Chest wall pain syndrome (CWPS) is a painful condition that manifests as direct or referred pain to the chest wall as a result of stress/injury to the body. CWPS is used to describe a multitude of pathologies that may result in pain that can be self-limiting or chronic. CWPS is readily mistaken for more serious conditions, such as acute coronary syndrome and pulmonary embolism, which must be ruled out before CWPS can be diagnosed.1-3
The etiology of CWPS is not well understood. 6 million people present to emergency departments each year with chest pain at a cost of $8 billion per year. Most of these patients will not have an underlying cardiac reason for their chest pain9. While the most common cause of non-cardiac chest pain is GERD, the most common cause of CWPS is musculoskeletal.1
The more common musculoskeletal conditions that are associated with CWPS include2
|Costochondritis||Degenerative Pathology of the Spine|
|Chest Wall Tenderness||Stress Fracture of the Thoracic Spine|
|Rib Dysfunction||Cervical Angina|
|Cervicothoracic Angina||Sternoclavicular Disease|
|Intercostal myalgia||Costovertebral dysfunctions|
|Segmental Thoracic Dysfunction||Myositis|
|Acute Trauma: Rib/Sternal Fractures, Contusions, Aortic Dissection, Diaphragmatic Rupture, Visceral Trauma|
|Neuralgia from Shingles||Neoplasm|
|Thoracic Radiculopathy||Infectious Sequelae|
|Referred Pain from Sphincter of Oddi||Seronegative Spondyloarthropathies|
|Thoracic Outlet Dysfunction||Tietze Syndrome|
Epidemiology including risk factors and primary prevention
In the primary care setting, CWPS has a mean age ± SD of 50.3±18 years, with nearly equal occurrence in men and women. It accounts for nearly 50% of all complaints in the ambulatory and emergency room setting. CWPS is the principal cause of pain in 44.6% of patients who present with thoracic pain. Additionally, 83% of patients will also have associated comorbidity, including psychiatric dysfunction (50%), cardiovascular disease (33%), coronary disease (19%), and rheumatologic conditions (20.7%). Approximately 2% of patients have primary non-specified lung carcinomas (33%) or non-specific metastatic neoplastic disease (67%). Among pediatric patients, 31% have nonspecific chest pain. In adolescents, costochondritis accounts for 14% of chest wall pain.1.4
Musculoskeletal: the chest is bordered by 12 ribs bilaterally, 12 vertebrae posteriorly, the sternum and xiphoid anteriorly, 2 clavicles superiorly, and an overlay of musculature and fascia giving function to these structures. This integrated framework provides strength, support, and protection of the viscera. Multiple bony areas are susceptible to fracture, and several joints and articulations can be injured. Once dysfunction occurs, collateral dysfunction can occur in the musculature. Equally, muscular strain/spasm will then restrict joints, creating discomfort at costochondral joints.
Neurology: the anterior rami of the first 11 thoracic spinal nerves form the intercostal nerves. These nerves course along the inferior border of the rib. If there is damage to the rib, rami, or coursing nerve, neural impingement may occur. Alteration to the skeletal formation of the thoracic outlet can also cause neural impingement, resulting in thoracic outlet syndrome. Nerve roots are also susceptible to viral infection and are a potential site for post-herpetic neuralgia.
Visceral: there can be referred pain from the viscera that appears to be chest wall oriented.2 Visceral pain receptors are found in most of the viscera (thoracic, abdominal and pelvic) and its surrounding connective tissue. Noxious stimulus of these receptors activates a few unmyelinated afferent fibers which in turn activate many central neurons. Combined with somatic input this often produces a poorly localized pain response.13 Obstruction of hollow organs will produce a poorly localized, deep, cramping pain referred to multiple cutaneous sites. However, damage to the organ capsule or direct injury to the deep tissue may be more easily localized.14
Disease progression including natural history, disease phases or stages, disease trajectory
Costochondritis: presents as sharp pinpoint tenderness in multiple areas of the chest localized over the costochondral joints along the sternum; it is a self-limiting condition that resolves in days to weeks.5,6 It may become chronic.
Herpes zoster/postherpetic neuralgia: once reactivated, burning with hyperesthesia presents, followed by a vesicular rash in 2 weeks. The rash is limited to 1 to 2 dermatomes and is unilateral. The rash resolves and neuralgia may set in or resolve.2
Postthoracotomy pain: a syndrome occurring after thoracotomy consisting of burning, hyperesthesia, and ache-like pain. Women have higher incidence. Only epidural placement prior to surgery changes disease course.2
Carcinoma: progression is based on tumor pathology, as well as risk for chest pain based on treatment method.
Intercostal neuralgia: a condition caused by arthritis, trauma, and impingement, which results in a burning, sharp, stabbing discomfort in the appropriate dermatomal distribution. It may resolve on its own, although intercostal nerve block can expedite recovery.
Myofascial pain: usually caused by irritation of the thoracic fascia from trauma or muscle spasm. Its course is variable depending on treatment. Early physical therapy focusing on myofascial release is recommended.
Specific secondary or associated conditions and complications
|Cardiac||Acute Myocardial Infarction|
|Mitral Valve Prolapse|
|Sickle Cell Crisis|
|Thoracic Aortic Dissection/non-dissecting Aneurysm|
|Precordial Catch Syndrome|
|Sphincter of Oddi Dysfunction|
|Paraesophageal Hiatal Hernia|
|Esophageal Motility Disorders|
|Epidural Spinal Cord Compression|
|Herpes Zoster/Postherpetic Neuralgia|
|Complex Reginal Pain Syndrome|
|Neoplasm (Primary or Metastatic)|
|Diffuse Idiopathic Skeletal Hypostosis|
|Slipped Rib Syndrome|
|Muscle||Myofascial Pain Syndromes|
|Mondor Disease (an uncommon disorder characterized by superficial thrombophlebitis of the thoracoabdominal wall.|
|Extrathoracic Disorders||Posterolateral disk protrusion C7-8|
|Thoracic Outlet Syndrome|
|Gas Entrapment Syndrome|
|Peptic Ulcer Disease|
|Post-Radiotherapy Chest Pain|
2. ESSENTIALS OF ASSESSMENT
History should always be comprehensive. Still, the goal in diagnosing chest wall pain is to differentiate a life threatening condition from CWPS. Top areas to focus include the following1,2,5:
- Quality of the pain: squeezing or crushing, dull, aching, sharp, hot, or tearing.
- Location: right/left/bilateral.
- Localization: pinpoint, inches wide, entire hemithorax.
- Exercised induced: yes or no, did it persist at rest.
- Reproducibility: yes or no, if yes, where.
- Positional exacerbation: certain actions or bodily positions.
- Previous event: similar or not, and how it differs.
- Psychiatric history
A comprehensive musculoskeletal evaluation should be performed,including the bilateral upper and lower extremities.
- Lymphadenopathy of the neck and axilla.
- Strength testing and evaluation for atrophy of the pectoral and scapular musculature.
- Range of motion of the shoulders, evaluate scapular movement, along with any restriction in the pectoralis musculature.
- Palpation should focus on 5 major areas: anterior muscle tenderness, costosternal/xiphoid junction tenderness, paraspinal tenderness, joint-play restriction, and end-play restriction. 5 of the top 6 indicators for strong associations with musculoskeletal chest pain were elements of palpation.11
- Dermatomal sensory testing.
- Inspection of myofascial tender points in the paraspinal muscles, levator scapulae muscles, pectoralis major and minor, supraspinatus, infraspinatus, and the serratus anterior.
- Abdominal examination.
- Auscultate the heart and lungs listening for bruits and other irregularities.
- Palpate peripheral pulses.2,5
There is no specific laboratory analysis for CWPS. Perform appropriate workup to rule out life-threatening conditions. For recurrent symptoms, appropriate laboratory studies may include the following:
- Complete blood count
- Comprehensive metabolic panel
- Cardiac markers
- C-reactive protein
- Sedimentation rate
- Antinuclear antibody
- Rheumatoid factor
- Human leukocyte antigen B27
- Arterial blood gas
Imaging studies are nonspecific for CWPS, but may aid in other diagnoses. Imaging will be necessary to rule out other life-threatening conditions. An EKG is especially important for a patient with Chest Wall Pain because it potentially helps eliminate serious cardiac issues that could be that cause of the pain.
Possible studies include the following:
- Chest radiograph
- Abdominal radiograph
- Cervical radiograph
- Computed tomography (CT) chest
- CT neck
- CT pelvis/abdomen
- Magnetic resonance imaging (MRI) chest
- MRI neck
- MRI pelvis/abdomen
CT and MRI studies should be performed with contrast to rule out vascular abnormalities or tumor.
Early predictions of outcomes
In patients with postherpetic neuralgia, when antiviral medication is dispensed within the first 72 hours of onset, there is a decreased likelihood of prolonged neuralgia. The greater the age of onset of a shingles outbreak, the greater the likelihood the patient will develop a prolonged neuralgia.2
In cases where particular physical motions or body positions cause symptom exacerbation,
it may be necessary to make environmental or postural modifications. Changes may include ergonomic adjustments or change in job assignment.
Social role and social support system
Understand your patient’s social and family needs. Anxiety results in frequent visits to the primary care physician and/or emergency room. The time commitment of seeing multiple physicians and undergoing testing procedures may pose a financial hardship.
When a patient with CWPS presents with a new onset of pain, it is of paramount importance that a comprehensive evaluation be performed, especially when the clinical presentation differs from the patient’s typical pattern of pain. It protects the patient from potential misdiagnosis of a serious illness.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Many conditions are initially treated with nonsteroidal anti-inflammatory drugs/COX-2 inhibitors, ice, and heat. Additional modalities for cases refractory to analgesics include:
- Costochondritis/myofascial syndromes: physical therapy, including modalities such as ultrasound, iontophoresis, dry needling, and cold laser. Periarticular steroid injections have shown benefits.3,5,7
- Rib fracture: intercostal nerve block. If flail chest is present, surgical consultation is recommended.3,5
- Postthoracotomy pain: paravertebral blocks, tricyclic antidepressants, gabapentin (maximum of 3600 mg), radiofrequency ablation, and cryoablation.2,3
- Intercostal neuralgia: tricyclic antidepressants, gabapentin, pregabalin, and steroid injections/blocks.2,3
- Postherpetic neuralgia: acutely treated with antivirals. Chronically treated with lidocaine patch, paravertebral block, and gabapentin/pregabalin.2,3
- Chronic conditions may benefit from an interdisciplinary pain management program that includes physical therapy, occupational therapy, nursing, psychology, and patient education with goals of functional restoration and learning pain management techniques.
At different disease stages
In the acute stage, a differential diagnosis should be considered to rule out the following life-threatening conditions:
- Acute coronary syndrome
- Aortic dissection
- Pulmonary embolism
- Mallory-Weiss tear
- Acute cholecystitis
- Rib fracture
Rehabilitative treatment for rib dysfunction
Once rib dysfunction has been identified on physical examination, rib mobilization therapy can be initiated. Soft tissue mobilization and muscle energy techniques can be performed to reposition the affected ribs. The mobilization process may take several treatment visits. An at-home rib mobilization program should be given to the patient, and the patient should be reassessed on completion of the treatment program.7
Physical therapy may be used for myofacial pain, postthoractomomy pain, and postherpetic neuralgia, with a focus on desensitization. Physical therapy can be used at multiple stages of the disease progress.
CWPS can become chronic in some cases; this can cause patients to have difficulty coping in the long term. These patients may require a behavioral approach, which is typically treated by a psychologist using cognitive-behavioral therapy.
Coordination of care
Chronic CWPS may need interdisciplinary care coordinated by their primary care physician, with input from physical and occupational therapists, other consulting physicians (cardiologists/pulmonologists), neuropsychologists, psychiatrists, and the patient’s family support network.
Patient & family education
When etiology of CWPS is from a musculoskeletal complaint, such as costochondritis, the patient and family should be reassured that symptoms will typically resolve in weeks or months.
If CWPS is related to a secondary cause, which is not benign and more likely chronic, the patient should be given proper access to support for coping strategies, especially in the later stages of their disease.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
In cases of thoracic nerve radiculopathy/neuropathy, cryoablation has recently been used. New clinical trials of cryoablation with a video-assisted thoracoscopic technique are being undertaken to improve accuracy and efficacy, and concomitantly decrease the need for repeat ablation.8
In patients with esophageal hypersensitivity as the cause of their pain, several studies of intravenous infusion of theophylline (an adenosine receptor antagonist) has shown to have significant improvement in pain when compared to placebo.10
The use of intravenous ketamine as treatment modality for CRPS and neuropathic pain has been gaining popularity, but still lacks high quality evidence.12 Further research is ongoing.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Despite the vast number of admissions for chest pain, the process involved with the diagnosis of non-cardiac causes for chest pain very often ends up as a diagnosis of exclusion. The shear number of possible diagnoses/factors for chest pain make high quality randomized, double blinded studies extremely hard to conduct. As a result, definitive conclusions about chest wall pain are difficult to reach due to the lack of sufficient evidence.
- Verdon F, Burnand B, Herzig L, Junod M, Pécoud A, Favrat B. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract. 2007; 8:51.
- Gundamraj NR, Richeimer S. Chest wall pain. In: Loeser JD, Butler SH, Chapman CR, et al. Bonica’s Management of Pain. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001:1142-1168.
- Waldman SD. Pain Management. Vol. 1. Philadelphia, PA: Saunders/Elsevier; 2007.
- Son MB, Sundel RP. Musculoskeletal causes of pediatric chest pain. Pediatr Clin North Am. 2010;57:1385-1395.
- Proulx AM, Zryd TW. Costrochondritits: diagnosis and treatment. Am Fam Physician. 2009;80:617-620.
- Patient information. Costochondritis: what you need to know. Am Fam Physician. 2009;80:617-s1.
- Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 2nd ed. Media, PA: Lippincott Williams and Wilkins; 1983:801-825.
- Hunt I, Eaton D, Maiwand O, Anikin V. Video-assisted intercostal nerve cryoablation in managing intracable chest wall pain. J Thorac Cardiovasc Surg. 2010;139:774-775.
- Wertli M, Ruchti K, et. al. Diagnostic indicators of non-cardiovascular chest pain: a systemic review and meta-analysis. BMC Medicine 2013, 11:239
- Hershcovici T, Achem SR, et al. Systemic review: the treatment of noncardiac chest pai Alimentary Pharmacology and Therapeutics 2012; 35; 5-14
- Stochkendahl M, et al. Reconstruction of the decision-making process in assessing musculoskeletal chest pain:an exploratory study using recursive partitioning. Journal of Manipulative and Physiological Therapeutics 2012; 35; 3:184-195.
- O’Connel l N, W and B, et a l. Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systemic reviews. Cochran Database of Systemic Reviews. 2013
- Cervero F. Visceral nociception: peripheral and central aspects of visceral nociceptive systems. Philosophical Transactions of the Royal Society B: Biological Sciences. 1985: 308(1136): 325-337.
- Markman J , Narasimhan S. Merck Manual: Overview of Pain. April 2014
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Boeti C, Arentz C, Klimberg VS. Scapulothoracic bursitis as a significant cause of breast and chest wall pain: underrecognized and undertreated. Ann Surg Oncol. 2010;17 Suppl 3:321-324.
Labra C, Collen J, Cho K, Mikita J. An uncommon cause of chest pain in the deployed soldier. Mil Med. 2011;176:414-419.
Mohammad AF, Ambrose N, Hamnvik OP, Kearns G. Meticillin-sensitive Staphylococcus aureus costochondritis in a healthy man. Nat Rev Rheumatol. 2009;5:708-710.
Sgouros SN, Pereira SP. Systematic review: sphincter of Oddi dysfunction–non-invasive diagnostic methods and long-term outcomes after endoscopic sphincterotomy. Aliment Pharmacol Ther. 2006;24:237-246.
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Original Version of the Topic
Jeffrey E. Oken, MD, Steve Dugan, DO. Chest wall pain syndrome. 09/20/2013.
Jeffrey E. Oken, MD
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Aaron Hanyu-Deutmeyer, DO
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