Chest pain is always an alarming symptom, since it usually raises the fear of heart disease. And because chest pain may indeed be a sign of angina or of some other underlying heart problem, it is always a good idea to have it checked out. But heart disease is only one of the many conditions that can produce chest pain.
One of the more frequent causes of non-cardiac chest pain is chest wall pain, or musculoskeletal chest pain – that is, chest pain related to the muscles and bones of the chest wall. Doctors diagnose some form of chest wall pain in at least 25% of patients who come to the emergency room for chest pain. There are several causes of chest wall pain, and fortunately, in the great majority of instances the underlying cause of chest wall pain is benign, and most often is self-limited. However, some types of chest wall pain may indicate a serious problem, and may require specific treatment.
Here are the most common causes of chest wall pain:
Trauma to the chest wall can cause muscle sprains or strains, and bruises or fractures of the ribs. The trauma may be due to some dramatic event (such as being struck by a baseball), or to some more subtle trauma (such as lifting a heavy object) that may be more difficult to recollect, or to relate to chest pain whose onset may be delayed. So the doctor will often need to ask the patient with suspected chest wall pain about activities that potentially might have caused chest wall trauma.
Costochondritis – sometimes called costosternal syndrome or anterior chest wall syndrome – merely indicates pain and tenderness in the costochondral junction – the area along the sides of the breast bone where the ribs attach. The pain is generally localized to one particular spot, most typically on the left side of the breast bone.
(Whether left-sided costochondritis is actually more common, or whether people with left-sided chest pain are simply more likely to see a doctor, is unknown.) The pain of costochondritis usually can be reproduced by pressing on the affected area.
The causes of costochondritis are very poorly understood. While the suffix “-itis” is generally used in medicine to indicate inflammation, there is actually no evidence of inflammation with costochondritis – that is, there is no swelling, redness or heat in the painful area. Especially in children and young adults this syndrome appears sometimes to be related to strain or weakening of the intercostal muscles (muscles between the ribs), following repetitive activities that stress those muscles, such as as carrying a heavy book bag.
In a few cases, costochondritis seems to be related to a subtle dislocation of a rib. (Chiropractors are well aware of rib dislocation as a cause for costochondritis; physicians have seldom heard of it.) The dislocation may actually originate in the back, at the junction of the rib and the spine. This relatively slight dislocation causes torsion of the rib, and along the breast bone (that is, at the costochondral junction), pain results. The rib may “pop” in and out of its proper orientation (usually with some reproducible movement of the trunk or shoulder girdle), in which case the pain will come and go. Chiropractors are generally adept at manipulating a dislocated rib back into its normal position, and relieving the pain.
Costochondritis is usually a self-limited condition. Sometimes it is treated with localized heat or stretching exercises, but it is unclear whether such measures help. If the pain of costochondritis persists for more than a week or so, an evaluation looking for other chest wall conditions may be a good idea; and consulting with a chiropractor may also be useful.
Lower Rib Pain Syndrome
Lower rib pain syndrome (also called slipping rib syndrome) affects the lower ribs, and people who have this condition usually complain of pain in the lower part of the chest, or in the abdomen. In this syndrome, one of the lower ribs (eighth, ninth or tenth rib) becomes loosened from its fibrous connection to the lower part of the breastbone, usually following some type of trauma. The “moving” rib impinges on nearby nerves, producing pain. This condition is usually treated conservatively (that is, avoiding activities that reproduce the pain, in an attempt to allow the ribs to heal), but surgery may be required to stabilize the slipping rib.
“Precordial catch” is a completely benign and very common condition, generally seen in children or young adults, in which sudden, sharp chest pain occurs, usually on the left side of the chest, lasting for a few seconds to a few minutes. It typically occurs at rest, and during the episode the pain increases with breathing. After a few seconds or a few minutes the pain resolves completely. This condition has no known medical significance.
Fibromyalgia is a relatively common syndrome consisting of various, diffuse musculoskeletal pains. Pain over the chest is common in this condition. Fibromyalgia often has many other symptoms in addition to pain – such as fatigue, sleep disorders, and gastrointestinal symptoms – that cause many to characterize this condition as one of the dysautonomias.
Rheumatic Diseases Associated With Chest Wall Pain
Chest wall pain associated with inflammation of the spine or rib joints can be seen with several rheumatic conditions, in particular rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. While it is uncommon for chest pain to be the only symptom associated with any of these conditions, unexplained chest wall pain – especially if an evaluation suggests it is related to arthritis or any other type of inflammatory disorder – should lead a physician to at least consider a rheumatic disease as a possible cause.
Stress fractures of the ribs can be seen in athletes who engage in strenuous, repetitive motions involving the upper body, such as rowers or baseball pitchers. Stress fractures can also be seen in people with osteoporosis or vitamin D deficiency.
Advanced stages of cancer invading the chest wall can produce significant pain. Breast cancer and lung cancer are the two most common kinds of cancer that produce this problem. Primary cancer of the ribs is an extremely rare condition that can produce chest wall pain.
Sickle Cell Crisis
It is now believed that the chest wall pain sometimes seen in patients with sickle cell crisis may be due to small infarctions in the ribs. The rib pain usually resolves relatively quickly as the sickle cell crisis is brought under control.
Chest wall pain is very common in people seen by doctors for chest pain. In the large majority of cases, it is relatively easy for an attentive physician to diagnose the cause of chest wall pain, and to recommend appropriate treatment.
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