Overview
Chest Wall Pain
Quick Reference
Critical Alerts
- Chest wall pain is a diagnosis of exclusion: Rule out cardiac, pulmonary, aortic causes first
- Reproducible tenderness does NOT exclude serious causes: ACS can have chest wall tenderness
- ECG, troponin, and risk assessment are essential: Before diagnosing musculoskeletal pain
- Costochondritis is most common: But clinical diagnosis after excluding other causes
- Red flags require workup: Even if pain seems musculoskeletal
- NSAIDs and reassurance are mainstay of treatment
Dangerous Causes to Exclude
| Diagnosis | Key Features |
|---|---|
| Acute coronary syndrome | Risk factors, ECG changes, troponin |
| Pulmonary embolism | Dyspnea, hypoxia, risk factors |
| Aortic dissection | Tearing pain, unequal pulses, wide mediastinum |
| Pneumothorax | Dyspnea, absent breath sounds |
| Esophageal rupture | Severe pain, vomiting history, fever |
Emergency Treatments
| Condition | Treatment |
|---|---|
| Costochondritis | NSAIDs, rest, reassurance |
| Muscle strain | NSAIDs, ice/heat, rest |
| Rib fracture | Analgesia, incentive spirometry |
| Post-herpetic | Antivirals if shingles active |
Definition
Overview
Chest wall pain (CWP) refers to pain originating from the musculoskeletal structures of the chest (ribs, sternum, costochondral junctions, muscles, and fascia). It is one of the most common causes of chest pain but is a diagnosis of exclusion. The ED priority is ruling out life-threatening cardiac and pulmonary causes before attributing pain to benign musculoskeletal etiology.
Classification
By Structure:
| Type | Examples |
|---|---|
| Costochondral | Costochondritis, Tietze syndrome |
| Osseous | Rib fracture, pathologic fracture |
| Muscular | Pectoral strain, intercostal strain |
| Neurogenic | Herpes zoster, intercostal neuralgia |
| Other | Fibromyalgia, xiphodynia |
Epidemiology
- Very common: 20-50% of patients with chest pain in primary care have musculoskeletal cause
- Costochondritis: Most common specific diagnosis
- More common in women
Etiology
Costochondritis:
- Inflammation of costochondral junctions
- Often idiopathic
- May follow viral illness, coughing, physical strain
Tietze Syndrome:
- Similar to costochondritis but with visible swelling
- Usually single upper rib (2nd or 3rd)
Muscular:
- Pectoralis strain (exercise, lifting)
- Intercostal strain (coughing, twisting)
Rib Fracture:
- Trauma
- Pathologic (metastases, osteoporosis)
- Stress fracture (golf, rowing)
Neurogenic:
- Herpes zoster
- Intercostal neuralgia (post-thoracotomy)
Pathophysiology
Mechanism
Costochondritis:
- Inflammation at costochondral or costosternal junction
- Likely microtrauma or repetitive strain
Muscle Strain:
- Overuse or acute injury
- Microscopic tears in muscle fibers
Rib Fracture:
- Direct trauma or stress
- Pathologic if underlying bone disease
Clinical Presentation
Symptoms
| Feature | Chest Wall Pain |
|---|---|
| Location | Localized, reproducible |
| Quality | Sharp, stabbing, aching |
| Duration | Variable; may be chronic |
| Reproduction | Worsened by movement, breathing, palpation |
| Rest | NOT relieved by rest alone |
| Diaphoresis, nausea | Absent (suggests cardiac) |
History
Key Questions:
Physical Examination
Chest Wall Exam:
| Finding | Significance |
|---|---|
| Reproducible tenderness | Suggests musculoskeletal (but doesn't exclude cardiac) |
| Costochondral junction tenderness | Costochondritis |
| Swelling | Tietze syndrome |
| Ecchymosis | Trauma |
| Dermatomal rash | Herpes zoster |
| Bony step-off | Rib fracture |
Cardiovascular and Pulmonary Exam:
Location and radiation of pain
Common presentation.
Character (sharp, dull, pressure)
Common presentation.
Duration and onset
Common presentation.
Reproducible with movement or palpation?
Common presentation.
History of trauma, exercise, heavy lifting
Common presentation.
Recent cough or viral illness
Common presentation.
Rash (herpes zoster)
Common presentation.
Cardiac risk factors
Common presentation.
Red Flags
Must Exclude Serious Causes
| Finding | Concern | Action |
|---|---|---|
| Pressure-like pain, diaphoresis, radiation | ACS | ECG, troponin |
| Dyspnea, hypoxia, tachycardia | PE | D-dimer, CTA |
| Tearing pain, unequal pulses | Aortic dissection | CTA |
| Absent breath sounds | Pneumothorax | Chest X-ray |
| Post-emesis severe pain | Esophageal rupture | Imaging |
| Fever, sick appearance | Infection | Workup |
Differential Diagnosis
Life-Threatening Causes (Rule Out First)
| Diagnosis | Key Features |
|---|---|
| ACS | Pressure, exertional, risk factors, ECG changes |
| PE | Dyspnea, pleuritic pain, risk factors |
| Aortic dissection | Tearing, back pain, unequal BP |
| Pneumothorax | Sudden onset, dyspnea |
| Tension pneumothorax | Hypotension, tracheal deviation |
Other Causes
| Diagnosis | Key Features |
|---|---|
| GERD | Burning, worse postprandially |
| Esophageal spasm | Retrosternal, relieved by nitrates |
| Pericarditis | Pleuritic, positional, friction rub |
| Pleuritis | Pleuritic, worse with breathing |
Diagnostic Approach
Essential Workup
| Test | Purpose |
|---|---|
| ECG | Rule out ischemia |
| Troponin | Rule out ACS (if concern) |
| Chest X-ray | Fracture, pneumothorax, widened mediastinum |
Further Testing (Based on Suspicion)
| Test | Indication |
|---|---|
| D-dimer | PE suspected |
| CTA chest | PE or aortic pathology |
| CT chest | Rib fracture detail, pathology |
Clinical Diagnosis
- Chest wall pain is a clinical diagnosis after excluding serious causes
- Reproducible tenderness supports but doesn't confirm diagnosis
Treatment
Principles
- Rule out life-threatening causes first
- NSAIDs for anti-inflammatory effect
- Rest and activity modification
- Reassurance
Pharmacological
NSAIDs:
| Agent | Dose |
|---|---|
| Ibuprofen | 400-600 mg TID × 7-10 days |
| Naproxen | 500 mg BID × 7-10 days |
Acetaminophen:
- If NSAIDs contraindicated
Muscle Relaxants (if muscle spasm):
| Agent | Dose |
|---|---|
| Cyclobenzaprine | 5-10 mg TID |
Topical:
| Agent | Notes |
|---|---|
| Lidocaine patch | Over tender area |
| Diclofenac gel | Topical NSAID |
Rib Fracture
| Intervention | Details |
|---|---|
| Analgesia | NSAIDs, acetaminophen, ± opioids |
| Incentive spirometry | Prevent atelectasis/pneumonia |
| Ice | First 48 hours |
| Avoid binding | Increases pneumonia risk |
| Rib belt | For comfort (controversial) |
Herpes Zoster
| Agent | Dose |
|---|---|
| Valacyclovir | 1 g TID × 7 days |
| Famciclovir | 500 mg TID × 7 days |
| Analgesia | NSAIDs, gabapentin for neuropathic pain |
Disposition
Discharge Criteria
- Serious causes excluded
- Pain controlled
- Able to take deep breaths (if rib fracture)
- Follow-up arranged
Admission Criteria
- Unable to exclude serious cause
- Multiple rib fractures (especially elderly)
- Flail chest
- Concern for pathologic fracture (malignancy)
Referral
| Indication | Referral |
|---|---|
| Recurrent or chronic pain | Primary care, rheumatology |
| Pathologic fracture | Oncology |
| Multiple fractures, elderly | Trauma surgery |
Follow-Up
| Situation | Follow-Up |
|---|---|
| Uncomplicated | PCP if not improved in 1-2 weeks |
| Rib fracture | PCP in 1-2 weeks |
Patient Education
Condition Explanation
- "Your chest pain is coming from the muscles, ribs, or cartilage in your chest wall, not your heart."
- "This is not dangerous, though it can be uncomfortable."
- "Anti-inflammatory medications and rest will help it heal."
Home Care
- Take NSAIDs as directed
- Apply ice or heat for comfort
- Avoid activities that worsen pain
- Use good posture
- Take deep breaths to prevent complications
Warning Signs to Return
- Chest pain with shortness of breath
- Pain pressure-like or radiating to arm/jaw
- Dizziness or fainting
- Worsening pain despite treatment
Special Populations
Elderly
- Higher risk of rib fracture with minor trauma
- Higher risk of complications (pneumonia)
- Consider pathologic fracture (osteoporosis, metastases)
Athletes
- Costochondritis and muscle strain common
- Stress fractures in rowers, golfers
Cancer Patients
- Consider metastatic bone disease
- Imaging if concern for pathologic fracture
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| ECG performed | 100% | Rule out ACS |
| Serious causes excluded before diagnosis | 100% | Safety |
| NSAIDs prescribed | >0% | First-line treatment |
| Follow-up arranged | >0% | Ensure resolution |
Documentation Requirements
- Risk factor assessment
- Physical exam findings (reproducible tenderness)
- Exclusion of serious causes
- Treatment and follow-up plan
Key Clinical Pearls
Diagnostic Pearls
- Chest wall pain is a diagnosis of exclusion: Rule out cardiac, pulmonary first
- Reproducible tenderness does NOT exclude ACS: Studies show overlap
- ECG and troponin are essential: Don't skip based on exam
- Costochondritis is most common: But requires ruling out other causes
- Tietze syndrome has visible swelling: Costochondritis does not
- Dermatomal rash = Zoster: May precede rash (zoster sine herpete)
Treatment Pearls
- NSAIDs are first-line: Anti-inflammatory effect
- Topical therapies are helpful: Lidocaine, diclofenac
- Avoid rib binding: Increases pneumonia risk
- Incentive spirometry for rib fractures: Prevent atelectasis
- Antivirals for zoster: If within 72 hours of rash
- Reassurance is therapeutic: Pain is benign
Disposition Pearls
- Most can be discharged: If serious causes excluded
- Elderly with rib fracture may need admission: Pulmonary toilet
- Follow-up if not improving: May need further workup
- Return precautions are essential: Red flags for ACS, PE
References
- Proulx AM, Zryd TW. Costochondritis: Diagnosis and Treatment. Am Fam Physician. 2009;80(6):617-620.
- Ayloo A, et al. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013;40(4):863-887.
- Verdon F, et al. Chest wall syndrome in primary care. BMC Fam Pract. 2007;8:51.
- Disla E, et al. Costochondritis: A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466-2469.
- Cayley WE Jr. Diagnosing the cause of chest pain. Am Fam Physician. 2005;72(10):2012-2021.
- Swap CJ, et al. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623-2629.
- NICE Guideline. Chest pain of recent onset: assessment and diagnosis. 2016.
- UpToDate. Musculoskeletal causes of chest pain. 2024.