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. 1985 Sep 1;133(5):379–389.

Musculoskeletal chest wall pain

Adel G Fam, Hugh A Smythe
PMCID: PMC1346531  PMID: 4027804

Abstract

The musculoskeletal structures of the thoracic wall and the neck are a relatively common source of chest pain. Pain arising from these structures is often mistaken for angina pectoris, pleurisy or other serious disorders. In this article the clinical features, pathogenesis and management of the various musculoskeletal chest wall disorders are discussed. The more common causes are costochondritis, traumatic muscle pain, trauma to the chest wall, “fibrositis” syndrome, referred pain, psychogenic regional pain syndrome, and arthritis involving articulations of the sternum, ribs and thoracic spine. Careful analysis of the history, physical findings and results of investigation is essential for precise diagnosis and effective treatment.

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Selected References

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  1. ARLET J., FICAT P. Osteo-arthritis of the sterno-clavicular joint. Ann Rheum Dis. 1958 Mar;17(1):97–100. doi: 10.1136/ard.17.1.97. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Ahles T. A., Yunus M. B., Riley S. D., Bradley J. M., Masi A. T. Psychological factors associated with primary fibromyalgia syndrome. Arthritis Rheum. 1984 Oct;27(10):1101–1106. doi: 10.1002/art.1780271004. [DOI] [PubMed] [Google Scholar]
  3. Anderson I. F., Corrigan A. B., Champion G. D. Rib erosions in rheumatoid arthritis. Ann Rheum Dis. 1972 Jan;31(1):16–21. doi: 10.1136/ard.31.1.16. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Arkin C. R., Masi A. T. Relapsing polychondritis: review of current status and case report,. Semin Arthritis Rheum. 1975 Aug;5(1):41–62. doi: 10.1016/0049-0172(75)90022-0. [DOI] [PubMed] [Google Scholar]
  5. Awad E. A. Interstitial myofibrositis: hypothesis of the mechanism. Arch Phys Med Rehabil. 1973 Oct;54(10):449–453. [PubMed] [Google Scholar]
  6. BAKER H., GOLDING D. N., THOMPSON M. Psoriasis and arthritis. Ann Intern Med. 1963 Jun;58:909–925. doi: 10.7326/0003-4819-58-6-909. [DOI] [PubMed] [Google Scholar]
  7. BLACKMAN N. S. Slipping rib syndrome with review of related anterior chest wall syndromes. N Y State J Med. 1963 Jun 1;63:1670–1675. [PubMed] [Google Scholar]
  8. Bayer A. S., Chow A. W., Louie J. S., Guze L. B. Sternoarticualr pyoarthrosis due to gram-negative bacilli. Report of eight cases. Arch Intern Med. 1977 Aug;137(8):1036–1040. [PubMed] [Google Scholar]
  9. Beetham W. P., Jr Diagnosis and management of fibrositis syndrome and psychogenic rheumatism. Med Clin North Am. 1979 Mar;63(2):433–439. doi: 10.1016/s0025-7125(16)31708-4. [DOI] [PubMed] [Google Scholar]
  10. Berges P. U. Myofascial pain syndromes. Postgrad Med. 1973 May;53(6):161–168. doi: 10.1080/00325481.1973.11713466. [DOI] [PubMed] [Google Scholar]
  11. Boland E. W. Psychogenic Rheumatism: The Musculoskeletal Expression of Psychoneurosis. Ann Rheum Dis. 1947;6(4):195–203. [PMC free article] [PubMed] [Google Scholar]
  12. Brower A. C., Sweet D. E., Keats T. E. Condensing osteitis of the clavicle: a new entity. Am J Roentgenol Radium Ther Nucl Med. 1974 May;121(1):17–21. doi: 10.2214/ajr.121.1.17. [DOI] [PubMed] [Google Scholar]
  13. CARABASI R. J., CHRISTIAN J. J., BRINDLEY H. H. Costosternal chondrodynia: a variant of Tietze's syndrome? Dis Chest. 1962 May;41:559–562. doi: 10.1378/chest.41.5.559. [DOI] [PubMed] [Google Scholar]
  14. CONDON W. B., HARPER F. R. Tumors of the chest wall. Dis Chest. 1950 Jun;17(6):741–755. doi: 10.1378/chest.17.6.741. [DOI] [PubMed] [Google Scholar]
  15. COOPER A. L. Trigger-point injection: its place in physical medicine. Arch Phys Med Rehabil. 1961 Oct;42:704–709. [PubMed] [Google Scholar]
  16. Calabro J. J. Costochondritis. N Engl J Med. 1977 Apr 21;296(16):946–947. [PubMed] [Google Scholar]
  17. Calabro J. J., Jeghers H., Miller K. A., Gordon R. D. Classification of anterior chest wall syndromes. JAMA. 1980 Apr 11;243(14):1420–1421. [PubMed] [Google Scholar]
  18. Campbell S. M., Clark S., Tindall E. A., Forehand M. E., Bennett R. M. Clinical characteristics of fibrositis. I. A "blinded," controlled study of symptoms and tender points. Arthritis Rheum. 1983 Jul;26(7):817–824. doi: 10.1002/art.1780260701. [DOI] [PubMed] [Google Scholar]
  19. Cone R. O., Resnick D., Goergen T. G., Robinson C., Vint V., Haghighi P. Condensing osteitis of the clavicle. AJR Am J Roentgenol. 1983 Aug;141(2):387–388. doi: 10.2214/ajr.141.2.387. [DOI] [PubMed] [Google Scholar]
  20. Dunlop R. F. Tietze revisited. Clin Orthop Relat Res. 1969 Jan-Feb;62:223–225. [PubMed] [Google Scholar]
  21. Epstein S. E., Gerber L. H., Borer J. S. Chest wall syndrome. A common cause of unexplained cardiac pain. JAMA. 1979 Jun 29;241(26):2793–2797. doi: 10.1001/jama.241.26.2793. [DOI] [PubMed] [Google Scholar]
  22. Fallet G. H., Arroyo J., Vischer T. L. Sternocostoclavicular hyperostosis: case report with a 31-year followup. Arthritis Rheum. 1983 Jun;26(6):784–790. doi: 10.1002/art.1780260613. [DOI] [PubMed] [Google Scholar]
  23. Fam A. G., Shuckett R., McGillivray D. C., Little A. H. Stress fractures in rheumatoid arthritis. J Rheumatol. 1983 Oct;10(5):722–726. [PubMed] [Google Scholar]
  24. Flynn K. T. Musculoskeletal chest wall pain. Nurse Pract. 1981 Jan-Feb;6(1):18-23, 27. [PubMed] [Google Scholar]
  25. Forestier J., Lagier R. Ankylosing hyperostosis of the spine. Clin Orthop Relat Res. 1971 Jan;74:65–83. [PubMed] [Google Scholar]
  26. GOOD A. E. The chest pain of ankylosing spondylitis. Its place in the differential diagnosis of heart pain. Ann Intern Med. 1963 Jun;58:926–937. doi: 10.7326/0003-4819-58-6-926. [DOI] [PubMed] [Google Scholar]
  27. Gill G. V. Epidemic of Tietze's syndrome. Br Med J. 1977 Aug 20;2(6085):499–499. doi: 10.1136/bmj.2.6085.499. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Gouliamos A. D., Carter B. L., Emami B. Computed tomography of the chest wall. Radiology. 1980 Feb;134(2):433–436. doi: 10.1148/radiology.134.2.7352225. [DOI] [PubMed] [Google Scholar]
  29. HARWOOD STEVENSON F. Nerve nipping at the intercostal margin. Lancet. 1951 Nov 24;2(6691):969–970. doi: 10.1016/s0140-6736(51)91930-7. [DOI] [PubMed] [Google Scholar]
  30. HUEBNER R. J., RISSER J. A., BELL J. A., BEEMAN E. A., BEIGELMAN P. M., STRONG J. C. Epidemic pleurodynia in Texas; a study of 22 cases. N Engl J Med. 1953 Feb 12;248(7):267–274. doi: 10.1056/NEJM195302122480701. [DOI] [PubMed] [Google Scholar]
  31. Haenel L. C., Bradway W. R., Costantini P. J. Thrombophlebitis complicating sternocostoclavicular hyperostosis. Postgrad Med. 1980 Nov;68(5):113-5, 117-8. doi: 10.1080/00325481.1980.11715594. [DOI] [PubMed] [Google Scholar]
  32. Hamberg J., Lindahl O. Angina pectoris symptoms caused by thoracic spine disorders. Clinical examination and treatment. Acta Med Scand Suppl. 1981;644:84–86. doi: 10.1111/j.0954-6820.1981.tb03130.x. [DOI] [PubMed] [Google Scholar]
  33. Harris J., Carter A. R., Glick E. N., Storey G. O. Ankylosing hyperostosis. I. Clinical and radiological features. Ann Rheum Dis. 1974 May;33(3):210–215. doi: 10.1136/ard.33.3.210. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Heinz G. J., Zavala D. C. Slipping rib syndrome. JAMA. 1977 Feb 21;237(8):794–795. [PubMed] [Google Scholar]
  35. Jelenko C., 3rd Tietze's syndrome at the xiphisternal joint. South Med J. 1974 Jul;67(7):818–820. doi: 10.1097/00007611-197407000-00017. [DOI] [PubMed] [Google Scholar]
  36. Jirik F. R., Stein H. B., Chalmers A. Clavicular hyperostosis with enthesopathy, hypergammaglobulinemia, and thoracic outlet syndrome. Ann Intern Med. 1982 Jul;97(1):48–50. doi: 10.7326/0003-4819-97-1-48. [DOI] [PubMed] [Google Scholar]
  37. KAYSER H. L. Tietze's syndrome; a review of the literature. Am J Med. 1956 Dec;21(6):982–989. doi: 10.1016/0002-9343(56)90111-5. [DOI] [PubMed] [Google Scholar]
  38. Kalliomäki J. L., Viitanen S. M., Virtama P. Radiological findings of sternoclavicular joints in rheumatoid arthritis. Acta Rheumatol Scand. 1968;14(3):233–240. doi: 10.3109/rhe1.1968.14.issue-1-4.25. [DOI] [PubMed] [Google Scholar]
  39. Kormano M. A microradiographic and histological study of the manubrio-sternal joint in rheumatoid arthritis. Acta Rheumatol Scand. 1970;16(1):47–59. [PubMed] [Google Scholar]
  40. Kraft G. H., Johnson E. W., LaBan M. M. The fibrositis syndrome. Arch Phys Med Rehabil. 1968 Mar;49(3):155–162. [PubMed] [Google Scholar]
  41. Kraus H. Triggerpoints. N Y State J Med. 1973 Jun 1;73(11):1310–1314. [PubMed] [Google Scholar]
  42. Köhler H., Uehlinger E., Kutzner J., West T. B. Sternocostoclavicular hyperostosis: painful swelling of the sternum, clavicles, and upper ribs. Report of two new cases. Ann Intern Med. 1977 Aug;87(2):192–197. doi: 10.7326/0003-4819-87-2-192. [DOI] [PubMed] [Google Scholar]
  43. LANDON J., MALPAS J. S. Tietze's syndrome. Ann Rheum Dis. 1959 Sep;18:249–254. doi: 10.1136/ard.18.3.249. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Lewit K. The needle effect in the relief of myofascial pain. Pain. 1979 Feb;6(1):83–90. doi: 10.1016/0304-3959(79)90142-8. [DOI] [PubMed] [Google Scholar]
  45. Loeser J. D., Black R. G., Christman A. Relief of pain by transcutaneous stimulation. J Neurosurg. 1975 Mar;42(3):308–314. doi: 10.3171/jns.1975.42.3.0308. [DOI] [PubMed] [Google Scholar]
  46. MILLER A. J., TEXIDOR T. A. Precordial catch, a neglected syndrome of precordial pain. J Am Med Assoc. 1955 Dec 3;159(14):1364–1365. doi: 10.1001/jama.1955.02960310028012a. [DOI] [PubMed] [Google Scholar]
  47. MITCHELL J. P. Cough fracture. Br Med J. 1951 Dec 22;2(4746):1492–1493. doi: 10.1136/bmj.2.4746.1492. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. McBeath A. A., Keene J. S. The rib-tip syndrome. J Bone Joint Surg Am. 1975 Sep;57(6):795–797. [PubMed] [Google Scholar]
  49. Miller J. H. Accumulation of gallium-67 in costochondritis. Clin Nucl Med. 1980 Aug;5(8):362–363. doi: 10.1097/00003072-198008000-00006. [DOI] [PubMed] [Google Scholar]
  50. Moldofsky H., Scarisbrick P., England R., Smythe H. Musculosketal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects. Psychosom Med. 1975 Jul-Aug;37(4):341–351. doi: 10.1097/00006842-197507000-00008. [DOI] [PubMed] [Google Scholar]
  51. Moldofsky H., Scarisbrick P. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosom Med. 1976 Jan-Feb;38(1):35–44. doi: 10.1097/00006842-197601000-00006. [DOI] [PubMed] [Google Scholar]
  52. Morgan-Hughes J. A. Painful disorders of muscle. Br J Hosp Med. 1979 Oct;22(4):360, 362-5. [PubMed] [Google Scholar]
  53. Murray G. C., Persellin R. H. Metastatic carcinoma presenting as monarticular arthritis: a case report and review of the literature. Arthritis Rheum. 1980 Jan;23(1):95–100. doi: 10.1002/art.1780230116. [DOI] [PubMed] [Google Scholar]
  54. Mynors J. M. Clicking rib. Lancet. 1973 Mar 24;1(7804):674–674. doi: 10.1016/s0140-6736(73)92247-2. [DOI] [PubMed] [Google Scholar]
  55. NATHAN H., WEINBERG H., ROBIN G. C., AVIAD I. THE COSTOVERTEBRAL JOINTS, ANATOMICAL-CLINICAL OBSERVATIONS IN ARTHRITIS. Arthritis Rheum. 1964 Jun;7:228–240. doi: 10.1002/art.1780070306. [DOI] [PubMed] [Google Scholar]
  56. O'NEAL L. W., ACKERMAN L. V. Cartilaginous tumors of ribs and sternum. J Thorac Surg. 1951 Jan;21(1):71–108. [PubMed] [Google Scholar]
  57. PASCUZZI C. A., DAHLIN D. C., CLAGETT O. T. Primary tumors of the ribs and sternum. Surg Gynecol Obstet. 1957 Apr;104(4):390–400. [PubMed] [Google Scholar]
  58. PRINZMETAL M., MASSUMI R. A. The anterior chest wall syndrome: chest pain resembling pain of cardiac origin. J Am Med Assoc. 1955 Sep 17;159(3):177–184. doi: 10.1001/jama.1955.02960200023005. [DOI] [PubMed] [Google Scholar]
  59. Pace J. B. Commonly overlooked pain syndromes responsive to simple therapy. Postgrad Med. 1975 Oct;58(4):107–113. doi: 10.1080/00325481.1975.11714172. [DOI] [PubMed] [Google Scholar]
  60. Park W. M., Ball J., Ward D., Bane A. Rheumatoid disease and rib defects. Ann Rheum Dis. 1971 Sep;30(5):466–475. doi: 10.1136/ard.30.5.466. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Payne T. C., Leavitt F., Garron D. C., Katz R. S., Golden H. E., Glickman P. B., Vanderplate C. Fibrositis and psychologic disturbance. Arthritis Rheum. 1982 Feb;25(2):213–217. doi: 10.1002/art.1780250216. [DOI] [PubMed] [Google Scholar]
  62. Peck C. L., Kraft G. H. Electromyographic biofeedback for pain related to muscle tension. A study of tension headache, back, and jaw pain. Arch Surg. 1977 Jul;112(7):889–895. doi: 10.1001/archsurg.1977.01370070103017. [DOI] [PubMed] [Google Scholar]
  63. Resnick D., Shapiro R. F., Wiesner K. B., Niwayama G., Utsinger P. D., Shaul S. R. Diffuse idiopathic skeletal hyperostosis (DISH) [ankylosing hyperostosis of Forestier and Rotes-Querol]. Semin Arthritis Rheum. 1978 Feb;7(3):153–187. doi: 10.1016/0049-0172(78)90036-7. [DOI] [PubMed] [Google Scholar]
  64. Resnick D. Sternocostoclavicular hyperostosis. AJR Am J Roentgenol. 1980 Dec;135(6):1278–1280. doi: 10.2214/ajr.135.6.1278. [DOI] [PubMed] [Google Scholar]
  65. Resnick D., Vint V., Poteshman N. L. Sternocostoclavicular hyperostosis. A report of three new cases. J Bone Joint Surg Am. 1981 Oct;63(8):1329–1332. [PubMed] [Google Scholar]
  66. Reuler J. B., Girard D. E., Nardone D. A. Sternoclavicular joint involvement in ankylosing spondylitis. South Med J. 1978 Dec;71(12):1480–1481. doi: 10.1097/00007611-197812000-00010. [DOI] [PubMed] [Google Scholar]
  67. Reynolds M. D. Clinical diagnosis of psychogenic rheumatism. West J Med. 1978 Apr;128(4):285–290. [PMC free article] [PubMed] [Google Scholar]
  68. Scobie B. A. Costochondral pain in gastroenterologic practice. N Engl J Med. 1976 Nov 25;295(22):1261–1261. doi: 10.1056/NEJM197611252952220. [DOI] [PubMed] [Google Scholar]
  69. Sebes J. I., Salazar J. E. The manubriosternal joint in rheumatoid disease. AJR Am J Roentgenol. 1983 Jan;140(1):117–121. doi: 10.2214/ajr.140.1.117. [DOI] [PubMed] [Google Scholar]
  70. Simons D. G. Muscle pain syndromes--Part I. Am J Phys Med. 1975 Dec;54(6):289–311. [PubMed] [Google Scholar]
  71. Smythe H. A., Moldofsky H. Two contributions to understanding of the "fibrositis" syndrome. Bull Rheum Dis. 1977;28(1):928–931. [PubMed] [Google Scholar]
  72. Sonozaki H., Kawashima M., Hongo O., Yaoita H., Ikeno M., Matsuura M., Okai K., Azuma A. Incidence of arthro-osteitis in patients with pustulosis palmaris et plantaris. Ann Rheum Dis. 1981 Dec;40(6):554–557. doi: 10.1136/ard.40.6.554. [DOI] [PMC free article] [PubMed] [Google Scholar]
  73. Sparrow M. J., Bird E. L. "Precordial catch": a benign syndrome of chest pain in young persons. N Z Med J. 1978 Oct 25;88(622):325–326. [PubMed] [Google Scholar]
  74. Stegman D., Mead B. T. The chest wall twinge syndrome. Nebr State Med J. 1970 Sep;55(9):528–533. [PubMed] [Google Scholar]
  75. Stonnington H. H. Tension myalgia. Mayo Clin Proc. 1977 Nov;52(11):750–751. [PubMed] [Google Scholar]
  76. TRAVELL J., RINZLER S. H. Pain syndromes of the chest muscles; resemblance to effort angina and myocardial infarction, and relief by local block. Can Med Assoc J. 1948 Oct;59(4):333–338. [PMC free article] [PubMed] [Google Scholar]
  77. TRAVELL J., RINZLER S. H. The myofascial genesis of pain. Postgrad Med. 1952 May;11(5):425–434. doi: 10.1080/00325481.1952.11694280. [DOI] [PubMed] [Google Scholar]
  78. Talucci R. C., Webb W. R. Costal chondritis: the costal arch. Ann Thorac Surg. 1983 Mar;35(3):318–321. doi: 10.1016/s0003-4975(10)61566-4. [DOI] [PubMed] [Google Scholar]
  79. Traut E. F. Fibrositis. J Am Geriatr Soc. 1968 May;16(5):531–538. doi: 10.1111/j.1532-5415.1968.tb02092.x. [DOI] [PubMed] [Google Scholar]
  80. WEHRMACHER W. H. The painful anterior chest wall syndromes. Med Clin North Am. 1958 Jan;42(1):111–118. doi: 10.1016/s0025-7125(16)34327-9. [DOI] [PubMed] [Google Scholar]
  81. Waylonis G. W. Long-term follow-up on patients with fibrositis treated with acupuncture. Ohio State Med J. 1977 May;73(5):299–302. [PubMed] [Google Scholar]
  82. Weinberg H., Nathan H., Magora F., Robin G. C., Aviad I. Arthritis of the first costovertebral joint as a cause of thoracic outlet syndrome. Clin Orthop Relat Res. 1972 Jul-Aug;86:159–163. doi: 10.1097/00003086-197207000-00023. [DOI] [PubMed] [Google Scholar]
  83. Wilke W. S., Sheeler L. R., Makarowski W. S. Hypothyroidism with presenting symptoms of fibrositis. J Rheumatol. 1981 Jul-Aug;8(4):626–631. [PubMed] [Google Scholar]
  84. Wolf E., Stern S. Costosternal syndrome: its frequency and importance in differential diagnosis of coronary heart disease. Arch Intern Med. 1976 Feb;136(2):189–191. doi: 10.1001/archinte.136.2.189. [DOI] [PubMed] [Google Scholar]
  85. Wolfe F., Cathey M. A., Kleinheksel S. M., Amos S. P., Hoffman R. G., Young D. Y., Hawley D. J. Psychological status in primary fibrositis and fibrositis associated with rheumatoid arthritis. J Rheumatol. 1984 Aug;11(4):500–506. [PubMed] [Google Scholar]
  86. Wolfe F., Cathey M. A. Prevalence of primary and secondary fibrositis. J Rheumatol. 1983 Dec;10(6):965–968. [PubMed] [Google Scholar]
  87. Yood R. A., Goldenberg D. L. Sternoclavicular joint arthritis. Arthritis Rheum. 1980 Feb;23(2):232–239. doi: 10.1002/art.1780230215. [DOI] [PubMed] [Google Scholar]
  88. Yunus M., Masi A. T., Calabro J. J., Miller K. A., Feigenbaum S. L. Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls. Semin Arthritis Rheum. 1981 Aug;11(1):151–171. doi: 10.1016/0049-0172(81)90096-2. [DOI] [PubMed] [Google Scholar]

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