Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Clinical evaluation of musculoskeletal chest pain

INTRODUCTION

Chest pain is one of the more common symptoms requiring medical attention in the outpatient setting. Cardiac and pulmonary problems are usually the focus of the initial diagnostic evaluation. After these areas are excluded, other conditions affecting the structures in and around the thoracic cage enter into the differential diagnosis, including diseases of the esophagus, upper abdomen, head, neck, and chest wall [1].

This topic will review the clinical evaluation of chest pain of musculoskeletal origin (table 1). The major causes of chest pain are reviewed separately. (See "Major causes of musculoskeletal chest pain in adults" and "Chest pain of esophageal origin" and "Angina pectoris: Chest pain caused by myocardial ischemia".)

Treatment of musculoskeletal chest pain is also presented separately. (See "Treatment of musculoskeletal chest pain".)

HISTORY

Demographic features, characteristics of the chest pain, and associated symptoms may favor the diagnosis of musculoskeletal chest pain or may suggest other causes of chest discomfort (table 2) [2]. As an example, a history of repetitive or unaccustomed activity involving the upper trunk or arms is common in the patient with musculoskeletal pain [3].

Demographic features — The initial evaluation of chest pain should be undertaken in the context of the patient’s age, sex, family history, other coronary risk factors, and additional elements of his/her general health. In middle-aged or older patients or in those with other risk factors for coronary artery disease, a cardiac source should always be considered first, since patients with a known cardiac source of chest pain may also have chest wall tenderness that reproduces their pain [4-6]. (See "Angina pectoris: Chest pain caused by myocardial ischemia".)

         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2014. | This topic last updated: Nov 15, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Stochkendahl MJ, Christensen HW. Chest pain in focal musculoskeletal disorders. Med Clin North Am 2010; 94:259.
  2. Yelland M, Cayley WE Jr, Vach W. An algorithm for the diagnosis and management of chest pain in primary care. Med Clin North Am 2010; 94:349.
  3. Fam AG, Smythe HA. Musculoskeletal chest wall pain. CMAJ 1985; 133:379.
  4. Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med 1994; 154:2466.
  5. Wolf E, Stern S. Costosternal syndrome: its frequency and importance in differential diagnosis of coronary heart disease. Arch Intern Med 1976; 136:189.
  6. Levine PR, Mascette AM. Musculoskeletal chest pain in patients with "angina": a prospective study. South Med J 1989; 82:580.
  7. Yelland MJ. Back, chest and abdominal pain. How good are spinal signs at identifying musculoskeletal causes of back, chest or abdominal pain? Aust Fam Physician 2001; 30:908.
  8. Epstein SE, Gerber LH, Borer JS. Chest wall syndrome. A common cause of unexplained cardiac pain. JAMA 1979; 241:2793.
  9. Heinz GJ, Zavala DC. Slipping rib syndrome. JAMA 1977; 237:794.
  10. Guglielmi G, Cascavilla A, Scalzo G, et al. Imaging of sternocostoclavicular joint in spondyloarthropaties and other rheumatic conditions. Clin Exp Rheumatol 2009; 27:402.
  11. Hiramuro-Shoji F, Wirth MA, Rockwood CA Jr. Atraumatic conditions of the sternoclavicular joint. J Shoulder Elbow Surg 2003; 12:79.
  12. Kahn MF, Chamot AM. SAPHO syndrome. Rheum Dis Clin North Am 1992; 18:225.
  13. Massie JD, Sebes JI, Cowles SJ. Bone scintigraphy and costochondritis. J Thorac Imaging 1993; 8:137.
  14. Ramonda R, Lorenzin M, Lo Nigro A, et al. Anterior chest wall involvement in early stages of spondyloarthritis: advanced diagnostic tools. J Rheumatol 2012; 39:1844.
  15. Rucknagel DL, Kalinyak KA, Gelfand MJ. Rib infarcts and acute chest syndrome in sickle cell diseases. Lancet 1991; 337:831.
  16. Kakhki VD, Zakavi SR. Age-related normal variants of sternal uptake on bone scintigraphy. Clin Nucl Med 2006; 31:63.
  17. Hillen TJ, Wessell DE. Multidetector CT scan in the evaluation of chest pain of nontraumatic musculoskeletal origin. Radiol Clin North Am 2010; 48:185.
  18. Hatfield MK, Gross BH, Glazer GM, Martel W. Computed tomography of the sternum and its articulations. Skeletal Radiol 1984; 11:197.
  19. Chigira M, Shimizu T. Computed tomographic appearances of sternocostoclavicular hyperostosis. Skeletal Radiol 1989; 18:347.
  20. Earwaker JW, Cotten A. SAPHO: syndrome or concept? Imaging findings. Skeletal Radiol 2003; 32:311.
  21. Sallés M, Olivé A, Perez-Andres R, et al. The SAPHO syndrome: a clinical and imaging study. Clin Rheumatol 2011; 30:245.
  22. White CS. Magnetic resonance imaging of the chest. Respir Care 2001; 46:922.
  23. Volterrani L, Mazzei MA, Giordano N, et al. Magnetic resonance imaging in Tietze's syndrome. Clin Exp Rheumatol 2008; 26:848.
  24. Laredo JD, Vuillemin-Bodaghi V, Boutry N, et al. SAPHO syndrome: MR appearance of vertebral involvement. Radiology 2007; 242:825.
  25. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore) 2004; 83:139.
  26. Rodríguez-Henríquez P, Solano C, Peña A, et al. Sternoclavicular joint involvement in rheumatoid arthritis: clinical and ultrasound findings of a neglected joint. Arthritis Care Res (Hoboken) 2013; 65:1177.