Costochondritis and Musculoskeletal Chest Pain
The patient, usually between the ages of 15 and 39, complains of a day or more of steady aching with intermittent stabbing chest pain. The pain may follow an episode of minor trauma, a period of frequent coughing, or unusual physical activity or overuse; may be localized to the left or right of the sternum, without radiation; and may worsen when the patient takes a deep breath, changes position, twists at the torso, pushes or pulls her arms against resistance, or moves her arm or arms overhead. Having the patient arch her back in extension while compressing her thoracic vertebrae with your examining hand may reveal a spinous origin for her pain. She may be concerned about the possibility of a heart attack (though she may not voice her fear), but there is no associated nausea, vomiting, diaphoresis, or dyspnea or any significant cardiac risk factors. The middle anterior costal cartilages (connecting the ribs to the sternum) may be diffusely tender to palpation, without swelling or erythema, and exactly matching the patient’s complaint. There may be sites other than the sternal borders, such as the anterior ribs, xyphoid process, or thoracic spine, that are the source of the patient’s pain. The rest of the physical examination is normal, along with normal vital signs that include pulse oximetry.
What To Do:
Obtain a thorough history and perform a complete physical examination. Pay special attention to the specific location and character of the pain (e.g., onset, severity, quality, radiation, duration, and whether or not it is related to strenuous activity, movement, deep breathing, and cough) and associated symptoms (e.g., sensation of a racing heart, palpitations, pallor, syncope or near-syncope, shortness of breath, nausea, vomiting, fever, weight loss, fatigue, diaphoresis, cough, or wheeze). Inquire about any risk factors for pulmonary embolism (e.g., estrogen use, recent surgery, immobilization, history of malignancy, personal or family history of thromboembolic disease) or about a history of preexisting cardiac risk factors (e.g., hypertrophic cardiomyopathy, aortic valvular stenosis, family history of early-onset coronary artery disease, smoking, hypertension, diabetes mellitus, obesity, elevated cholesterol levels, cocaine use). Read the nurse’s notes and/or check for critical details the patient may not have repeated to you.
Look for abnormal vital signs, pleural or pericardial rubs, new murmurs and dysrhythmias, single or paradoxic splitting of the second heart sound, new gallops, unilateral leg swelling, asymmetric pulses, and signs of congestive heart failure, which include rales, peripheral edema, and jugular venous distention. Carefully examine the abdomen using deep palpation under the costal margins, looking for signs of intra-abdominal tenderness.
At a minimum, obtain a cardiogram, oxygen saturation level, and chest radiograph. If there is some concern for pulmonary embolism (PE), but the patient is low risk, an enzyme-linked immunosorbent assay (ELISA) D-dimer may be obtained to exclude PE.
If any abnormalities are discovered and there is any suspicion of a pulmonary, cardiac, vascular, or gastrointestinal disorder, begin the appropriate treatment and clinical investigation. The presence of costochondritis does not exclude the possibility of aortic dissection, myocardial infarction, pericarditis, esophageal or peptic ulcer perforation, pulmonary embolus, pneumomediastinum, pneumothorax, pneumonia, mediastinitis, or pleural effusion. When there is a reasonable possibility for one of these more serious clinical entities to be present, a more complete medical workup is required.
If there is any suggestion of cardiac, aortic, or serious gastrointestinal or pulmonary disease; if there are complaints of chest tightness or pressure; or if there are significant cardiac risk factors or risk factors for pulmonary embolus, obtain appropriate consultation and strongly consider admission.
If the ECG and chest radiograph are normal and there is no evidence of other disease (the symptoms are purely musculoskeletal, there are no associated symptoms or significant risk factors, vital signs are normal, and the abnormal physical findings are limited to the chest wall tenderness that mimics their pain), prescribe anti-inflammatory analgesics, have the patient apply heat to ease discomfort, explain the benign nature of the chest wall pain to the patient, and direct the patient to seek follow-up with a primary care practitioner.
Exquisite tenderness localized over the xiphoid cartilage may represent the rare condition of xiphoidalgia, which may be treated with a course of nonsteroidal anti-inflammatory drugs (NSAIDs) as described earlier. Local injection of a combination of bupivacaine (Marcaine), 0.5% 5 mL mixed with methylprednisolone (Depo-Medrol), 20 to 40 mg, may be helpful in refractory cases or where immediate pain relief clarifies the diagnosis. If this is attempted, extreme caution should be used to not inject posterior to the xiphoid because of the risk of injury to underlying structures.
Instruct all of these patients to return if they experience any fever, palpitations, lightheadedness, shortness of breath, diaphoresis, change in the character of their pain, or radiation of pain to their arm, shoulder, or jaw.
What Not To Do:
Do not rule out myocardial infarction or acute coronary syndrome, especially in the middle-aged or elderly patient, simply because there is tenderness over the costal cartilage, which could represent a coincidental finding, skin hypesthesia, or contiguous inflammation secondary to an infarct.
This local inflammatory process is probably related to minor trauma and would not be brought to medical attention so often if it did not occur in the chest, thereby invoking fear of a heart attack. Carefully reassuring the patient and her family is, therefore, most important. This disorder is self-limited, but there may be remissions and exacerbations. The pain usually resolves in weeks to months.
Tietze syndrome is a rare variant that is generally less diffuse and is associated with local swelling. Tumors of the anterior chest wall can also cause these symptoms; if the complaints persist or any swelling progresses, CT or MRI scans should be obtained.
Precordial catch syndrome, or Texidor twinge, is described as a sharp, needle-like pain that is well localized. The pain usually occurs at rest and has a split-second onset, taking the patient by surprise. Typically, the pain lasts only seconds to minutes, with deep breathing making the pain worse. Patients may sit straight up to help relieve the pain. Physical examination is normal, without reproducible pain. These patients are usually young, of light or medium build, and apparently healthy. It can occur once or twice in some people or several times a day for a number of weeks in others. Patients with these symptoms require only reassurance.
Slipping rib syndrome may cause lower chest and upper abdominal pain because of hypermobility at the anterior ends of lower costal cartilages. The diagnosis is made by eliciting tenderness over the costal margin, as well as by performing the “hooking maneuver.” This is done by curving your fingers under the costal margin and pulling the ribs forward, thereby eliciting a click that reproduces the patient’s pain. Treat with rest and physical therapy.
Chest pain in the pediatric population is most commonly benign, but a careful history and physical examination are critical. If there are any concerning elements in the history (e.g., syncope, dyspnea or pain with exertion, shortness of breath, family history of sudden death), or abnormalities on examination, a workup is indicated. When the history and physical examination reveal a healthy child, routine testing has not been shown to be helpful. An ECG may be useful for providing reassurance, which is the mainstay of therapy in this situation.
In adults, a recent study showed that almost 3% of patients thought to have noncardiac chest pain had an adverse cardiac event (myocardial infarction, coronary artery bypass graft, death) within 30 days. It is always the medical practitioner’s primary responsibility to rule out the worst case scenario. Even when your first impression is that of noncardiac chest pain, if your patient has known coronary artery disease or a history of congestive heart failure, coronary risk factors, weakness, diaphoresis, or chest pain similar to what he may have experienced in a previous acute coronary syndrome event, it may be prudent to pursue a more extensive workup.
Do not let yourself be led down an incorrect “noncardiac” path by a patient who is downplaying his or her symptoms, acting in a histrionic manner, or has the reputation of being a frequent flyer with similar symptoms. When there are underlying risk factors and symptoms or signs that are not inconsistent with a serious medical disorder of any cause, always play it safe, investigate, consult, and, when necessary, admit.