Management of isolated musculoskeletal chest pain

INTRODUCTION — Isolated musculoskeletal chest pain has been attributed to a number of conditions (table 1). Their management usually involves a range of general measures, topical agents, analgesics, and anti-inflammatories, which individually or together may be helpful for most patients with isolated musculoskeletal chest pain. Most musculoskeletal chest pain improves over the course of a few weeks or months. However, some patients require specialist referral for persistent symptoms.

There are few data that specifically address the efficacy and safety of therapeutic interventions for patients with isolated musculoskeletal chest pain. In general, the use of these interventions in treating musculoskeletal chest pain is based upon analogy with their usefulness in treating pain of similar origin elsewhere in the body (eg, neck and low back pain).

The management of isolated musculoskeletal chest pain will be discussed here. Causes of chest pain and the evaluation of chest pain in adults and children are discussed separately:

●(See "Major causes of musculoskeletal chest pain in adults".)

●(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".)

TYPES OF ISOLATED MUSCULOSKELETAL CHEST PAIN — There are several types of isolated musculoskeletal chest pain, a subset of the many local and systemic diseases and disorders that cause chest pain (table 1 and table 2). However, in primary care, pain localization in the sternal or retrosternal region is extremely common and does not reliably distinguish musculoskeletal chest pain from chest pain due to other causes [1]. The range of conditions that cause musculoskeletal chest pain, including isolated musculoskeletal chest pain, are discussed in more detail separately. (See "Major causes of musculoskeletal chest pain in adults".)

Briefly, this topic summarizes treatments for conditions that cause isolated musculoskeletal chest pain, including:

●Muscle strains, particularly of the intercostal muscles, which may cause musculoskeletal chest pain. Tenderness over the affected muscle is present and increases with stretching the involved muscle (eg, taking a deep breath).

●Costochondritis and costochondral junction syndrome (also termed Tietze syndrome or chondropathia tuberosa), which are both associated with tenderness of one or more of the costochondral joints.

●Posterior chest wall syndromes, which include costovertebral joint dysfunction and thoracic disc herniations and present as tenderness over the affected area or band-like chest pain with a dermatomal distribution.

●Lower rib pain syndromes, for which many different names have been used, including slipping or clicking rib syndrome, rib-tip syndrome, or twelfth rib. Pain can be diffuse or localized. Palpation of the costal margin characteristically reproduces the pain.

●Osteoarthritis of the sternoclavicular joint, which is uncommon but can cause focal pain of the sternoclavicular joint.

●Xiphoidalgia or xiphodynia, which is an uncommon syndrome with localized pain and tenderness over the xiphoid process.

●Sternalis syndrome, which is a rare disorder characterized by localized tenderness over the body of the sternum; palpation of the tender area often causes radiation of pain bilaterally.

INITIAL MANAGEMENT — Initial management for most patients includes general nonpharmacologic interventions (see 'General measures for most patients' below) and the use of short-term analgesic medications (see 'Analgesia' below). Most isolated musculoskeletal pain improves over the course of a few weeks or months, and sometimes even within seconds, minutes, or hours. Hence, it is usually appropriate for clinicians to reassure patients, emphasize a favorable prognosis, and channel patients toward therapeutic measures with minimal risk for adverse effects (eg, cryotherapy or acetaminophen), even if studies confirming efficacy are limited in this population. Patients with symptoms lasting more than three months may also have a chronic widespread pain syndrome.

Rule out urgent conditions — It is important to first confirm the suspicion of a musculoskeletal cause of the patient's chest pain, which must be differentiated from chest pain due to potentially life-threatening disorders, such as myocardial ischemia or infarction, pulmonary embolism, aortic dissection, or pneumothorax, and from chest pain due to systemic illnesses for which it may be one of multiple manifestations (table 2). The evaluation of chest pain is described in detail separately. (See "Outpatient evaluation of the adult with chest pain", section on 'Initial triage'.)

General measures for most patients — A few general measures may be helpful for patients with isolated musculoskeletal chest pain, including education, activity restriction or modification, and local application of heat and/or cold to the affected area. Although the efficacy and safety of these measures have not been specifically evaluated in patients with isolated musculoskeletal chest pain, they have been beneficial in treating musculoskeletal back and neck pain. (See 'Patient education and reassurance' below and 'Activity restriction' below and 'Application of cold and heat' below.)

Patient education and reassurance — All patients should receive education regarding the nature of their condition and the general management strategy. A common patient concern, stated or unstated, is that the pain is due to heart disease, and this concern must be addressed. Demonstration of the ability to reproduce or exacerbate the chest pain by palpation or with various maneuvers helps the patient understand the noncardiac nature of the problem. A careful explanation of the diagnosis may be therapeutic for some patients, with reassurance that watchful waiting without any other specific intervention is appropriate.

Activity restriction — Any activity that causes or reliably exacerbates the pain should be reduced or stopped, at least temporarily, if possible. As examples, overload and overuse, as during weight training, lifting, or pushing heavy objects, may cause musculoskeletal chest pain. Activity modification is particularly important for patients with spontaneous sternoclavicular subluxation (see 'Spontaneous sternoclavicular joint subluxation' below). Anecdotal reports of benefit from activity restriction are widespread, although not assessed in the scientific literature.

Application of cold and heat — For isolated musculoskeletal chest pain, the application of cold or heat may be helpful. We usually prefer heat in patients with more muscle spasm and cold for patients experiencing localized swelling, and we advise trying the alternate modality if the first is not beneficial. This approach is based upon clinical experience and common practice, but this approach has not been established in randomized trials.

●Cold therapy – Cold may reduce swelling and discomfort [2]. Crushed ice (covered, not directly applied) can be compressed against the injured area for up to 20 minutes followed by an exposure to room temperature for one to two hours; this treatment may be repeated every 2 to 2.5 hours and continued for 48 hours.

●Heat therapy – Heat therapy increases blood flow and is thought to promote relaxation of tightened muscles. The usual recommendation is to avoid application of heat during the first 48 hours after an injury because of the potential to increase inflammation, although there are few high-quality data to support this approach. Heat is applied with either a heating pad, hot compress, or chemical heat pack for 20 minutes several times daily. Single-use, disposable heating pads or patches that can provide a source of heat for up to eight hours are available without a prescription; they can be applied to any part of the body. Thus, if local heat (eg, a heating pad) helps at home, such pads or patches may provide benefit in other settings, such as at the workplace. Care should be taken to avoid thermal injury from excessive temperature or prolonged exposure time.

Analgesia — In addition to the general nonpharmacologic measures, initial management usually includes analgesics. Although the efficacy and safety of the agents discussed below have not been specifically evaluated in patients with isolated musculoskeletal chest pain, some agents provide clinically significant benefit in musculoskeletal back pain [3-6].

Mild pain — For patients with mild isolated musculoskeletal chest pain, defined as pain that does not interfere with light activity, we typically use acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) in a low to moderate dose, rather than nonpharmacologic or topical measures alone. In addition, patients may also add a topical pain therapy.

Comorbidities, patient preferences, and response to therapy influence the choice of agent. Although use of an oral analgesic has the advantage of ease of use, some patients may have relative or absolute contraindications to such agents (eg, renal, gastrointestinal, or cardiovascular disease). In others, the combination of a systemic and topical analgesic therapy together may be more effective.

●Nonsteroidal anti-inflammatory drugs – In patients without a relative or absolute contraindication to NSAIDs, we suggest initial treatment with an NSAID. These medications have the advantages of being both available without a prescription and likely more effective than acetaminophen. We use the lowest effective dose for the shortest duration required. Details on dosing and adverse effects are discussed in the table (table 3) and elsewhere. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Nonsteroidal anti-inflammatory drugs'.)

●Acetaminophen – In patients with mild pain, clinicians may also consider initial treatment with acetaminophen. Although data regarding efficacy are limited in this population, anecdotal reports suggest patients can experience musculoskeletal pain relief with acetaminophen, and it is a reasonable option for those who have a contraindication to NSAIDs. Details on dosing and adverse effects are discussed elsewhere. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Acetaminophen'.)

●Topicals – Topical analgesic and anti-inflammatory agents, applied as creams, gels, or patches, can be used for a trial period of up to two weeks to determine efficacy of a given agent, which should then be discontinued if it does not provide adequate relief of symptoms. The medication can be continued as needed if it improves symptoms. Choice between agents is based upon patient preference and treatment response. Randomized trials lend the strongest support for topical NSAID preparations versus other topical options, including:

•Topical NSAID preparations (eg, 1% topical diclofenac gel or diclofenac patch) may also provide some clinically significant pain improvement, are available over the counter, and can be used up to several times daily. However, we generally avoid the concurrent use of topical and systemic NSAID therapy due to the potential increased risk of adverse effects and lack of added benefit [7,8].

•Capsaicin cream or salicylate-containing creams or gels, which may be employed, with application three to four times daily [7-10]. These agents are widely available without a prescription; although, randomized trial data supporting their use for acute pain are sparse [7].

•A lidocaine patch or topical lidocaine gel may also provide local pain relief [7].

Moderate pain — For patients with moderate isolated musculoskeletal chest pain, defined as pain that interferes with light to moderate activity, we typically suggest initial pharmacologic treatment with systemic NSAIDs rather than acetaminophen, and we initiate treatment with higher doses of naproxen (375 to 500 mg twice daily) or ibuprofen (400 to 800 mg three to four times daily). If pain relief with oral NSAID treatment alone is inadequate, we add acetaminophen (500 mg; one to two every three to four hours to a maximum, if needed, of up to 3000 mg daily). In addition, if a maximum acceptable dose of a particular NSAID does not relieve symptoms or efficacy wanes, anecdotal reports suggest that switching classes of NSAIDs may prove helpful (from an acetic acid to a propionic acid, for example) (table 3) [11]. We treat with the lowest effective dose for the shortest duration required.

NSAIDs should be avoided or used with particular caution in patients with increased risk of adverse effects due to comorbid renal, cardiovascular, or gastrointestinal disease (see "Nonselective NSAIDs: Overview of adverse effects" and "Overview of COX-2 selective NSAIDs", section on 'Toxicities and possible toxicities'). Patients should be cautioned about the potential gastrointestinal adverse effects of NSAIDs, including gastritis, peptic ulcer disease, and gastrointestinal bleeding. Those at high risk of NSAID-induced gastroduodenal damage may benefit from ulcer prophylaxis with a proton pump inhibitor or misoprostol. Risk factors and prevention strategies are discussed separately. Use of a selective cyclooxygenase 2 (COX-2) inhibitor may be an alternative for patients at high risk of gastrointestinal toxicity. (See "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity".)

Interference by some NSAIDs with the beneficial antiplatelet effects of aspirin may be a concern for those taking low doses of aspirin for prophylaxis or treatment of cardiovascular disease. (See "NSAIDs: Adverse cardiovascular effects".)

Severe pain — We define musculoskeletal chest pain as severe if it interferes with activities of daily living. Severe musculoskeletal chest pain usually occurs in the setting of trauma (eg, rib fracture, muscle tear). The evaluation and management of patients with chest wall trauma is discussed separately. (See "Initial evaluation and management of chest wall trauma in adults" and "Initial evaluation and management of rib fractures" and "Pectoralis muscle and tendon injuries".)

Adjunctive exercise — Several particular conditions may benefit from specific interventions in addition to the measures described for initial management of most patients. (See 'Costochondritis' below and 'Spontaneous sternoclavicular joint subluxation' below.)

Costochondritis — Patients with musculoskeletal chest pain from costochondritis may improve with stretching exercises (table 4) in addition to activity restriction, ice or heat, and analgesics [12,13]. (See 'General measures for most patients' above and 'Analgesia' above.)

Spontaneous sternoclavicular joint subluxation — Patients with spontaneous subluxation of the sternoclavicular joint can be referred to physical therapy for shoulder/scapular strengthening exercises if symptoms persist after initial management with activity restriction, ice or heat, and analgesics. (See 'General measures for most patients' above and 'Analgesia' above.)

FOLLOW-UP — Patients should be seen by the treating clinician four to six weeks after the onset of pain to address patient concerns, assess effectiveness of initial therapy, and identify patients with persistent symptoms who may require treatment modification, further evaluation, or additional treatment.

MANAGEMENT OF PERSISTENT PAIN — In patients in whom isolated musculoskeletal chest pain persists beyond four to six weeks, or if symptoms are not adequately controlled with initial treatment measures, additional interventions or specialty referral may be warranted depending upon the cause of pain or expertise required for effective management. These interventions are typically provided by a pain management specialist, orthopedist, physical medicine and rehabilitation specialist (physiatrist), rheumatologist, or interventional radiologist, depending upon the specific intervention, local referral and practice patterns, and the expertise and interest of the potential consultant. In some cases, referral to other specialists with an interest in these conditions, including primary care clinicians, pulmonologists, and cardiologists, may be appropriate. (See 'Individualized interventions' below.)

Individualized interventions — For patients who do not respond to initial therapies or who have certain conditions, local injections or other interventional techniques may be necessary. (See 'Posterior chest wall syndromes' below and 'Sternoclavicular osteoarthritis' below and 'Costochondritis or costochondral junction syndrome' below and 'Xiphoidalgia' below.)

Posterior chest wall syndromes — Patients with pain from posterior chest wall syndromes may require referral to a pain specialist or an interventional radiologist for intercostal nerve block or glucocorticoid injections of the costovertebral facet joints.

●Intercostal nerve blocks may be useful in patients with thoracic disc herniations who do not respond to initial management [14,15]. Surgical decompression is usually not required for treatment. In one series of patients with thoracic disc herniation, surgical decompression was required in only 27 percent of patients, as a majority of those treated with conservative measures (including rest, NSAIDs, physical therapy, and patient education) returned to normal activities [16]. (See "Thoracic nerve block techniques", section on 'Intercostal nerve block'.)

●Glucocorticoid injections of the costovertebral facet joints have been used to treat pain in patients with degenerative changes in these joints. However, the efficacy of such injections has not been studied. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)

●Botulinum toxin injections have been used to treat posterior chest pain due to slipping rib syndrome (sometimes called rib-tip syndrome or painful rib syndrome) if palpable rib subluxation or hypermobility is present and conservative interventions have failed [17,18].

Sternoclavicular osteoarthritis — Patients with pain localized to the sternoclavicular joint due to osteoarthritis may require referral to a pain specialist for injection of the sternoclavicular joint with an anesthetic-glucocorticoid combination. Local injection of the sternoclavicular joint must be performed with caution in order to reduce the risk of pneumothorax or injury to blood vessels. The approach to injection of the sternoclavicular joint is similar to aspiration and injection of other joints. (See "Joint aspiration or injection in adults: Technique and indications".)

Costochondritis or costochondral junction syndrome — Patients with costochondral junction syndrome (Tietze syndrome) that does not respond to initial therapy may be referred to a pain specialist for treatment. Infiltration of the region of the costochondral junctions with an anesthetic-glucocorticoid combination may be beneficial for such patients who have one or two tender areas due to costochondritis or costochondral junction syndrome. Local injection of the costochondral junctions must be performed with caution in order to reduce the risk of pneumothorax or laceration of blood vessels in the chest wall or mediastinum.

Costochondral junction injection was evaluated in an observational study in which ultrasonography was used to confirm the diagnosis of Tietze syndrome in nine patients [19]. The point of maximal tenderness and/or ultrasonographically enlarged costochondral joint was injected with a mixture of triamcinolone and lidocaine. Complete resolution of swelling and tenderness was noted after one week in eight patients and "substantial" improvement was noted in the one remaining patient. In another single-center study, 75 percent of 28 patients with Tietze syndrome received benefit from a single injection [20,21].

Xiphoidalgia — Referral to a pain specialist may be required for patients who have persistent chest pain localized to the xiphoid process. This can be treated with local infiltration with an anesthetic-glucocorticoid combination [20]. Local injection of the xiphoid must be performed with caution in order to reduce the risk of pneumothorax or laceration of blood vessels in the chest wall or mediastinum. Options for referral for these procedures, which should be done with imaging visualization for safe localization of needle placement, include interventional radiology, interventional pain centers, and physical medicine and rehabilitation specialists with training in these techniques.

Medications for chronic musculoskeletal chest pain — In patients with persistent isolated musculoskeletal chest pain that significantly affects a patient's quality of life, it may be helpful to prescribe medications used for treatment of chronic widespread (centralized) pain, such as fibromyalgia syndrome. The agents and dosing are described in detail separately. (See "Treatment of fibromyalgia in adults".)

INDICATIONS FOR REFERRAL — Indications for referral to a specialist such as a rheumatologist, physiatrist (physical medicine and rehabilitations specialist), or a pain management specialist, depending upon the specific condition or expertise required, include:

●Persistent pain from posterior chest wall syndrome requiring intercostal nerve block or facet joint injection

●Persistent pain from other isolated musculoskeletal conditions requiring local glucocorticoid injection

●Uncertainty about the diagnosis

●Lack of improvement after one to three months of treatment with several interventions, depending upon the severity of symptoms, local referral practices, and availability of specialists

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 e-mail 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

●Initial evaluation – The first step in the management of suspected musculoskeletal chest pain is to confirm that the patient is not experiencing chest pain due to a potentially life-threatening disorder, such as myocardial ischemia or infarction, pulmonary embolism, aortic dissection, or pneumothorax, and that the patient does not have pain due to a systemic illness. The diagnostic evaluation of chest pain is described in detail separately. (See 'Initial management' above and "Outpatient evaluation of the adult with chest pain".)

●Mild or moderate pain – For patients with isolated musculoskeletal chest pain of mild to moderate severity, we suggest initial treatment with both nonpharmacologic and pharmacologic measures rather than nonpharmacologic measures alone (Grade 2C). Most isolated musculoskeletal pain improves over the course of a few weeks or months. The use of these interventions in treating musculoskeletal chest pain is similar to other types of musculoskeletal pain (eg, neck and low back pain).

•Nonpharmacologic measures – Nonpharmacologic measures include reassurance that the pain is not life threatening, avoidance of activities that cause or aggravate the pain, and local application of heat or cold. (See 'Initial management' above and 'General measures for most patients' above.)

•Choice of initial pharmacologic treatment – For most patients, we suggest initial treatment with an oral analgesic (ie, a nonsteroidal anti-inflammatory drug [NSAID] or acetaminophen) rather than topical analgesics (Grade 2C). (See 'Analgesia' above.)

Comorbidities, patient preferences, and response to therapy influence the choice of pharmacologic agent. In addition, some patients may have relative or absolute contraindications to oral analgesic agents (eg, kidney, gastrointestinal, or cardiovascular disease). For some patients, the combination of a systemic and topical analgesic therapy together may be more effective, although we generally avoid the concurrent use of topical and systemic NSAID therapy due to the potential increased risk of adverse effects and lack of benefit. (See 'Mild pain' above.)

-Patients with mild pain (ie, pain that does not limit activity) may be treated initially with a low-dose NSAID taken on an as-needed basis. These may be administered with or without topical capsaicin or lidocaine preparations. (See 'Mild pain' above.)

-Patients with mild pain and contraindication to NSAIDs may be offered acetaminophen, which may be combined with topical therapy including topical NSAIDs. (See 'Mild pain' above.)

-Patients with moderate pain (ie, pain that interferes with light to moderate activity) are typically treated with oral NSAIDs in moderate to high doses; see the table (table 3) for options and doses. (See 'Moderate pain' above.)

•Adjunctive physical therapy – Patients with costochondritis may improve with the addition of stretching exercises (table 4), and patients with spontaneous subluxation of the sternoclavicular joint can be referred to physical therapy for shoulder/scapular strengthening exercises. (See 'Adjunctive exercise' above.)

●Severe pain – Severe musculoskeletal chest pain (ie, pain that interferes with activities of daily living) usually occurs in the setting of trauma (eg, rib fracture, muscle tear) and thus requires referral to an appropriate specialist for evaluation and management. (See "Initial evaluation and management of chest wall trauma in adults".)

●Persistent pain – Isolated musculoskeletal chest pain that persists beyond six weeks or does not respond to initial treatment measures may warrant specialty referral for injections or other interventional techniques (see 'Individualized interventions' above). Persistent musculoskeletal chest pain that adversely affects quality of life may be an indication of a chronic widespread (centralized) pain syndrome, such as fibromyalgia or myofascial pain syndrome. Management of these disorders is discussed in detail separately. (See "Treatment of fibromyalgia in adults" and "Overview of soft tissue musculoskeletal disorders", section on 'Myofascial pain syndrome'.)

●Indications for referral – Specialist referral may be indicated depending on chronicity and response to initial management. (See 'Indications for referral' above.)

•Patients with pain that persists beyond four to six weeks

•Patients with symptoms that are not adequately controlled with initial treatment measures

•Patients who may benefit from referral to a specialist for treatment with local nerve blocks or glucocorticoid injections (see 'Individualized interventions' above)

•Patients with lack of improvement after one to three months of interventions are tried

•Patients in whom the diagnosis is uncertain