• Chest wall pain accounts for up to a quarter of all patients in the ED who present with chest pain.
• Recommend an anatomic approach and classifying as traumatic or nontraumatic.
• Non-traumatic types of chest wall pain can be divided into the following 3 categories:

• Traumatic chest wall injury causing chest wall pain includes the following differential diagnosis:
  • Osseous fracture(s), costochondral tear, nerve laceration, and soft tissue injuries (lacerations, muscle strains and contusions).

Clinical findings associating with chest wall pain:

• At least 2 of the following: A. localized muscle tension; B. pain reproducible by palpation; C. stinging pain; D. absence of cough.

Differentiating features for non-traumatic chest wall pain in history:

Table adapted from UptoDate

Physical examination for chest wall pain:

Table adapted from UptoDate

Investigations to consider:

• General: CBC, liver enzymes, renal function tests, urinalysis, chest radiography, ECG, other cardiac studies.
• Rheumatologic: ESR/CRP, rheumatoid factor, synovial fluid analysis and culture.
• Chest wall: rib, sternoclavicular and/or manubriosternal joint radiographs, CT imaging.
• Systemic non-rheumatologic disease: CT chest with or without IV contrast.

Clinical pitfalls:

• Chest wall pain does not exclude more serious and potentially life-threatening disorders:
• Ischemic heart disease
  • Most common critical diagnosis not to miss.
  • HEART Score.
  • Classic symptoms and risk factors but can be atypical in elderly.
  • Usually little to find on exam.
  • ECG but may need serial troponins.
• Pulmonary embolism
  • Risk factors – many have no known risk factor.
  • Classic: sudden pleuritic CP and dyspnea.
  • Syncope, persistent tachycardia.
  • Use Wells and/or PERC Rules.
  • D Dimer useful in low clinical suspicion.
  • POCUS legs for DVT/cardiac for RV strain.
• Thoracic Aortic Dissection
  • Risk factors = HTN; connective tissue disorder; late term pregnancy.
  • Syncope.
  • 1/3 have neurological deficits.
  • Pulse deficit; new murmur of aortic regurgitation.
  • CXR if low clinical suspicion.
  • POCUS/CT.
• Boerhaave’s Syndrome
  • Alcoholic (even without hx vomiting); recent scope/NG tube.
  • CXR.
• Cardiac Tamponade
  • Becks Triad – muffled hrt sounds, Elevated JVP, Hypotension.
  • POCUS.
• Tension Pneumothorax
  • POCUS.
• Incarcerated Diaphragmatic Hernia
  • CXR, CT chest.

• ALSO consider:
  • Cholecystitis
  • Pericarditis
  • Pyelonephritis
  • Pneumonia

Other benign causes:

• Costochondritis (Tietze’s syndrome)
  • Use caution when making this diagnosis – reserve it for classic presentations where there is clear marked tenderness over the costochondral joints.
  • NSAIDs should improve pain and tenderness.
    • ECG and CXR should be negative.
• GERD (Gastroesophageal reflux disease)
  • Usually also have epigastric tenderness, provoked by food, alleviated by antacids.
• Esophageal spasm
  • Clinical suspicion and response to Rx (Nitroglycerin) and negative cardiac WU if indicated.
• Psychogenic
  • Anxiety and depression are very common in patients with chest pain.
  • Try not to label pain as psychogenic in the ED setting,
• It is important to confirm that the patient is not experiencing chest pain due to any life threatening condition before proceeding to management of the chest wall tenderness.

Approach to initial management:

• For trauma cases, evaluate for life threatening intrathoracic and intraabdominal injuries.
  • abnormal vital signs, penetrating injury, altered mental status.
• Analgesics for pain relief
  • Mild isolated chest wall pain (does not interfere with light activity)
    • Acetaminophen (1^st line) 1000 mg TID/QID maximum in adults.
    • And/or an NSAID (naproxen over ibuprofen) in low to moderate dose:
      • Ibuprofen 200-400 mg TID with food/glass of water.
      • Naproxen 220-250 mg BID-TID with food/glass of water.
    • Topical analgesics (capsaicin cream, salicylate-containing gel, diclofenac gel, lidocaine patch) may be added for a trial period up to 2 weeks to determine efficacy and discontinued if there is no benefit.
  • Moderate chest wall pain (interferes with light to moderate activity)
    • higher doses of naproxen or ibuprofen
      • Ibuprofen 600-800 mg TID with food/glass of water.
      • Naproxen 500 mg BID with food/glass of water.
    • If a maximum acceptable dose of a particular NSAID has no benefit or becomes less effective, it is recommended to switch the class of NSAID.
  • Severe chest wall pain (interferes with activities of daily living) – may need short course of narcotics. Avoid if possible.
  • Gabapentin/pregapalin, cyclobenzaprine, and duloxetine may be tried if already taking above meds. Weak evidence for benefit. Should see effect in 2 weeks – reassessment with health care provider.

Cautions:

• NSAIDs
  • For patients at high risk of GI toxicity, alternative medication is vimovo or arthrotec, use of a selective COX-2 inhibitor (Celecoxib) or prophylactic PPI or misoprostol to prevent gastroduodenal damage.
• Muscle relaxants are not recommended for older adult patients (age ≥ 65) with chest wall pain due to increased risk of adverse events.

Discharge notes:

• Patients with chest wall pain due to minor injuries or non-life threatening etiologies, and those at low risk of complications may be discharged following appropriate work-up and advised to return to the emergency department if there are new concerning symptoms (ex. shortness of breath, sudden increase in pain).
• A common patient concern is the assumption that their pain is due to heart disease, therefore, all patients should receive reassurance and education regarding their condition.

1. Wise, C.M. (2021). Major causes of musculoskeletal chest pain in adults. UptoDate. Retrieved April 15^th, 2022.

   
   

2. Wise, C.M. (2022). Clinical evaluation of musculoskeletal chest pain. UptoDate. Retrieved April 15^th, 2022.