MSK Chest Pain

Question 1

Give some causes of MSK chest pain

Answer 1

1) Costochondritis

2) Lower rib pain syndromes

3) Rib fractures/chest trauma

4) Fibromyalgia

5) 1ary or 2ary bone mets to the rib

6) Inflammatory arthritides - generally there will be other joint involvement

7) Tietze syndrome

8) Spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction)

Question 2

What is costochondritis?

Answer 2

The ribs articulate with costal cartilage at the costochondral joints.

These joints become inflamed in costochondritis causing pain.

Question 3

Clinical features of MSK chest pain?

Answer 3

Site: localised

Radiation: can radiate

Character: Sharp, nagging pain

Exacerbating: movement, changes in position, deep inspiration

Question 4

Features that suggest the underlying cause is NOT MSK:

Answer 4

• Central crushing chest pain and tearing chest pain (these may be red flags for cardiac ischaemia and aortic dissection)
• Dyspnoea
• Fever
• Diaphoresis
• Syncope and collapse

Question 5

Clinical features of MSK chest pain caused by costochondritis?

Answer 5

• Sharp
• Worse on inspiration and movement
• Localised tenderness to palpation; commonly in multiple areas, most frequently in upper costal cartilages
• Pain may be chronic: (~50% of patients with costochondritis still have pain 6-12months after symptom onset).

Question 6

What may there be a history of in MSK chest pain?

Answer 6

• cough
• vomiting
• over-exercising etc

Question 7

What typically makes the pain worse in MSK chest pain?

Answer 7

Inspiration & movement

Question 8

What is lower (slipping) rib pain syndrome?

Answer 8

Excessive movement of the lower rib tips as they pass under the costal arch.

This causes intense lower chest pain/upper abdominal pain with an identifiably tender spot on the costal margin.

Question 9

How may the pain be reproduced in lower rib pain sydnrome?

Answer 9

1) During examination by pressing on this spot.

2) Using the ‘hooking manoeuvre’

Question 10

What is the hooking manouevre?

Answer 10

The examiner hooks fingers under the patient’s ribs and pulls gently forward.

It may be difficult to perform the manoeuvre in patient with this syndrome due to exquisite sensitivity in the subcostal margins

Question 11

Where is the pain located in lower rib pain syndrome?

Answer 11

Lower chest pain/upper abdominal pain with an identifiably tender spot on the costal margin.

Question 12

What are the 2 types of rib fractures?

Answer 12

Traumatic & stress fractures

Question 13

What may there be a history of in rib fractures?

Answer 13

History of trauma to the ribs: may be severe trauma, minor to moderate (generally blunt) trauma, or repetitive minor trauma (stress fractures).

Question 14

Trauma vs stress fracture?

Answer 14

A stress fracture is a micro-break or crack in the bone. It’s a common overuse injury among athletes.

While a regular fracture is a traumatic injury that occurs immediately during impact, a stress fracture develops over time.

Question 15

Features of a rib fracture?

Answer 15

1) There is usually tenderness over the affected rib(s), and potentially bruising.

2) The pain may be elicited by deep inspiration and movement.

3) Bony crepitus may be present.

Question 16

Describe the chest pain in fibromyalgia

Answer 16

• sharp
• worse on inspiration & movement
• often tenderness to palpation

Question 17

Where is chest pain in fibromyalgia most commonly located?

Answer 17

• Most commonly of the second anterior costochondral junctions.
• Typically affecting more than one rib.

Question 18

What are some other features of fibromyalgia?

Answer 18

Pain in other areas, depression, anxiety, congitive impairment, memory & sleep issues etc.

Question 19

Describe chest pain in 1ary/2ary bone cancer in the ribs

Answer 19

Often a dull, aching pain that is frequently worse at night.

May be poorly localised.

Question 20

When is chest pain due to 1ary/2ary bone cancer in the ribs worse?

Answer 20

Frequently worse at night.

Question 21

Which type of inflammatory arthritides can cause chest wall pain?

Answer 21

Ankylosing spondylitis

Question 22

What is Tietze syndrome?

Answer 22

When the cartilage in the joint where your ribs (costal cartilage) connect to your breastbone (costochondral joint) is irritated.

This leads to inflammation around the joint and causes chest pain and swelling

Question 23

Describe the chest pain in Tietze’s syndrome

Answer 23

typically sharp and worse on inspiration and movement.

Question 24

What may there be a history of in Tietze’s syndrome?

Answer 24

• cough
• vomiting
• over-exercising etc

Question 25

Features of Tietze’s syndrome?

Answer 25

• chest pain: typically sharp and worse on inspiration and movement.
• tender on palpation at costochondral junction:
• typically unilateral
• commonly only affects a single joint
• history: cough, vomiting, over-exercising, or similar.

Question 26

What type of chest pain do spinal disorders tend to cause?

Answer 26

• Dull aching chest pain that is typically aggravated by specific neck movements.
• Pain may also radiate down the arm, into the head, or into the shoulder or across scapulae (non-segmental distribution).
• Patient may have pain in the spine and may have paraesthesia.

Question 27

What does diagnosis of MSK chest pain typically rely on?

Answer 27

Clinical exam & ruling out of other causes (cardiac, pulmonary and abdominal).

Question 28

What investigations may be done in suspected MSK chest pain?

Answer 28

1) ECG: rule out cardiac causes

2) Bloods (all the usual plus):
- troponin
- d-dimer
- CRP/ESR

3) Imaging (not routinely recommended)
- CXR (generally 1st line)
- CT/MRI
- US

Question 29

Cardiac differentials for MSK chest pain?

Answer 29

1) angina

2) MI

3) arrhythmias

4) pericarditis

5) thoracic aortic aneurysm (rupture)

Question 30

Pulmonary differentials for MSK chest pain?

Answer 30

1) pneumonia

2) pleural effusion

3) PE

4) lung malignancy

5) pneumothorax

Question 31

What may be seen in chest pain caused by arrythmias?

Answer 31

Chest pain may be accompanied by palpitations, dyspnoea and lightheadedness. Patient may be haemodynamically unstable.

Question 32

Characteristic exam features in chest pain due to MI?

Answer 32

1) Cardiac sounding pain:
- heavy, central chest pain they may radiate to the neck and left arm
- nausea, sweating
- elderly patients and diabetics may experience no pain

2) Risk factors for CVS disease

Question 33

Characteristic exam features in chest pain due to pneumothorax?

Answer 33

1) History of asthma, Marfan’s etc

2) Sudden dyspnoea and pleuritic chest pain

Question 34

Characteristic exam features in chest pain due to PE?

Answer 34

1) Sudden dyspnoea and pleuritic chest pain

2) Calf pain/swelling

3) Current combined pill user, malignancy

Question 35

Characteristic exam features in chest pain due to pericarditis?

Answer 35

1) Sharp pain relieved by sitting forwards

2) May be pleuritic in nature

Question 36

Characteristic exam features in chest pain due to a dissecting aortic aneurysm?

Answer 36

1) ‘Tearing’ chest pain radiating through to the back

2) Unequal upper limb blood pressure

Question 37

Characteristic exam features in chest pain due to GORD?

Answer 37

1) Burning retrosternal pain

2) Other possible symptoms include regurgitation and dysphagia

Question 38

Characteristic exam features in MSK chest pain?

Answer 38

1) The pain is often worse on movement or palpation.

2) May be precipitated by trauma or coughing

Question 39

Characteristic exam features in chest pain caused by shingles?

Answer 39

Pain often precedes rash.

Question 40

What is Boerhaaves syndrome?

Answer 40

Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting.

Question 41

Where is the rupture typically located in Boerhaaves syndrome?

Answer 41

The rupture is usually distally sited and on the left side.

Question 42

What history is typically seen in Boerhaaves syndrome?

Answer 42

Patients usually give a history of sudden onset of severe chest pain that may complicate severe vomiting.

Question 43

What is the diagnostic investigation in Boerhaaves syndrome?

Answer 43

CT contrast swallow.

Question 44

What are most rib fractures caused by?

Answer 44

Blunt trauma to the chest wall

Question 45

What can spontaneous rib fractures occur 2ary to?

Answer 45

Coughing or sneezing –> usually there is a past medical history of osteoporosis, steroid use or COPD

Question 46

Different causes of rib fractures?

Answer 46

1) Blunt trauma

2) Spontaneous: history of osteoporosis, steroid use or COPD

3) Pathological: due to cancer metastases:

Question 47

What are the 2 most common cancers that predispose to pathological rib fractures?

Answer 47

Men - prostate

Women - breast

Question 48

Clinical features of rib fractures?

Answer 48

1) severe, sharp chest wall pain: often more severe with deep breaths or coughing

2) significant chest wall tenderness over the site, bruising

3) auscultation: crackles or reduced breath sounds if there is an underlying lung injury

4) drop in O2 sats: if pain and underlying lung injury

5) pneumothorax

Question 49

What is a flail chest?

Answer 49

This is a serious consequence of multiple rib fractures that can occur following trauma.

It is caused by two or more rib fractures along three or more consecutive ribs, usually anteriorly
the flail segment moves paradoxically during respiration and impairs ventilation of the lung on the side of injury.

The segment can cause serious contusional injury to the underlying lung if left untreated.

Question 50

What is the best diagnostic investigation in rib fractures?

Answer 50

CT chest

Question 51

Management of rib fractures?

Answer 51

Majority are managed conservatively with good analgesia to ensure breathing is not affected by pain –> inadequate ventilation may predispose to chest infections

Chest physiotherapy.