Musculoskeletal Chest Wall Pain
MCWP
What percent of chest wall pain
is musculoskeletal in children?
General Incidence (MCWP)
• In the emergency
department,
approximately 10 to 15
percent of adults and
20 to 25 percent of
children presenting
with chest pain have a
musculoskeletal cause.
Describe some general features
of MCWP?
General features of MCWP
• Onset: often insidious,
with history of minor or
repetitive trauma or
unaccustomed physical
activity.
• Pain: often sharp,
nagging and localized to
the affected site but may
radiate widely.
General features of MCWP
Positional component:
pain brought on by
changes in position,
turning of the chest, deep
breathing or movements
of the shoulder girdle.
General features of MCWP
• Modulating factors:
duplication of pain by
movements involving
the painful area or
chest wall palpation;
relief by local
application of heat or
use of NSAID
General - MCWP
• painful areas are found
in zones of muscular or
tendinous insertions on
the bones, or on
cartilage or mobile
zones of bone-cartilage
transitions, such as the
costochondral
junctions.
General - MCWP
linical characteristics of Chest Wall Syndrome (CWS) versus the other conditions
causing chest pain
The six most discriminative clinical
characteristics of CWS
Logistic regression Odd Ratio (IC95%)1
Pain is
- not squeezing nor oppressive
- localised on the left or median-left part
of the chest wall
2.53 (1.21–5.28)
2.28 (1.58–3.28)
- well localised on the chest wall
2.10 (1.37–3.22)
- non exercise-induced chest pain
1.58 (1.00–2.49)
- influenced by mechanical factors2
1.54 (1.06–2.24)
- reproducible by palpation
5.72 (1.20–5.28)
Clinical factors significantly associated with having a CWS were identified in univariate
analysis then introduced in a multiple logistic regression
2A movement or a body position
1
General - MCWP
• History and sensibility to palpation were the keys for
diagnosis.
• Pain was generally moderate, well localized, continuous or
intermittent over a number of hours to days or weeks, and
amplified by position or movement.
• The pain however, may be acute. May be at several painful
sites, and if at a single site, most frequently in the midline or
a left-sided site.
• Pain was a cause of anxiety and cardiac concern, especially
when acute. CWS coexisted with coronary disease in 19 and
neoplasm in 6.
• Outcome at one year was favorable even though CWS
recurred in half of patients.
General - MCWP
• MCWP is a frequent condition with good prognosis, low morbidity
and no mortality.
• Evolution has only been negative in cases of misdiagnosis, mainly
in the presence of malignant conditions or in cases of coincidental
diseases such as heart or neoplasic disease or pneumonitis.
• Nevertheless, this condition tends to recur.
•
It also causes real anxiety and frequently suggests to the patient
the possibility of heart disease. Moreover, in a few cases, it is
difficult to distinguish between coronary heart disease and CWS
on a clinical basis partly because the majority of chest wall pain is
left-sided.
What is Tietze Syndrome?
Tietze Syndrome
is a benign inflammation of one or more of the
costal cartilages. It was first described in 1921
by the German surgeon Alexander Tietze
(1864–1927)
Tietze Syndrome
• usually comes on abruptly, with chest pain
radiating to your arms or shoulder and lasting
several weeks.
• is accompanied by a localized swelling at the
painful area (the junction of the ribs and
breastbone).
Tietze Syndrome
• is differentiated from costochondritis by
swelling of the costal cartilages, which does
not appear in costochondritis.
• It, like costochondritis, was at one time
thought to be associated with, or caused by,
a viral infection acquired during surgery. This
is now known not to be the case, as most
sufferers have not had recent surgery.
Tietze’s Syndrome
• While the true causes of Tietze's Syndrome are not well
understood, it often results from a physical strain or minor
injury, such as repeated coughing, sneezing, vomiting, or
impacts to the chest.
• It has even been known to occur after hearty bouts of
laughter.
• It can occur by over exerting or by an injury in the chest and
breast.
Tietze's Syndrome
• The primary presentation of the syndrome is significant, acute
pain in the chest, along with tenderness and some swelling of the
cartilages affected, which is commonly palpable on examination.
• Although many times it can be extremely painful, to the point of
being debilitating, Tietze's Syndrome is considered to be a benign
condition that generally resolves in 12 weeks.
•
However, it can often be a chronic condition.
•
The pain can be identical to a heart attack and can cause hyper
ventilating, anxiety attacks, passing out, panic attacks and
temporary numbness/paralysis.
What is costochrondritis?
Costochondritis
• is a self-limiting condition of unknown aetiology that typically
presents with pain around the second to fifth costochondral
joints.
• It can be differentiated from Tietze's syndrome in which there is
swelling and pain of the articulation.
• Both conditions eventually settle spontaneously although a
corticosteroid injection may be useful in particularly troublesome
cases.
• The intercostal muscles may be injured causing tenderness
between the ribs.
Costochondritis
• Inflammation of the junctions where the upper ribs join with the
cartilage that holds them to the breastbone or sternum.
• The condition causes localized chest pain that you can reproduce
by pushing on the cartilage in the front of your rib cage.
• Relatively harmless condition and usually goes away without
treatment.
• The cause is usually unknown.
• Affects females more often than males (70% versus 30%).
Costochondritis
• (with unknown cause) is a common cause of
chest pain in children and adolescents.
• It accounts for 10% to 30% of all chest pain in
children.
• Annually, doctors evaluate about 650,000
cases of chest pain in young people 10-21
years of age.
• The peak age for the condition is 12-14 years.
What is manubriosternal joint
pain?
Manubriosternal Joint Pain
• can serve as a source of pain
that often mimics the pain of
cardiac origin.
• The manubrium articulates
with the body of the sternum
via the manubriosternal joint.
• The joint articulates at an
angle called the angle of
Louis, which allows for easy
identification.
Manubriosternal Joint Pain
• The joint is a fibrocartilaginous
joint, or synchondrosis, that
lacks a true joint cavity.
• The manubriosternal joint allows
protraction and retraction of the
thorax. Above, the manubrium
articulates with the sternal end
of the clavicle and the cartilage
of the first rib.
• Below, the body of the sternum
articulates with the xiphoid
process. Posterior to the
manubriosternal joint are the
structures of the mediastinum.
Manubriosternal Joint Pain
• The manubriosternal joint
is susceptible to the
development of arthritis,
including osteoarthritis,
rheumatoid arthritis,
ankylosing spondylitis,
Reiter's syndrome, and
psoriatic arthritis. The joint
is often traumatized during
acceleration/deceleration
…
What is pectus carinatum?
Pectus carinatum*
• incidence of 1:1000 teenagers,
is oligosymptomatic. However,
for aesthetic and emotional
reasons, it accounts for a large
number of medical
appointments. Such patients
are introverted and do not
engage in physical activities,
since they are unwilling to
expose their chest, which also
discourages them from going
to the beach or to swimming
pools. The diagnosis is clinical
and visual, and details are
obtained through chest X-rays
Dislocation
What is sternalis syndrome?
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.
Sternum Stress fractures
• Stress fractures of the
sternum reported in
wrestlers cause pain
and tenderness of the
sternum
What is xiphoid syndrome?
Xiphoidalgia or Xiphoidynia or
Xiphoid Syndrome
• is also a rare syndrome
with localized pain and
tenderness over the
xiphoid
• The word derives from
the Greek word xiphos
for straight sword, the
tip of which the process
somewhat resembles.
xiphoid process, or xiphisternum or
metasternum
• is a small cartilaginous process (extension) of the
lower part of the sternum which is usually ossified in
the adult human.
• By age 15 to 29, the xiphoid usually fuses to the body
of the sternum with a fibrous joint.
• Unlike the synovial articulation of major joints, this is
non-movable.
• Much the way the first seven ribs articulate with the
sternum, the cartilage in the celiac plexus joins on the
xiphoid process, reinforcing it, and indirectly attaches
the costal cartilage to the sternum.
Xiphoid Syndrome
• Pain and discomfort that occurs in the lowest
portion of the sternum called the xiphoid
process.
• The symptoms may occur sporadically or be
associated with conditions such as heart
disease, gallbladder disease and bone
disease.
• Certain movements (bending, lifting) or
eating large meals may precipitate an attack.
Xiphoidalgia — Xiphoidalgia
(xiphoidynia)
• is another relatively rare syndrome that is characterized by
localized discomfort and tenderness over the xiphoid
process of the sternum
• 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.
• Analgesics or local injection of an anesthetic-steroid
combination are frequently curative [17,18].
What is slipping rib syndrome?
Slipping Rib Syndrome
• causes intermittent
costal margin pain
related to posture or
movement, and may be
diagnosed by the
'hooking manoeuvre',
which reproduces pain
and sometimes a click.
Slipping Rib Syndrome
• described by Davies Colley in 1922, slipping rib
syndrome is characterized by a dull ache lasting hours
or days that is punctuated by intermittent, sharp,
stabbing pain and precipitated by certain postures
and movements.
• 128-129 The 8th, 9th, and 10th ribs (false ribs) are not
attached to the sternum; they are connected
anteromedially by fibrous tissue.
• Pain results from inadequate stabilization of the rib
tips, allowing them to move upward and posteriorly,
impinging upon the superior intercostal nerve. In
some cases, this disruption may be posttraumatic.
Slipping Rib Syndrome
• “hooking” maneuver: grabbing under the costal
margin and pulling anteriorly.132 Treatment
consists of reassurance and NSAIDs.
• Persistent symptoms may be managed with
local anesthetic injections or surgical resection
in recalcitrant cases.
• As with many unusual conditions, the key to
successful management is making the correct
diagnosis.
What is fibromyalgia?
Fibromyalgia
• a common chronic
musculoskeletal pain
syndrome that presents
with diffuse myalgias,
multiple tender points,
sleep disturbance, and
fatigue.
• Many patients report
tenderness over the
second costochondral
junctions.
Lower rib pain syndrome
• goes 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.
What is devils grip?
Devil's Grip
• Symptoms may include fever and headache, but the
distinguishing characteristic of this disease is attacks of
severe pain in the lower chest, often on one side.
• The slightest movement of the rib cage causes a sharp
increase of pain, which makes it very difficult to breathe,
and an attack is therefore quite a frightening experience,
although it generally passes off before any actual harm
occurs.
• The attacks are unpredictable and strike "out of the blue"
with a feeling like an iron grip around the rib cage.
Devil's Grip
• The illness lasts about a week and is rarely fatal.
• Treatment includes the administration of nonsteroidal antiinflammatory agents or the application of heat to the
affected muscles.
• Relapses during the weeks following the initial episode are a
characteristic feature of this disease.
• Boerhaave’s Syndrome
What is precordial catch
syndrome?
Precordial Catch Syndrome
• or Texidor’s twinge,( named after T.A. Texidor) serves as a
descriptive term for a brief, intense left precordial chest pain that
is common in the young. The best description was that of Richard
Asher:
• “Have any of you ever had a very brief, sharp, needle-like pain,
near the apex of the heart, acutely localized to one point
seemingly inside the chest wall, but feeling as if something was
adherent to it?
•
Breathing sharpens it, so there is often a disinclination to take a
deep breath while it lasts.
•
It comes on out of the blue, it passes off in a few minutes, and
although acute it is not at all distressing.”
Precordial Catch Syndrome
It is nonexertional and may be
exacerbated with inspiration before
it resolves less than a minute later.
Others note that it is extremely
localized, with a sudden onset and
resolution, lasting less than a couple
of minutes.
The etiology is unknown but the
prognosis for a long and fruitful life
is excellent.
Name three types of neuropathic
chest wall pain?
Chest Wall Neuropathic Pain
• Thoracic radiculopathy
• Postherpetic
neuropathy
• Intercostal neuralgia
• Diagnosis is one of
exclusion
• After surgery
(thoracotomy)
Treat?
Like all neuropathic pain
Physiatrist Prescription for
MCWP?
Summary