. These include:
  • Full blood count (FBC)
  • Urea & electrolytes/liver function tests
  • Bone profile
  • Thyroid function tests
  • Blood glucose and lipid profile

Imaging

Most imaging is not recommended routinely for musculoskeletal pain however, the following may be appropriate in some cases.

Chest x-ray is the predominant and, generally, first-line method of imaging used in patients with chest pain. It is particularly used in the context of the Emergency Department.

Chest x-ray can:
  • Help to rule out some respiratory and cardiac causes.
  • Visualise rib fractures
  • Visualise tumours of the ribs.

It is important to note that, while chest x-ray is a useful investigation, rib tumours and fractures are not always visible on this medium and may require further imaging if a confirmed diagnosis is required.

Other forms of imaging that may be helpful but are usually second-line, include:
  • CT/MRI
    • May be used to rule out pulmonary or pleural based diagnoses.
    • May be useful in characterising lesions of the sternoclavicular joints, sternum, soft tissue and spine.
    • In the case of major trauma where the patient is haemodynamically stable and without severe respiratory compromise, CT is may be used as the primary investigation for assessing thoracic injury.
  • Ultrasound
    • May be useful for evaluating rheumatoid arthritis.
    • Dynamic ultrasound of the ribs may be valuable for diagnosis of the lower rib pain syndrome.
  • Bone scintigraphy
    • May be used to visualise skeletal metastasis, occult fractures, Paget disease, and bone infection

Differential diagnosis

Cardiac causes

  • Angina
    • Similarities: Pain may be associated with physical exertion.
    • Differences: Chest pain is typically central and crushing - may radiate to the arm(s) or jaw. May also occur after eating large meals, with emotional distress, or with extremes in temperature.
  • Myocardial infarction (MI)
    • Similarities: Chest pain
    • Differences: Patient will typically have other symptoms such as dyspnoea, nausea, vomiting, diaphoresis or pallor, and may be haemodynamically unstable. ECG changes usually present depending on type.
  • Arrhythmias
    • Differences: Chest pain may be accompanied by palpitations, dyspnoea and lightheadedness. Patient may be haemodynamically unstable.
  • Pericarditis
    • Similarities: Chest pain may be sharp and worsen on inspiration. It may be positionally worse - particularly if lying flat.
    • Differences: Pain 'typically' improves when patient sits forward, the patient may be generally unwell. There may be ECG changes (wide-spread saddle-shaped ST elevation and PR depression are characteristic)
  • Thoracic aortic aneurysm (rupture)
    • Similarities: Chest pain
    • Differences: Chest pain typically described as 'tearing', often with radiation to the back. The patient is typically hypotensive and shocked. Mortality rate is high.

Pulmonary causes

  • Pneumonia
    • Similarities: Chest pain that may be sharp, often worse on inspiration
    • Differences: Patient generally unwell. Other symptoms include dyspnoea, fever, chills/rigors, cough +/- sputum. Patient may have crackles, bronchial breathing and reduced breath sounds (etc.) on auscultation. Oxygen saturations may be decreased.
  • Pleural effusion
    • Similarities: Chest pain that may be sharp, often worse on inspiration
    • Differences: Often patients will have a cough and have dyspnoea (particularly of exertion). Examination may show dullness to percussion. Oxygen saturation may be decreased.
  • Pulmonary embolism
    • Similarities: Chest pain that may be sharp, often worse on inspiration
    • Differences: Pain often accompanied by dyspnoea, tachypnoea, and sometimes haemoptysis, cyanosis, circulatory instability and collapse. Oxygen saturations may be decreased.
  • Lung malignancy
    • Similarities: Chest pain
    • Differences: Patients often have associated symptoms such as cough, dyspnoea, haemoptysis, weight loss, fatigue, fever, and sometimes finger clubbing
  • Pneumothorax (tension pneumothorax)
    • Similarities: Chest pain that may be sharp, often worse on inspiration
    • Differences: Patient will often have dyspnoea. In tension pneumothorax, the patient is often collapsed, will be severely dyspnoeic, and may have tracheal deviation. On examination, there may be hyper-resonance to percussion of the affected side, and diminished breath sounds and absent vocal fremitus on auscultation. Oxygen saturations may be low.

Other causes

  • Psychogenic or non-specific pain, anxiety
    • Similarities: Chest pain
    • Differences: Patient may feel anxious, may feel breathless, have palpitations, or other symptoms of anxiety.
  • Precordial catch - generally older children and young adults
    • Similarities: Chest pain - usually sharp and worse with breathing
    • Differences: Episodes typically no more than a few minutes with no pain between episodes. Pain is usually relieved by a deep breath or by straightening posture. Examination is normal.
  • Bornholm disease
    • Similarities: Chest pain - generally sharp and worse on inspiration and movement
    • Differences: May have other symptoms of coxsackievirus, particularly fever, chest pain is paroxysmal.

Management

Overview

NICE guidelines on chest pain suggest the mainstay of management of musculoskeletal chest pain is ensuring adequate analgesia.
  • Non-steroidal anti-inflammatories (NSAIDs) and paracetamol are usually first-line as analgesia.

Specific management for differential causes are mentioned below:

Costochondritis and Tietze syndrome

The BMJ Best Practice guidelines for costochondritis suggest the following management:
  • Oral NSAIDs are first line.
  • Local injection of long-acting corticosteroids may be used - typically this is performed by a specialist.
  • For refractive symptoms referral to a rheumatologist should be considered.
  • If costochondritis is infective then the patient requires surgical drainage/debridement and antibiotics.

Rib fractures

The BMJ Best Practice guidelines for rib fractures suggest the following management:
  • Rib fractures also are managed with NSAIDs and other analgesics (including morphine) as required.
  • Patients also benefit from physiotherapy exercises and breathing techniques to prevent infections secondary to shallow breathing and inadequate cough due to pain.
  • Complications of rib fractures must be managed appropriately with correct referral (e.g. pneumothorax/haemothoraxes should be decompressed/drained appropriately).

Lower rib pain syndrome

  • One article published in the British Journal of Urology, stated the following to be appropriate treatment options:
    • NSAIDs
    • Physiotherapy
    • Local anaesthetic and Local long-acting steroids
    • Intercostal nerve blocks
    • Surgical resection (rib excision)
  • Another study from the Clinical Journal of Sport Medicine investigating patients with lower rib pain syndrome over 15 years, determined that osteopathic manipulative treatment, surgical resection and diclofenac gel were the most successful treatment options overall.

Primary/secondary bone cancer in the ribs

The following guidelines are taken from the NICE guidelines for palliative cancer care (managing bone pain), they recommend:
  • For symptomatic relief (bone pain), NICE recommends hot/cold packs, stepwise analgaesia with appropriate breakthrough pain relief.
  • If pain management is difficult, referral should be made to pain specialists in secondary care.
  • Management of the metastatic bone disease or primary bone cancer itself should be under an oncologist.
  • Radiotherapy may be an appropriate treatment.

Inflammatory arthritides

  • Management predominantly consists of managing the underlying disease and appropriate analgaesia.