Major causes of musculoskeletal chest pain in adults

INTRODUCTION — 

Potentially life-threatening cardiac and pulmonary problems are usually the focus of the initial diagnostic evaluation for chest pain, although conditions affecting the musculoskeletal structures of the chest wall are among the most common causes of chest pain, particularly of discomfort that is often described as atypical or noncardiac chest pain. Early recognition of musculoskeletal syndromes causing chest pain is an important element in the efficient and specific management of pain in patients with these conditions [1-6].

This topic will review the major causes of musculoskeletal chest pain in adults. Other topics discuss the evaluation and management of chest pain in different settings, including adult and pediatric patients:

●(See "Clinical evaluation of musculoskeletal chest pain".)

●(See "Management of isolated musculoskeletal chest pain".)

●(See "Approach to the adult with nontraumatic chest pain in the emergency department".)

●(See "Outpatient evaluation of the adult with chest pain".)

●(See "Causes of nontraumatic chest pain in children and adolescents".)

●(See "Nontraumatic chest pain in children and adolescents: Approach and initial management".)

PREVALENCE — 

The proportion of patients with chest pain having a musculoskeletal source varies with the clinical setting; it affects up to a quarter of patients in the emergency setting and over a third of those in nonemergency ambulatory clinics. Chest wall tenderness is common but does not always reproduce the presenting symptoms, and such tenderness can occasionally be present even in patients with pain that is cardiac in origin. (See "Outpatient evaluation of the adult with chest pain".)

●Emergency department – In the emergency department, estimates of the frequency of a musculoskeletal origin for chest pain in adults range from approximately 4 to 50 percent, depending upon the setting and study design [7-14]. As examples:

•In a prospective study of 122 consecutive emergency department patients with chest pain, 30 percent were felt to have chest wall tenderness due to costochondritis [8]. In 17 of these patients, the tenderness reproduced their pain. Two of these patients had an acute myocardial infarction, indicating that chest wall tenderness does not exclude the possibility of acute coronary syndrome.

•In one large study of emergency department visits for chest pain in a small town in Sicily, the pain was felt be musculoskeletal in 49 percent of patients [7]. However, a study performed in rural Australia attributed chest pain to a musculoskeletal cause in only 15 percent [12].

•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 [9].

•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 pain syndromes (50 percent), fibromyalgia (26 percent), or inflammatory joint disease (24 percent) [10].

●Nonemergency settings – Estimates of the prevalence of musculoskeletal chest pain in the ambulatory care setting range from 20 to 47 percent, making this the most common diagnostic category in nonemergency settings [15-18]. In one prospective study of 399 presentations of chest pain in the primary care setting, musculoskeletal chest pain was the most common etiology (36 percent) followed by reflux esophagitis and other gastrointestinal etiologies (19 percent) [18]. Cardiac etiologies of chest pain were diagnosed in 16 percent, including acute coronary syndromes in 1.5 percent, and nonurgent cardiac etiologies (eg, stable angina) in 14 percent of presentations.

In prospective studies of patients with chest pain who have had reassuring cardiology evaluations, 13 to 20 percent have chest wall tenderness that reproduces their pain, suggesting a musculoskeletal etiology [19,20]. Notably, in one study, 2.8 percent of such patients had both coronary heart disease and a musculoskeletal source of pain in longitudinal follow-up [19].

TYPES OF CHEST WALL PAIN — 

Musculoskeletal chest pain can be divided into three broad categories:

●Isolated musculoskeletal pain syndromes (chest wall syndrome, including costochondritis or painful lower rib syndromes) (table 1) (see 'Isolated musculoskeletal chest pain syndromes' below)

●Rheumatic disease-related causes (eg, fibromyalgia, rheumatoid arthritis, spondyloarthritis) (table 2) (see 'Rheumatic disease-related causes' below)

●Systemic nonrheumatologic conditions (eg, insufficiency fractures or neoplasia) (table 2) (see 'Nonrheumatic systemic conditions' below)

In addition, chest wall pain may result from conditions other than those directly affecting the musculoskeletal structures, including dermatologic and neuropathic causes (eg, herpes zoster), and sometimes occurs in association with myocardial ischemia or pulmonary embolic disease. (See "Outpatient evaluation of the adult with chest pain", section on 'Differential Diagnosis'.)

ISOLATED MUSCULOSKELETAL CHEST PAIN SYNDROMES — 

There are a number of chest wall syndromes with chest pain associated with local or regional tenderness, such as costosternal or costochondral pain syndromes, which are sometimes due to musculoskeletal inflammation, excessive coughing, or athletic injuries (table 1) [21-23].

Costosternal syndromes (costochondritis) — A majority of patients with musculoskeletal chest wall syndromes have a more diffuse regional pain syndrome, in which multiple areas of tenderness are found that reproduce the described pain. The upper costal cartilages at the costochondral or costosternal junctions are most frequently involved [19,24]. The areas of tenderness are not accompanied by heat, erythema, or localized swelling.

A variety of diagnostic terms have been used in this group of patients, including costochondritis, costosternal syndrome, and anterior chest wall syndrome. The diagnosis is based solely upon the ability to reproduce pain by palpation of tender areas. In some studies, certain maneuvers, such as the "crowing rooster" and horizontal arm flexion maneuvers, have also been found to be useful. A study involving 1212 patients, done in an outpatient primary care setting, showed that the presence of at least two of four specific features (localized muscle tension, stinging pain, pain reproducible by palpation, and absence of cough) was associated with a diagnosis of chest wall syndrome, with 63 percent sensitivity and 79 percent specificity [16]. (See "Clinical evaluation of musculoskeletal chest pain", section on 'Physical examination'.)

Although the costosternal syndrome is a frequent diagnosis in patients with noncardiac chest pain, the causes, natural history, and treatment of this condition are poorly documented. Most prospective studies suggest that approximately half of these patients will continue to have chest pain for 6 to 12 months, with moderate limitation of activities in most [25].

Lower rib pain syndromes — A variety of names have been given to pain syndromes involving the lower ribs, including rib-tip syndrome, slipping rib, twelfth rib, and clicking rib; this condition is characterized by pain in the lower chest or upper abdomen, a tender spot on the costal margin, and reproduction of the pain by pressing on the spot [26]. In some reports, hypermobility of the anterior end of a costal cartilage has been implicated, possibly related to indirect trauma due to lifting or twisting.

In addition to direct palpation, another useful diagnostic test is the "hooking maneuver," in which the examiner's curled fingers are hooked under the ribs at the costal margin and the ribs are gently pulled forward, reproducing the patient's symptoms. Ultrasound may also be useful in diagnosing this condition [27].

Painful lower rib syndromes have been found in 3 to 5 percent of patients referred to some gastroenterology practices [26]. A majority of patients with this condition are women, with a mean age in the mid-40s; slipping rib syndrome is also a common cause of lower chest pain in younger female athletes [28]. Among patients followed for an average of four years after diagnosis, the pain persisted in 70 percent. One-third of these patients undergo further evaluations for other causes of pain, even after a definitive diagnosis is made.

Less common syndromes

Sternalis syndrome — The sternalis syndrome is a presumably rare condition in which localized tenderness is found directly over the body of the sternum or overlying sternalis muscle, and palpation often causes radiation of pain bilaterally [29]. This syndrome is generally self-limited and less likely to cause persistent pain than the more diffuse costosternal syndrome. It should be differentiated from arthritis of the manubriosternal joint, which can sometimes be involved in various types of systemic arthritis. Radiographic changes may be apparent (image 1) or increased uptake may be demonstrated by bone scanning (image 2).

Tietze's syndrome — Tietze's syndrome has been defined as a benign, painful, nonsuppurative localized swelling of the costosternal, sternoclavicular, or costochondral joints, most often involving the area of the second and third ribs [30]. Only one area is usually involved, and young adults are more commonly affected. The relationship between Tietze's syndrome and the anterior chest wall involvement of spondyloarthritides (see 'Ankylosing spondylitis' below) and sternocostoclavicular hyperostosis (see 'Sternocostoclavicular hyperostosis (SAPHO syndrome)' below) is uncertain, but some experts have questioned the existence of Tietze's syndrome as a discrete entity [31].

Tietze's syndrome is rare, and should be differentiated from more diffuse forms of myofascial chest pain (costochondritis) in which no areas of localized swelling are detected on examination (see 'Costosternal syndromes (costochondritis)' above). The cause of Tietze's syndrome is unknown, but antecedent upper respiratory infections and excessive coughing have been described in some patients.

Xiphoidalgia — Xiphoidalgia (xiphodynia) is another relatively rare syndrome that is characterized by localized discomfort and tenderness over the xiphoid process of the sternum [32]. Symptoms are often aggravated by eating a heavy meal or bending or twisting movements; they may also be associated with resumption of heavy work or a recent cough, suggesting a traumatic cause in some patients. Therapy may include exercise; local injection; or, rarely, xiphoidectomy [33].

Spontaneous sternoclavicular subluxation — Spontaneous, atraumatic subluxation of the sternoclavicular joint, not associated with any systemic process, has been described in small numbers of patients [34]. This syndrome occurs almost exclusively in women in the 40- to 60-year age group, most often on the dominant hand side, and is associated with moderate to heavy repetitive tasks. The subluxation is typically in a cranial and/or anterior direction. Sclerosis of the medial clavicle is often seen radiographically.

Posterior chest wall pain syndromes — Thoracic spinal pain syndromes are relatively common in workplace settings, with an annual prevalence ranging from 3 to 55 percent, and pain in this area may be associated with chest pain [35]. There are several causes of posterior chest wall pain:

●Thoracic disc herniations – Thoracic disc herniations are rare and difficult to diagnose but should be considered in patients with unilateral dermatomal pain. This condition is most common in patients in their 40s, two-thirds of whom have "band-like" chest pain [36]. Pain in the upper back, associated with overhead or throwing activities of the upper extremities, may be suggestive of snapping scapula syndrome. Along with pain in the subscapular region, this condition can be associated with a grinding, snapping, or slapping sensation with scapular movement.

●Costovertebral joint dysfunction – Costovertebral joint dysfunction is another uncommon condition causing posterior chest wall pain. Patients usually present with pain that is made worse with coughing or deep breathing, and often undergo evaluation for an intrapulmonary process, most often pulmonary embolism [37]. On physical examination, pain is often reproduced by palpation in the area of the costovertebral junctions or directly over the affected rib, and local hyperalgesia may be caused by skin pinching. In some cases, degenerative changes are seen in the affected joints.

The costovertebral joints may be diffusely involved in ankylosing spondylitis, but the chest pain associated with this condition is usually more diffuse and associated with other features of the disease, including limited chest expansion on physical examination. (See 'Ankylosing spondylitis' below.)

●Chest wall tumors – A heterogeneous group of benign and malignant thoracic neoplasms can affect the posterior chest wall. These include osteosarcomas, angiosarcomas, liposarcomas, and numerous others. They may arise from different chest wall structures, including the thorax, cartilage, muscle, blood vessels, and neurogenic tissues. Computed tomography is the modality of choice for initial evaluation, though more advanced imaging may be required [38].

RHEUMATIC DISEASE-RELATED CAUSES — 

Increased sensitivity to ordinarily nonpainful stimuli in patients with fibromyalgia and involvement of thoracic joints in rheumatic and autoinflammatory diseases can be associated with musculoskeletal chest wall pain (table 2).

More common causes

Fibromyalgia — Fibromyalgia is a common chronic musculoskeletal pain syndrome, characterized by diffuse musculoskeletal pain, widespread soft tissue tenderness found on physical examination, and fatigue and sleep disturbance; it is often also accompanied by symptoms of depression, anxiety, and cognitive dysfunction. The most common areas of reported pain in patients with this condition are the low back, neck, shoulders, and hips (figure 1 and figure 2 and figure 3). (See "Fibromyalgia: Clinical manifestations and diagnosis in adults".)

Chest pain occurs in fibromyalgia with frequency estimates over a broad range, from 8 to 71 percent. However, 85 percent of patients with fibromyalgia have tenderness over the second anterior costochondral junctions (over 60 percent characterized as moderate or greater), making this one of the most common sites of tenderness in fibromyalgia [39].

In the emergency department setting, only 3 percent of all patients and 8 percent of those with chest wall tenderness appear to have fibromyalgia [8]. Similar frequencies have been reported in patients evaluated after negative coronary angiography [20].

Rheumatoid arthritis — Diffuse chest wall pain, as in costochondritis or costosternal syndrome, is not part of rheumatoid arthritis, but symptomatic involvement of the sternoclavicular joint may occur in up to 19 percent of patients with established, generalized rheumatoid arthritis, and radiographic or ultrasound changes may be apparent in 30 percent [40]. Establishing the diagnosis is usually not difficult, except in the rare case in which involvement of the sternoclavicular joint is the initial manifestation of the disease. (See "Diagnosis and differential diagnosis of rheumatoid arthritis".)

Ankylosing spondylitis — Pain in the thoracic spine and around the chest wall, resulting from inflammatory disease of the costovertebral, costotransverse, and thoracic apophyseal joints, is common in ankylosing spondylitis and related conditions. Patients with this spondyloarthritis typically have symptoms in the lower back or buttocks and some element of morning stiffness; in addition, many patients present with pain in the upper spine and anterior rib cage, particularly in the sternum, costosternal areas, and sternoclavicular joints [41,42]. Involvement of these joints often results in limitation of chest expansion. This finding was frequent and typical enough to be included in criteria for this disease and is often used in clinical practice for monitoring activity and progress of disease. (See "Clinical manifestations of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults".)

Symptoms in the anterior chest wall occur in 5 to 25 percent of patients with ankylosing spondylitis. Radiographic evidence of anterior chest involvement is more common, with 18 percent having sternoclavicular and 51 percent manubriosternal involvement [43,44].

Psoriatic arthritis — Approximately 10 to 25 percent of patients with typical psoriasis develop arthritis, which may be axial or peripheral in distribution. Some patients with psoriatic arthritis have spinal involvement, peripheral arthritis, enthesitis, and dactylitis similar to that seen in ankylosing spondylitis and other forms of spondyloarthritis. However, anterior chest wall involvement is uncommonly reported, and some confusion exists regarding the relationship of this finding to sternocostoclavicular hyperostosis. As in other disorders, anterior chest wall symptoms (1 percent) are less common than radiologic evidence of disease in the manubriosternal and sternoclavicular joint (10 to 25 percent) [43]. (See "Clinical manifestations and diagnosis of psoriatic arthritis".)

Less common causes

Sternocostoclavicular hyperostosis (SAPHO syndrome) — 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 [43,45-49]. Clinical descriptions of this syndrome have appeared most frequently in the European and Japanese literature under a variety of different names, including acne-associated spondyloarthropathy, nonbacterial osteitis (NBO), chronic recurrent multifocal osteomyelitis (CRMO), and pustulotic arthrosteitis [50]. The acronym SAPHO syndrome has been used as a unifying term to include the various features common to these closely related disorders: synovitis, acne, pustulosis, hyperostosis, and osteitis [49,51].

●Skin manifestations – The skin lesions associated with the SAPHO syndrome include palmoplantar pustulosis, acne conglobata, acne fulminans, hidradenitis suppurativa, and dissecting cellulitis of the scalp, all of which are characterized pathologically by neutrophilic pseudo-abscesses. (See "Neutrophilic dermatoses".)

●Osteoarticular manifestations – Various patterns of asymmetric peripheral and axial arthritis have been described in association with these skin lesions, many resembling the seronegative spondyloarthritides [52]. However, no consistent association with human leukocyte antigen (HLA) B27 has been demonstrated [53]. (See "Pathogenesis of spondyloarthritis".)

The anterior chest wall is the most frequent area of involvement, particularly in patients with palmoplantar pustulosis [54-57]. Affected patients may present with pain, tenderness, and swelling of the sternum and its articulations, and some patients have restricted mobility. Enlargement and sclerosis of one or both medial clavicles may be seen radiographically, sometimes progressing to involvement of the lateral aspects. Osteolytic lesions may be visible within sclerotic areas.

Similar involvement may be seen in the sternum, particularly the manubrium, and the anterior segments of the ribs. In some patients, the condition progresses to total or partial fusion and ossification involving the ribs, sternum, medial clavicles, and adjacent ligaments [58]. Outside the chest wall, similar findings have been described in the mandible, peripheral long bones, and vertebral bodies [59].

Patients who present with bone lesions alone often develop other manifestations over time. In one study of 15 patients followed for more than a decade, 12 eventually suffered from extraosseous features, including sacroiliitis, psoriasis, and palmoplantar pustulosis [60].

The histopathology of the bony lesions in this syndrome resembles a sterile osteomyelitis. Although the etiology of the SAPHO syndrome is unknown, occult disseminated infection or an abnormal systemic immune response to a low virulence organism, such as Cutibacterium acnes, has been implicated in some studies [46,61,62]. SAPHO syndrome has also been considered to represent an autoinflammatory disorder [63-65] and has been associated with spondyloarthritis in some cases [60].

The natural history of this condition is not well defined, but one report suggests that a minority of patients have a self-limited course, while a majority have either a relapsing-remitting pattern or chronic indolent pattern after an early acute phase, and many require chronic therapy [66]. Further details regarding the evaluation and management of SAPHO syndrome are discussed separately. (See "SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome".)

Systemic lupus erythematosus — Chest pain in patients with systemic lupus erythematosus (SLE) that originates in skeletal muscle or joints of the chest wall may be aggravated by breathing and therefore be described as pleuritic in quality. Finding one or more areas of tenderness helps distinguish a musculoskeletal source. Other causes of pleuritic chest pain in patients with SLE are discussed in more detail separately. (See "Pulmonary manifestations of systemic lupus erythematosus in adults", section on 'Pleural disease'.)

Infectious arthritis of the chest wall — Infection of the ribs and joints of the chest wall is uncommon. When infectious arthritis does occur, it usually affects the sternoclavicular joint. Sternoclavicular infections are most often associated with a history of injection drug use, a distant site of infection, diabetes, and rheumatoid arthritis [67,68]. The most common causative organism has been Pseudomonas aeruginosa in patients with a history of injection drug use, while Staphylococcus aureus and various streptococcal species have predominated in those without such a history. In one study, the risk of developing an abscess in the surrounding area was approximately 20 to 25 percent, and such spread has been associated with mediastinitis [69]. (See "Septic arthritis in adults".)

Relapsing polychondritis — This rare condition, characterized by inflammatory lesions of cartilage, classically presents with inflammation of the ears, nasal cartilage, and respiratory tract. Associated problems in some patients include a nonerosive synovitis, ocular inflammation, and inner ear dysfunction. Inflammation of the costochondral and manubriosternal areas may occur in up to one-quarter of patients, with rare reports of destructive lesions resulting in flail chest [70]. (See "Clinical manifestations of relapsing polychondritis".)

NONRHEUMATIC SYSTEMIC CONDITIONS — 

Several systemic disorders are characterized by bony involvement that can lead to chest wall pain due to fracture, often associated with metabolic changes in the skeleton such as osteoporosis; neoplasia affecting the chest wall or bone; and bone infarcts associated with sickle cell disease.

Insufficiency or stress fractures — An insufficiency fracture occurs when the mechanical strength of a bone is reduced to the point that a stress, which would not fracture a healthy bone, breaks the weak one. Insufficiency fractures of the ribs should be considered in patients with chest pain and risk factors for osteoporosis or osteomalacia, including rheumatoid arthritis treated chronically with glucocorticoids [71], chronic kidney disease, and vitamin D deficiency, especially in older adults. (See "Hypophosphatemia: Causes of hypophosphatemia", section on 'Vitamin D deficiency or resistance' and "Screening for osteoporosis in postmenopausal women and men" and "Epidemiology and etiology of premenopausal osteoporosis" and "Clinical manifestations, diagnosis, and treatment of osteomalacia in adults" and "Epidemiology and etiology of osteomalacia".)

Stress fractures occur as a result of repeated loading of otherwise healthy, well-mineralized bone. Vigorous repetitive athletic activities such as rowing or throwing may cause stress fractures of bones of the chest wall [21] (see "Overview of bone stress injuries and stress fractures"). A number of other musculoskeletal syndromes and injuries can be a cause of chest pain among athletes [72].

Neoplasms — Primary or secondary neoplasms infrequently involve the chest wall, usually as mass lesions. Lung or breast carcinoma, for example, may involve the chest wall by direct extension or metastases, while other neoplasms occasionally cause hematogenous metastases. Primary neoplasms of the chest wall are rare and include various sarcomas (both bone and soft tissue) and multiple myeloma [73]. (See "Clinical presentation, diagnostic evaluation, and staging of soft tissue sarcoma" and "Osteosarcoma: Epidemiology, pathology, clinical presentation, and diagnosis" and "Clinical presentation, staging, and prognostic factors of Ewing sarcoma" and "Chondrosarcoma" and "Multiple myeloma: Clinical features, laboratory manifestations, and diagnosis".)

Sickle cell disease — The acute chest syndrome described as a part of sickle cell crisis has usually been attributed to pulmonary infarction. However, one report, using technetium bone scans, found that rib infarctions may contribute in many cases [74]. There may also be an association of rib involvement with the abdominal pain and distension that is part of some crises [75]. (See "Overview of the clinical manifestations of sickle cell disease" and "Acute and chronic bone complications of sickle cell disease" and "Acute chest syndrome (ACS) in sickle cell disease (adults and children)".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Costochondritis (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Prevalence – Musculoskeletal problems are a common cause of chest pain in adults presenting to emergency departments, outpatient clinics, and other settings. Disorders with musculoskeletal chest pain as a clinical feature may be due to either isolated (nonsystemic) inflammation or injury, rheumatic diseases, or nonrheumatic systemic causes. (See 'Prevalence' above and 'Types of chest wall pain' above.)

The presence of chest wall tenderness, the hallmark of chest pain of musculoskeletal origin, does not exclude a more serious, potentially life-threatening disorder such as ischemic heart disease or pulmonary embolism. Coexistence of chest wall tenderness and myocardial infarction has been noted in a small minority of patients presenting to an emergency department with chest pain.

●Types of chest wall pain – Musculoskeletal chest pain can be divided into three broad categories (see 'Types of chest wall pain' above):

•Isolated musculoskeletal chest pain syndromes – These include costochondritis, painful lower rib syndromes, and other less common syndromes (table 1). (See 'Isolated musculoskeletal chest pain syndromes' above.)

•Rheumatic disease-related causes – Rheumatic conditions associated with musculoskeletal chest pain include fibromyalgia, rheumatoid arthritis, spondyloarthritis, and other less common syndromes (table 2). (See 'Rheumatic disease-related causes' above.)

•Nonrheumatic systemic conditions – Nonrheumatic systemic conditions associated with musculoskeletal chest pain include insufficiency or stress fractures or neoplasia (table 2). (See 'Nonrheumatic systemic conditions' above and "Overview of bone stress injuries and stress fractures".)