Clinical evaluation of musculoskeletal chest pain

INTRODUCTION — Chest pain is one of the more common symptoms requiring medical attention in the outpatient setting. 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, head, neck, and chest wall [1].

This topic will review the clinical evaluation of chest pain of musculoskeletal origin (table 1). The major causes of chest pain in adults are reviewed separately:

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

●(See "Evaluation of the adult with chest pain of esophageal origin".)

●(See "Approach to the patient with suspected angina pectoris".)

The management of patients with musculoskeletal chest pain is also presented separately. (See "Management of isolated musculoskeletal chest pain".)

HISTORY — Demographic features, characteristics of the chest pain, precipitants, and associated symptoms may favor the diagnosis of musculoskeletal chest pain or may suggest other causes of chest discomfort (table 2) [2].

Demographic features — The initial evaluation of chest pain should be undertaken in the context of the patient’s age, sex, family history, other coronary risk factors, and additional elements of his/her general health. In middle-aged or older patients or in those with other risk factors for coronary artery disease, a cardiac source should always be considered first, since patients with a known cardiac source of chest pain may also have chest wall tenderness that reproduces their pain [3-5]. (See "Approach to the patient with suspected angina pectoris".)

The diagnosis of musculoskeletal chest pain occurs more frequently among females than males. One study examined the incidence of musculoskeletal chest pain in 122 consecutive patients presenting with chest pain [3]. Of 36 patients diagnosed with costochondritis, 69 percent were female. By comparison, females represented only 31 percent of those presenting with chest pain but without a subsequent diagnosis of costochondritis.

Characteristics of the chest pain — Musculoskeletal chest pain is often insidious and persistent, lasting for hours to days [6]. It is frequently sharp and localized to a specific area (such as the xiphoid, lower rib tips, or midsternum), but in some cases it may be diffuse and poorly localized. Most chest wall pain is positional and is exacerbated by deep breathing, turning, or arm movement. These associations, however, may also be seen in a variety of visceral processes, particularly those involving the pleura and pericardium. Localization of pain, in particular, is not helpful in differentiating musculoskeletal chest pain from chest pain due to other causes [7]. (See "Outpatient evaluation of the adult with chest pain", section on 'Diagnostic approach'.)

Certain characteristics of the chest pain or associated symptoms may suggest a non-musculoskeletal origin (table 3). These include:

●Exertional pain

●Radiation to the neck or arms

●Numbness

●Fever

●Chills

●Cough

●Dyspnea

●Pain localized to atypical areas such as the axilla or midthoracic spine

One large study, done in an outpatient primary care setting, showed that four determinants (localized muscle tension, stinging pain, pain reproducible by palpation, and absence of cough) were associated with a diagnosis of chest wall syndrome (noninflammatory musculoskeletal chest wall pain associated with local or regional tenderness, such as costosternal or costochondral pain syndromes) with 63 percent sensitivity and 79 percent specificity when three or more of these were present [8].

Other musculoskeletal symptoms — The presence of musculoskeletal symptoms in areas other than the chest may alert the clinician to a possible musculoskeletal cause. As examples:

●Pain in the neck, thoracic spine, or even the shoulder may cause pain referred to the chest wall.

●A history of chronic low back pain (particularly in a younger patient with morning stiffness) may suggest ankylosing spondylitis or another spondyloarthropathy which frequently involves the chest wall. A history of ocular inflammation (uveitis, conjunctivitis), psoriasis, or other skin lesions may also be a clue to the presence of a spondyloarthropathy. (See "Diagnosis and differential diagnosis of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults".)

●Chronic widespread musculoskeletal pain associated with sleep disturbance and fatigue is suggestive of fibromyalgia. (See "Clinical manifestations and diagnosis of fibromyalgia in adults".)

●Patients with rheumatoid arthritis may have involvement of the sternoclavicular joints. (See "Diagnosis and differential diagnosis of rheumatoid arthritis".)

PHYSICAL EXAMINATION — The general physical examination should be directed toward detecting abnormalities of the heart, lungs, and abdomen that might cause chest pain. In addition, careful attention to the skin may reveal lesions (sometimes not mentioned by the patient) associated with specific musculoskeletal chest wall syndromes, such as psoriasis, palmoplantar pustulosis, acne, hidradenitis suppurativa, or dissecting cellulitis of the scalp. Symptoms of conjunctivitis or uveitis are typically symptomatic, and an ocular examination should be performed in patients with eye symptoms, including photophobia, eye pain, or eye redness (table 4).

Musculoskeletal examination — The general musculoskeletal examination should begin with an assessment for mobility of the cervical spine and shoulders. The lumbar spine should then be examined for range of motion, particularly any deficit in forward flexion that might suggest ankylosing spondylitis or one of the spondyloarthropathies (figure 1). Discomfort in the posterior pelvic girdle from sacroiliitis should also be sought by compression of the anterior iliac crests or by external rotation of the hip.

In the thoracic spine, tenderness or pain on motion is very suggestive of a musculoskeletal cause of chest pain [9]. Movement of the articulations of the ribs with the thoracic vertebrae (the costovertebral joints) should be assessed by measurement of chest expansion. Chest expansion is measured at the level of the fourth intercostal space, or just below the breasts in females. The patient is instructed to exert a maximal forced expiration followed by a maximal inspiration. The expansion is usually 5 cm or more; an expansion less than 2.5 cm is abnormal. (See "Diagnosis and differential diagnosis of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults".)

Multiple soft tissue and joint sites should be palpated in patients with suspected musculoskeletal chest pain, particularly in those with a history of widespread musculoskeletal pain and a generally normal musculoskeletal examination. In the evaluation of possible fibromyalgia, the enumeration of a specific number of pre-determined "tender points" is no longer required; instead, an estimation of the degree of widespread soft tissue tenderness should be performed based upon tenderness to palpation in different body regions (figure 2 and figure 3 and figure 4). (See "Clinical manifestations and diagnosis of fibromyalgia in adults".)

Ribs and chest wall examination — The most important diagnostic feature in musculoskeletal chest wall syndromes is chest wall tenderness that consistently reproduces the patient's pain [4-6,10]. This finding is generally considered diagnostic for a chest wall syndrome. Many chest wall syndromes are defined on the basis of the location of areas of tenderness. (See "Major causes of musculoskeletal chest pain in adults", section on 'Isolated musculoskeletal chest pain syndromes'.)

Examination of the ribs and chest wall begins with an assessment for areas of localized swelling, such as the sternoclavicular joints and upper costochondral junctions. The articulations at either end of the clavicle (acromioclavicular and sternoclavicular joints) should then be palpated. Along the course of the sternum in the midline, tenderness may be found beside the sternalis muscle, the manubriosternal and xiphisternal joints, or the xiphoid process. In addition, tenderness should be sought at the costochondral junctions along both sides of the sternum and over the lower rib tips laterally. In the posterior thorax, costovertebral joint dysfunction may be assessed by palpation over the areas just lateral to the vertebral bodies or over the affected rib.

In addition to direct palpation, various maneuvers have been utilized to reproduce chest wall pain. These include the “crowing rooster” maneuver, horizontal arm flexion, and the “hooking” maneuver [5,10].

●The “crowing rooster” maneuver is done with the clinician standing behind the patient and exerting traction on the upper arms by pulling them backward and slightly superiorly (figure 5). (See "Major causes of musculoskeletal chest pain in adults", section on 'Costosternal syndromes (costochondritis)'.)

●In horizontal arm flexion, the arm is flexed across the anterior chest and steady, prolonged traction is applied in a horizontal direction (figure 6). Both horizontal arm flexion and the “crowing rooster” maneuver may be done at the same time as neck extension or rotation.

●The “hooking” maneuver, helpful in diagnosing “slipping rib syndrome" (SRS), is done by hooking the fingers under the anterior costal margins and pulling the rib cage anteriorly (figure 7) [11]. (See "Major causes of musculoskeletal chest pain in adults", section on 'Lower rib pain syndromes'.)

As with palpation, findings with all three of these maneuvers should be considered diagnostic only if the patient’s presenting pain is reproduced.

DIAGNOSTIC APPROACH — The choice of laboratory and other diagnostic studies in a patient with an apparent musculoskeletal chest wall syndrome is directed by the history and physical examination.

In the young, healthy patient with pain of relatively short duration and with a normal general physical examination, the likelihood of an underlying visceral or systemic illness is low; laboratory and radiographic evaluation is, therefore, unlikely to be fruitful in this setting. By comparison, in older patients or in those with persistent pain, fever, cough, weight loss, abdominal symptoms, or chronic medical illnesses, visceral processes should be excluded before chest wall syndromes are considered.

In addition, in any patient with a suspected systemic process, laboratory tests and chest radiography are indicated. Scintigraphy may be most useful in patients with diffuse pain and tenderness in whom ankylosing spondylitis or SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis, formerly known as sternocostoclavicular hyperostosis [SCCH]) is suspected, or when an area of localized tenderness is found without swelling. Areas of localized swelling in the area of the sternoclavicular joint should be aspirated, and cell counts and cultures should be obtained. Other areas of localized swelling are best visualized by computed tomography (CT), with special attention to soft tissue and bony structures. One of these advanced imaging studies is also recommended if there is proven sternoclavicular joint infection.

Laboratory and radiographic studies have three major purposes in the evaluation of a patient with suspected musculoskeletal chest wall pain (table 5):

●To evaluate the patient’s general health and to exclude cardiac, pulmonary, and abdominal sources of pain

●To determine whether a suspected chest wall syndrome might be associated with a specific rheumatic disease

●To directly assess an anatomic area of the chest wall or surrounding structures

The evaluation in such patients should consist of a complete blood count, routine chemistries (including serum creatinine concentration), urinalysis, a chest radiograph, and an electrocardiogram. A more complete evaluation for coronary disease is often indicated in patients with risk factors for coronary disease, even if the chest pain is atypical. (See "Approach to the patient with suspected angina pectoris".)

In most rheumatic diseases in which the chest wall is involved, the diagnosis is based upon the pattern of joint involvement outside the chest, extraarticular features, and laboratory abnormalities (table 5). As an example, the erythrocyte sedimentation rate (ESR) is a relatively nonspecific test for inflammatory disease which is elevated in a majority of patients with septic arthritis, active rheumatoid arthritis, ankylosing spondylitis, and other spondyloarthropathies. An elevated ESR is not as predictable in psoriatic arthritis or sternocostoclavicular hyperostosis.

●In patients with unexplained arthritis of the sternoclavicular joint, an evaluation for rheumatoid factor is indicated, since some patients with rheumatoid arthritis present with an atypical, monoarticular pattern of arthritis. (See "Clinical manifestations of rheumatoid arthritis".)

●In patients with pain or stiffness in the lower or upper back, with evidence of sacroiliac tenderness, or with limited lumbar flexion or chest expansion on examination, radiographs of the sacroiliac joints are the initial step in evaluation for ankylosing spondylitis or another of the spondyloarthropathies. In most cases, irregularity, narrowing, or sclerosis will suggest sacroiliac inflammation. When sacroiliac films are equivocal, checking for human leukocyte antigen (HLA)-B27 may be useful in increasing or decreasing the likelihood of diagnosing these conditions. (See "Diagnosis and differential diagnosis of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults".)

●In patients with obvious swelling and erythema of an isolated joint (usually the sternoclavicular joint), aspiration and synovial fluid analysis should be attempted (see "Monoarthritis in adults: Etiology and evaluation"). In this uncommon situation, an infectious process should be the initial concern, and cultures should be the first studies obtained, with a cell count done on any remaining fluid. In patients with negative cultures and a strong suspicion for an infectious process, a repeat aspiration and cultures for atypical organisms, such as mycobacteria and fungi, should be obtained. Direct biopsy of areas of persistent swelling and tenderness may be necessary to definitively diagnose atypical infections or primary or metastatic neoplasms of the chest wall. (See "Synovial fluid analysis".)

Radiographic studies of the chest wall — The radiologic evaluation of the anterior chest wall in patients with different musculoskeletal disorders presents difficulties due to the anatomic complexity of the region and the variability of the radiographic findings [12,13]. The integrated use of plain radiography, computed tomography (CT), magnetic resonance imaging (MRI), nuclear scintigraphy, and ultrasonography may be needed to fully define abnormalities and to allow for clinical correlation [14]. In particular, imaging of the sternoclavicular joint may reveal findings characteristic of a number of different conditions that may be associated with musculoskeletal chest pain [15].

●Plain radiographs – Plain radiographs of the ribs can detect localized tumors (primary or metastatic) or fractures; however, subsequent films may be needed in up to one-half of patients with fractures to confirm a diagnosis.

●Scintigraphy – Nuclear scintigraphy may show increased uptake in involved areas in inflammatory syndromes, after trauma, or with tumors; these studies are usually normal with the common localized chest wall syndromes when not associated with a more generalized arthropathy. As a result, a positive bone scan in the rib cage area increases the possibility of ankylosing spondylitis, SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis, formerly known as sternocostoclavicular hyperostosis [SCCH]), rheumatoid arthritis, or infection (image 1) [16-19]. In addition, bone infarcts of the ribs may be seen in patients with chest pain in sickle cell crisis [20]. Experience in interpreting scintigraphy is essential in differentiating abnormal tracer uptake from variable areas of uptake seen in this area in asymptomatic healthy people [21]. (See "Clinical manifestations of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults", section on 'Musculoskeletal imaging' and "SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome" and "Clinical manifestations of rheumatoid arthritis" and "Acute and chronic bone complications of sickle cell disease".)

●CT and MRI – CT is extremely useful in further characterizing lesions of the sternoclavicular joint or sternum and may be needed when a pulmonary or pleural-based lesion is suspected on clinical grounds. The multidetector CT scan (MDCT), using pulmonary embolism, aortic dissection, or coronary artery protocols, may be very useful in imaging of the musculoskeletal structures of the chest wall [22]. Important normal variants of the sternum and findings of osteoarthritis seen on CT need to be differentiated from findings of pathologic significance [23,24]. Identification of an associated soft tissue mass is important in distinguishing destructive lesions due to infection or neoplasm from normal areas of cortical irregularity. The lesions of SAPHO syndrome are seen earliest in the periosteal and ligamentous structures, with relative sparing of the sternoclavicular joint [25-27], and spinal imaging shows vertebral body lesions and paravertebral ossifications in most patients [28].

Although several descriptions of MRI studies of the chest wall have been reported, the role of this technique has not been fully defined in this setting [29,30]. MRI findings described in a series of patients with Tietze’s syndrome include enlargement and thickening of cartilage at the site of complaint, focal or widespread increased signal intensities of affected cartilage on both T2 and short tau inversion recovery (STIR)-weighted images, bone marrow edema in the subchondral bone, and gadolinium uptake in cartilage and subchondral bone marrow. It is unclear whether these findings might be more characteristic of the closely related SAPHO syndrome [31,32].

Erosive changes of the corners of vertebral bodies appear to be a consistent finding in patients with SAPHO syndrome with vertebral involvement [33]. Chest CT or MRI should be considered in patients with sternoclavicular joint infections to better define the extent of soft tissue involvement in nearby structures [34]. (See "SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome", section on 'Musculoskeletal imaging features' and "Major causes of musculoskeletal chest pain in adults", section on 'Tietze's syndrome'.)

●Ultrasound – Ultrasound study of the sternoclavicular joint has been evaluated in patients with rheumatoid arthritis and SAPHO syndrome and may be useful for the detection of synovitis, increased blood flow, erosions, and osteophytes in these joints in patients with rheumatoid arthritis [35,36]. Dynamic ultrasound of the ribs, particularly with crunch and push maneuvers, can be an effective in diagnosing “slipping rib syndrome” [37].

SUMMARY AND RECOMMENDATIONS

●Clinical history – The evaluation of patients with an apparent musculoskeletal chest wall pain syndrome is directed by the history and physical exam (table 2 and table 3). Demographic features, characteristics of the chest pain, and associated symptoms may favor the diagnosis of musculoskeletal chest pain or may suggest other causes of chest discomfort. (See 'History' above.)

●Physical examination – The general physical examination should be directed toward detecting abnormalities of the heart, lungs, and abdomen that might cause chest pain; cutaneous lesions that may be associated with specific musculoskeletal chest wall syndromes; and ocular disease (table 4).

•The musculoskeletal examination should focus on the neck, shoulders, back, and chest, and an examination for evidence of fibromyalgia should be performed. (See 'Physical examination' above and 'Musculoskeletal examination' above.)

•The most important diagnostic feature in musculoskeletal chest wall syndromes is chest wall tenderness that consistently reproduces the patient’s pain. This finding is generally considered diagnostic for a chest wall syndrome, many of which are defined based upon the location of areas of tenderness. (See 'Ribs and chest wall examination' above.)

●Laboratory and radiographic evaluation

•Healthy young patients with tender areas, but without swelling or other musculoskeletal or systemic findings, can usually be managed without any other further laboratory studies. Older patients or those with persistent pain, fever, cough, weight loss, abdominal symptoms, or chronic medical illnesses should have a complete blood count, routine chemistries, urinalysis, a chest radiograph, and an electrocardiogram. A more complete evaluation for coronary disease is often indicated in patients with risk factors for coronary disease, even if the chest pain is atypical. (See 'Diagnostic approach' above.)

•The major purposes of laboratory and radiographic studies in the evaluation of a patient with suspected musculoskeletal chest wall pain are to evaluate the patient’s general health and to exclude cardiac, pulmonary, and abdominal sources of pain; to determine whether a suspected chest wall syndrome might be associated with a specific rheumatic disease; and to directly assess an anatomic area of the chest wall or surrounding structures. In most rheumatic diseases in which the chest wall is involved, the diagnosis is based upon the pattern of joint involvement outside the chest, extraarticular features, and laboratory abnormalities (table 5). (See 'Diagnostic approach' above.)

•The integrated use of different imaging studies may be needed to fully define abnormalities and to allow for clinical correlation because of the anatomic complexity of the region and the variability of the imaging findings. In particular, imaging of the sternoclavicular joint may reveal findings characteristic of a number of different conditions that may be associated with musculoskeletal chest pain. (See 'Radiographic studies of the chest wall' above.)