INTRODUCTION

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".)

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 and the differential diagnosis of chest pain are presented separately. (See "Diagnostic approach to chest pain in adults" and "Differential diagnosis of chest pain in adults".)

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, that the pain is due to heart disease, 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".) 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.
• Sternalis syndrome is a rare disorder characterized by localized tenderness found over the body of the sternum, often with tenderness that causes radiation of pain bilaterally.
• Xiphoidalgia or xiphoidynia is also a rare syndrome with localized pain and tenderness over the xiphoid process.
• Sternocostoclavicular hyperostosis is a syndrome characterized by a unique arthropathy that frequently involves the anterior chest wall and is associated with a spectrum of neutrophilic skin lesions. The acronym SAPHO syndrome has been proposed as a unifying term to include the various features that may occur: synovitis; acne; pustulosis; hyperostosis; and osteomyelitis.
• Lower rib pain syndromes go by many different names such as slipping or clicking rib syndrome, rib-tip syndrome, or twelfth rib. Pain can be diffuse or localized, and is accompanied by tenderness on the costal margin that reproduces the pain.
• Fibromyalgia is a common chronic musculoskeletal pain syndrome that presents with diffuse myalgias, multiple tender points, sleep disturbance, and fatigue. Many patients report tenderness over the costochondral junctions.