Treatment of musculoskeletal chest pain
- Kristine Phillips, MD, PhD
Kristine Phillips, MD, PhD
- Assistant Professor
- University of Michigan
- Peter H Schur, MD
Peter H Schur, MD
- Editor-in-Chief — Rheumatology
- Section Editor — Basic Science
- Professor of Medicine
- Harvard Medical School
- Section Editor
- Don L Goldenberg, MD
Don L Goldenberg, MD
- Section Editor — Pain Disorders in Rheumatology
- Emeritus Professor of Medicine, Tufts University School of Medicine
- Affiliate Assistant, Rheumatology Division, Oregon Health Science University
- Affiliate Instructor, School of Nursing Oregon Health Sciences University
There are many causes of chest pain that can be referred to as musculoskeletal. They can be separated into isolated musculoskeletal chest pain syndromes (table 1) and systemic disorders, the latter associated with either rheumatic or nonrheumatic diseases (table 2). The major causes of musculoskeletal chest pain are presented separately. (See "Major causes of musculoskeletal chest pain in adults".)
Musculoskeletal chest pain must be differentiated from chest pain due to potentially life-threatening disorders such as myocardial ischemia or infarction, pulmonary embolism, aortic dissection, or pneumothorax. The diagnostic approach to a patient with chest pain is presented separately. (See "Outpatient evaluation of the adult with chest pain".)
Therapeutic interventions for musculoskeletal disorders affecting the chest are generally similar to those for musculoskeletal pain elsewhere in the body. However, in the case of chest pain, a common patient concern, stated or unstated, is that the pain is due to heart disease, and this concern must be addressed as well. In this regard, the physical examination itself, particularly the examiner's ability to reproduce or exacerbate the chest pain by palpation or with various maneuvers, helps the patient understand the noncardiac nature of the problem. (See "Clinical evaluation of musculoskeletal chest pain".)
CAUSES OF MUSCULOSKELETAL CHEST PAIN
As mentioned in the introduction, there are many local and systemic diseases and disorders that cause musculoskeletal chest pain (table 1 and table 2). These causes are discussed in more detail elsewhere (see "Major causes of musculoskeletal chest pain in adults"). A brief summary of some selected causes follows:
●Costochondritis and Tietze's syndrome are both associated with tenderness of one or more of the costochondral joints. Although there is some controversy over whether these two disorders are truly distinct, in this discussion the term Tietze's syndrome is used for the combination of pain, tenderness and swelling, while costochondritis is used when swelling is absent.
- Chambers J, Bass C, Mayou R. Non-cardiac chest pain: assessment and management. Heart 1999; 82:656.
- Mason L, Moore RA, Derry S, et al. Systematic review of topical capsaicin for the treatment of chronic pain. BMJ 2004; 328:991.
- Mason L, Moore RA, Edwards JE, et al. Systematic review of efficacy of topical rubefacients containing salicylates for the treatment of acute and chronic pain. BMJ 2004; 328:995.
- Long J. The Essential Guide To Prescription Drugs, Harper Collins, New York 1995.
- Borenstein DG, Korn S. Efficacy of a low-dose regimen of cyclobenzaprine hydrochloride in acute skeletal muscle spasm: results of two placebo-controlled trials. Clin Ther 2003; 25:1056.
- O'Malley PG, Jackson JL, Santoro J, et al. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract 1999; 48:980.
- Phillips K, Clauw DJ. Central pain mechanisms in the rheumatic diseases: future directions. Arthritis Rheum 2013; 65:291.
- Arnold LM, Zhang S, Pangallo BA. Efficacy and safety of duloxetine 30 mg/d in patients with fibromyalgia: a randomized, double-blind, placebo-controlled study. Clin J Pain 2012; 28:775.
- Pollack M, Scott E. Gabapentine and lamotrigine: Novel treatments for mood and anxiety disorders. CNS Spectr 1997; 2:56.
- Saunders S, Cameron G. Injection techniques in orthopedic and sports medicine, WB Saunders, London 1997.
- Doherty M, Hazleman B, Hutton C, et al. Rheumatology Examination and Injection Techniques, 2nd, WB Saunders, London 1999.
- Doube A, Clarke AK. Symptomatic manubriosternal joint involvement in rheumatoid arthritis. Ann Rheum Dis 1989; 48:516.
- Kamel M, Kotob H. Ultrasonographic assessment of local steroid injection in Tietze's syndrome. Br J Rheumatol 1997; 36:547.
- Klimes I, Mayou RA, Pearce MJ, et al. Psychological treatment for atypical non-cardiac chest pain: a controlled evaluation. Psychol Med 1990; 20:605.
- Mayou RA, Bryant BM, Sanders D, et al. A controlled trial of cognitive behavioural therapy for non-cardiac chest pain. Psychol Med 1997; 27:1021.
- Kisely S, Campbell LA, Skerritt P. Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy. Cochrane Database Syst Rev 2005; :CD004101.
- Cannon RO 3rd, Quyyumi AA, Mincemoyer R, et al. Imipramine in patients with chest pain despite normal coronary angiograms. N Engl J Med 1994; 330:1411.
- Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon 2009; 31:169.
- LIPKIN M, FULTON LA, WOLFSON EA. The syndrome of the hypersensitive xiphoid. N Engl J Med 1955; 253:591.
- Howell JM. Xiphodynia: a report of three cases. J Emerg Med 1992; 10:435.
- Brown CW, Deffer PA Jr, Akmakjian J, et al. The natural history of thoracic disc herniation. Spine (Phila Pa 1976) 1992; 17:S97.
- Olivieri I, Padula A, Palazzi C. Pharmacological management of SAPHO syndrome. Expert Opin Investig Drugs 2006; 15:1229.
- Assmann G, Kueck O, Kirchhoff T, et al. Efficacy of antibiotic therapy for SAPHO syndrome is lost after its discontinuation: an interventional study. Arthritis Res Ther 2009; 11:R140.
- Kerrison C, Davidson JE, Cleary AG, Beresford MW. Pamidronate in the treatment of childhood SAPHO syndrome. Rheumatology (Oxford) 2004; 43:1246.
- Colina M, La Corte R, Trotta F. Sustained remission of SAPHO syndrome with pamidronate: a follow-up of fourteen cases and a review of the literature. Clin Exp Rheumatol 2009; 27:112.
- Olivieri I, Padula A, Ciancio G, et al. Successful treatment of SAPHO syndrome with infliximab: report of two cases. Ann Rheum Dis 2002; 61:375.
- Wagner AD, Andresen J, Jendro MC, et al. Sustained response to tumor necrosis factor alpha-blocking agents in two patients with SAPHO syndrome. Arthritis Rheum 2002; 46:1965.
- Ben Abdelghani K, Dran DG, Gottenberg JE, et al. Tumor necrosis factor-alpha blockers in SAPHO syndrome. J Rheumatol 2010; 37:1699.
- Jung J, Molinger M, Kohn D, et al. Intra-articular glucocorticosteroid injection into sternocostoclavicular joints in patients with SAPHO syndrome. Semin Arthritis Rheum 2012; 42:266.
- CAUSES OF MUSCULOSKELETAL CHEST PAIN
- THERAPEUTIC INTERVENTIONS
- Patient education
- Physical measures
- Topical agents
- Nonopioid analgesics
- Nonsteroidal antiinflammatory drugs
- Muscle relaxants
- Local glucocorticoid injections
- - Sternoclavicular joint injection
- - Manubriosternal joint
- - Costochondral junctions
- Intercostal nerve block
- Disease modifying antirheumatic drugs
- Psychiatric evaluation and treatment
- TREATMENT OF SELECTED CONDITIONS
- Isolated musculoskeletal chest pain syndromes
- Sternoclavicular hyperostosis (SAPHO syndrome)
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Nonpharmacologic interventions
- Pharmacologic interventions
- - Acute pain
- - Chronic pain