Chest pain is one of the more common symptoms requiring medical attention in the outpatient setting. Potentially life-threatening 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, and head and neck (table 1). Conditions affecting the musculoskeletal structures of the chest wall are frequently listed as potential causes of atypical or noncardiac chest pain (table 2). Early recognition of these syndromes should allow more efficient and specific management of pain in patients with these conditions [1-5].
This topic will review the major causes of musculoskeletal chest pain. The evaluation of such patients and approaches to treatment are discussed separately. (See "Clinical evaluation of musculoskeletal chest pain" and "Treatment of musculoskeletal chest pain".)
The proportion of patients with chest pain having a musculoskeletal source varies with the clinical setting (table 3).
Emergency department — In the emergency department, approximately 10 to 49 percent of adults and 20 to 25 percent of children presenting with chest pain have a musculoskeletal cause [6-8].
- In one large retrospective study, for example, 11 percent of adults presenting with chest pain were felt to have a musculoskeletal cause. The incidence rose to 26 percent in those patients considered at low suspicion for myocardial infarction, making this the most common category of noncardiac chest pain in this setting.
- In a prospective emergency department study of 122 consecutive patients, 36 (30 percent) were felt to have chest wall tenderness due to costochondritis . In 17, the tenderness reproduced their pain. Two of these patients had acute myocardial infarction (6 percent), indicating that chest wall tenderness does not exclude the presence of serious coronary disease.
- In a study of 250 patients hospitalized for chest pain, 25 of the 108 patients with atypical (noncardiac) chest pain were felt to have a musculoskeletal cause .
- Another study of 50 patients hospitalized with chest pain without apparent cardiorespiratory cause and findings of a musculoskeletal source was able to characterize patients as having regional syndromes (50 percent), fibromyalgia (26 percent), or inflammatory joint disease (24 percent) .
- Among patients with a history of cocaine use, a musculoskeletal cause is commonly found. In an emergency department based study, a musculoskeletal cause was responsible for pain in 21 percent of cocaine users presenting with recurrent chest pain .