Sternal Pain - Different Causes: Difference between revisions
(adding content) |
(adding content) |
||
| Line 56: | Line 56: | ||
* Stress fractures of the rib | * Stress fractures of the rib | ||
* [[Sternoclavicular Joint Disorders|Sternoclavicular joint disorders]] | * [[Sternoclavicular Joint Disorders|Sternoclavicular joint disorders]] | ||
* Costochondritis: an inflammatory condition affecting costochondral junctions or chondrosternal joints. In 90% of patients, more than one area is affected and the most commonly affected areas are the second to fifth junctions. <ref name=":2">Proulx AM, Zryd TW. Costochondritis; diagnosis and treatment. Am Fam Physician. 2009;80(6):617-20.</ref> Those affected are typically over the age of 40.<ref name=":2" /> Clinical signs include localized pain on palpation which may radiate on the chest wall. No swelling occurs with this condition.<ref name=":2" /> Recent illness involving coughing and recent strenuous exercise or upper extremity use can cause this type of inflammation. | * Costochondritis: an inflammatory condition affecting costochondral junctions or chondrosternal joints. In 90% of patients, more than one area is affected and the most commonly affected areas are the second to fifth junctions. <ref name=":2">Proulx AM, Zryd TW. Costochondritis; diagnosis and treatment. Am Fam Physician. 2009;80(6):617-20.</ref> Those affected are typically over the age of 40.<ref name=":2" /> Clinical signs include localized pain on palpation which may radiate on the chest wall. No swelling occurs with this condition.<ref name=":2" /> Recent illness involving coughing and recent strenuous exercise or upper extremity use can cause this type of inflammation. | ||
* [[Tietzes|Tietze syndrome]]: a rare inflammatory condition affecting a single costal cartilage (usually the second or third).<ref name=":2" /> Those affected are typically under the age of 40. Localized pain and swelling are found with this condition. It can be caused by infection (particularly from chest wall trauma), neoplasms or rheumatological conditions.<ref name=":2" /> | * [[Tietzes|Tietze syndrome]]: a rare inflammatory condition affecting a single costal cartilage (usually the second or third).<ref name=":2" /> Those affected are typically under the age of 40. Localized pain and swelling are found with this condition. It can be caused by infection (particularly from chest wall trauma), neoplasms or rheumatological conditions.<ref name=":2" /> | ||
| Line 62: | Line 61: | ||
* Pectoral muscle ruptures generally occur during forceful activities.<ref name=":0">Petilon J, Carr DR, Sekiya JK, Unger DV. Pectoralis major muscle injuries: evaluation and management. J Am Acad Orthop Surg. 2005;13(1):59-68.</ref> ** | * Pectoral muscle ruptures generally occur during forceful activities.<ref name=":0">Petilon J, Carr DR, Sekiya JK, Unger DV. Pectoralis major muscle injuries: evaluation and management. J Am Acad Orthop Surg. 2005;13(1):59-68.</ref> ** | ||
* Intercostal muscles can become strained often as a result of rapid twisting of the torso. It is common in sports such as basketball and tennis.(Lynn Hetzler, therapy for intercostal muscles, jul. 2011)<sup>11 **</sup> | * Intercostal muscles can become strained often as a result of rapid twisting of the torso. It is common in sports such as basketball and tennis.(Lynn Hetzler, therapy for intercostal muscles, jul. 2011)<sup>11 **</sup> | ||
* Inflammatory joint disease including osteoarthritis, rheumatoid arthritis and psoriatic arthritis<ref name=":3" /> | |||
* [[Fibromyalgia]]: a rheumatological condition that can cause persistent and widespread pain including symmetrical tender points at the second costochondral junction as well as the neck, back hip and extremities.<ref name=":2" /> | * [[Fibromyalgia]]: a rheumatological condition that can cause persistent and widespread pain including symmetrical tender points at the second costochondral junction as well as the neck, back hip and extremities.<ref name=":2" /> | ||
* General myalgia related to a history of chest trauma or recent onset of strenuous exercise to upper body (e.g. rowing). It may be bilateral and affecting multiple costochondral areas. Local muscle groups may also be tender to palpation.<ref name=":2" /> | * General myalgia related to a history of chest trauma or recent onset of strenuous exercise to upper body (e.g. rowing). It may be bilateral and affecting multiple costochondral areas. Local muscle groups may also be tender to palpation.<ref name=":2" /> | ||
| Line 71: | Line 71: | ||
=== '''Psychological causes''' === | === '''Psychological causes''' === | ||
* Anxiety | * Anxiety and depression - found to be correlated with atypical chest pain but it is unknown whether mental health issues are a cause or a consequence<ref name=":3" /> *** | ||
=== '''Cancer''' === | === '''Cancer''' === | ||
| Line 91: | Line 91: | ||
== Diagnostic procedures == | == Diagnostic procedures == | ||
It is important that once a diagnosis of acute cardiopulmonary disease is ruled out, patients with atypical chest pain are followed up with by health care professionals. | It is important that once a diagnosis of acute cardiopulmonary disease is ruled out, patients with atypical chest pain are followed up with by health care professionals. Persistent pain, poor quality of life and inability to return to work are common in this cohort yet in a study published in 2003, the authors found that musculoskeletal diagnoses are most common when patients are reassessed one year following discharge without a diagnosis for their atypical chest pain.<ref name=":3">How J, Volz G, Doe S, Heycock C, Hamilton J, Kelly C. The causes of musculoskeletal chest pain in patients admitted to hospital with suspected myocardial infarction. Eur J Intern Med. 2005;16(6):432-6.</ref><ref name=":4">Spalding L, Reay E, Kelly C. Cause and outcome of atypical chest pain in patients admitted to hospital. J R Soc Med. 2003;96(3):122-5.</ref> Further assessment and management are therefore important with these types of cases. Reassurance that life-threatening illness such as myocardial infarction has been ruled out is important to reduce the risk of persistent anxiety related to the chest pain.<ref name=":4" /> | ||
blood test for rheumatoid factor and C-reactive protein (CRP)<ref name=":3" /> | |||
== Outcome measures == | == Outcome measures == | ||
== Examination == | == Examination == | ||
Chest pain persisting longer than 12 hours and tenderness on palpation of the anterior chest wall are strong clinical indicators of a musculoskeletal cause of sternal pain.<ref name=":3" /> | |||
== Medical management == | == Medical management == | ||
Surgery is most recommended for complete tears of chest muscles. Patients who have partial tears may be able to avoid surgical treatment.<ref name=":0" /> | Surgery is most recommended for complete tears of chest muscles. Patients who have partial tears may be able to avoid surgical treatment.<ref name=":0" /> | ||
The management of a patient with sternal pain depends on the specific cause of the pain. In the presence of diagnosed joint inflammation, NSAIDs, local steroid injections or topical analgesics may be indicated.<ref name=":3" /><ref name=":4" /> Systemic arthropathies such as rheumatoid arthritis may require medications such as methotrexate while low-dose amitriptyline may be indicated for a diagnosis of fibromyalgia.<ref name=":3" /> | |||
Psychological management such as Cognitive Behavioural Therapy is indicated in the presence of anxiety and/or depression that may be magnifying pain and disability.<ref name=":3" /> | |||
== Physical therapy management == | == Physical therapy management == | ||
Revision as of 04:27, 27 January 2018
Original Editor - Sofie Van Cutsem
Top Contributors - Laura Ritchie, Kim Jackson, Sofie Van Cutsem, Lucinda hampton, Evan Thomas, Blessed Denzel Vhudzijena, Oyemi Sillo and Joao Costa
PLEASE NOTE THAT THIS PAGE IS CURRENTLY UNDERGOING UPDATES
Definition/ description[edit | edit source]
Sternal pain is an acute or chronic pain or discomfort felt in the region of sternum and the associated structures. (Dr. C.A. Jenner MB BS, FRCA, Sternal Pain, Nov 2006.)1
Clinical relevant anatomy[edit | edit source]
The sternum is a flat bone, located in the center of the anterior thoracic wall. It consists of three segments; the manubrium (uppermost part), the body (middle part) and the xiphoid process (lowest part).(Gray’s Anatomy of the Human Body, fig. 115 – anterior surface of sternum and costa cartilages.,A. Iqbal, Human anatomy, sternum, 2001) 2,7 The manubrium articulates with the right and left clavicles, the right and left first rib and the upper part of the second costal cartilage.(A. Iqbal, Human anatomy, sternum, 2001)7 The manubrium is quadrangular and lies at the level of the 3rd and 4th thoracic vertebrae. The jugular notch is the thickest part of the bone and is convex anteriorly and concave posteriorly. (A. Iqbal, Human anatomy, sternum, 2001)7 The body of the sternum is longer and thinner. Its margins articulate with the first seven costal cartilages.(Gray’s Anatomy of the Human Body, fig. 115 – anterior surface of sternum and costa cartilages.,A. Iqbal, Human anatomy, sternum, 2001)2,7 The xiphoid process is the lowest and smallest part of the sternum. It does not articulate with ribs.(A. Iqbal, Human anatomy, sternum, 2001)7 The xiphoid process anchors several important muscles such as rectus abdominus, transversus thoracis and the abdominal diaphragm, a muscle necessary for normal breathing. [1]
Causes of Sternal Pain[edit | edit source]
Cardiovascular causes[edit | edit source]
- Heart valve disease
- Hypertrophic cardiomyopathy
- Coronary artery disease
- Myocarditis
- Pericarditis
- Aortic dissection
- Amyloidosis
Respiratory causes[edit | edit source]
- Asthma
- Bronchitis
- Bronchiectasis
- Chronic Obstructive Pulmonary Disease (COPD)
- Bronchiectasis
- Tracheitis
- Tuberculosis
- Pneumonia
- Pulmonary embolism
- Pleurisy
- Pneumothorax
- Pulmonary hypertension
- Pulmonary sarcoidosis
Abdominal and gastrointestinal causes[edit | edit source]
- Gastroesophageal reflux disease (GERD)
- Pancreatitis
- Peptic ulcers
Musculoskeletal causes[edit | edit source]
- Sternal fractures
- Clavicular fractures account for 5 to 10 % of all fractures and are most common in children and young adults. (S. Mozes, Family practice notebook, LLC, 2011. [2] [3] The typical mechanism is a fall on the lateral shoulder and upper arm during contact sport. This type of fracture can also occur during a fall on an outstretched arm or elbow or by direct trauma to the clavicle. (S. Mozes, Family practice notebook, LLC, 2011.) 8
- Traumatic rib fractures
- Stress fractures of the rib
- Sternoclavicular joint disorders
- Costochondritis: an inflammatory condition affecting costochondral junctions or chondrosternal joints. In 90% of patients, more than one area is affected and the most commonly affected areas are the second to fifth junctions. [4] Those affected are typically over the age of 40.[4] Clinical signs include localized pain on palpation which may radiate on the chest wall. No swelling occurs with this condition.[4] Recent illness involving coughing and recent strenuous exercise or upper extremity use can cause this type of inflammation.
- Tietze syndrome: a rare inflammatory condition affecting a single costal cartilage (usually the second or third).[4] Those affected are typically under the age of 40. Localized pain and swelling are found with this condition. It can be caused by infection (particularly from chest wall trauma), neoplasms or rheumatological conditions.[4]
- Osteomyelitis is an inflammation due to infection of the bone or bone marrow
- Pectoral muscle ruptures generally occur during forceful activities.[5] **
- Intercostal muscles can become strained often as a result of rapid twisting of the torso. It is common in sports such as basketball and tennis.(Lynn Hetzler, therapy for intercostal muscles, jul. 2011)11 **
- Inflammatory joint disease including osteoarthritis, rheumatoid arthritis and psoriatic arthritis[6]
- Fibromyalgia: a rheumatological condition that can cause persistent and widespread pain including symmetrical tender points at the second costochondral junction as well as the neck, back hip and extremities.[4]
- General myalgia related to a history of chest trauma or recent onset of strenuous exercise to upper body (e.g. rowing). It may be bilateral and affecting multiple costochondral areas. Local muscle groups may also be tender to palpation.[4]
- Xiphodynia (or hypersensitive xiphoid syndrome): a condition involving referral of pain to the chest, abdomen, throat, arms and head from an irritated xiphoid process.[7] While xiphodynia is usually insidious in nature, trauma may precipitate the syndrome. Acceleration/deceleration injuries, blunt trauma to the chest, unaccustomed heavy lifting and aerobics have been known to lead to the condition.[7]
- Precordial catch syndrome (Texidor’s Twinge): a common but under recognized cause of benign chest pain in children and adolescents.[8]
- Slipping rib syndrome *** [4]
- Post-surgical****
- ?Muscle strain (http://pubs.rsna.org/doi/abs/10.1148/radiology.210.3.r99fe43785, https://journals.lww.com/jaaos/Abstract/2005/01000/Pectoralis_Major_Muscle_Injuries__Evaluation_and.8.aspx)
Psychological causes[edit | edit source]
- Anxiety and depression - found to be correlated with atypical chest pain but it is unknown whether mental health issues are a cause or a consequence[6] ***
Cancer[edit | edit source]
- Breast cancer
- Lung cancer
- Lymphoma
- Bone cancer
Clinical presentation[edit | edit source]
The presentation of a patient with sternal pain depends on the specific cause of the pain. All patients presenting with sternal/chest pain should be screened for potential cardiac sources.
The most obvious sign of a strained muscle is pain. However, the level of pain felt relates to the degree of injury. It can also cause swelling in the chest area and muscle spasms. A moderate or severe strain will also result in weakness, due to a muscle tear.(D. Allyson, signs of a pulled chest muscle, mart 2011.)14
You feel pain when your injured intercostal muscles try to move your ribs during inhalation.(Hetzler L. Therapy for intercostal muscles [Internet]. 2011 [updated 14 August 2017; cited 24 January 2018]. Available from: https://www.livestrong.com/article/490733-therapy-for-intercostal-muscles/)11
Diagnostic procedures[edit | edit source]
It is important that once a diagnosis of acute cardiopulmonary disease is ruled out, patients with atypical chest pain are followed up with by health care professionals. Persistent pain, poor quality of life and inability to return to work are common in this cohort yet in a study published in 2003, the authors found that musculoskeletal diagnoses are most common when patients are reassessed one year following discharge without a diagnosis for their atypical chest pain.[6][10] Further assessment and management are therefore important with these types of cases. Reassurance that life-threatening illness such as myocardial infarction has been ruled out is important to reduce the risk of persistent anxiety related to the chest pain.[10]
blood test for rheumatoid factor and C-reactive protein (CRP)[6]
Outcome measures[edit | edit source]
Examination[edit | edit source]
Chest pain persisting longer than 12 hours and tenderness on palpation of the anterior chest wall are strong clinical indicators of a musculoskeletal cause of sternal pain.[6]
Medical management[edit | edit source]
Surgery is most recommended for complete tears of chest muscles. Patients who have partial tears may be able to avoid surgical treatment.[5]
The management of a patient with sternal pain depends on the specific cause of the pain. In the presence of diagnosed joint inflammation, NSAIDs, local steroid injections or topical analgesics may be indicated.[6][10] Systemic arthropathies such as rheumatoid arthritis may require medications such as methotrexate while low-dose amitriptyline may be indicated for a diagnosis of fibromyalgia.[6]
Psychological management such as Cognitive Behavioural Therapy is indicated in the presence of anxiety and/or depression that may be magnifying pain and disability.[6]
Physical therapy management[edit | edit source]
A grade 1 (strain) or a grade 2 (partial tear) of chest muscle injury could be treated with physical therapy. After the initial treatment for managing the inflammation, the therapy is based on increasing circulation, collagen production and extensibility of connective tissues. Ultrasound therapy reduces muscle spasm. Massage and electrical stimulation treat muscle injuries by releasing tension, stimulating blood flow and promoting healing. Flexibility training after pain and swelling has diminished, will help improve range of motion and mobility. Weight training will increase muscle and tendon strength.(E. Ahders, therapy for an injured pectoral muscle, Apr 2012.)12
References[edit | edit source]
- ↑ Broyles R. The location and purpose of the Xiphoid process [Internet]. Troy: Bright Hub Inc; 2009 [updated 7 March 2017; cited 24 January 2018]. Available from:http://www.brighthub.com/science/medical/articles/57775.aspx
- ↑ Stanley D, Norris SH, Recovery fractures of clavicle treated conservatively. Injury. 1988;19(3):162-4.
- ↑ Pecci M, Kreher J. Clavicle fractures. Am Fam Physician. 2008;77(1):65-70.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Proulx AM, Zryd TW. Costochondritis; diagnosis and treatment. Am Fam Physician. 2009;80(6):617-20.
- ↑ 5.0 5.1 Petilon J, Carr DR, Sekiya JK, Unger DV. Pectoralis major muscle injuries: evaluation and management. J Am Acad Orthop Surg. 2005;13(1):59-68.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 How J, Volz G, Doe S, Heycock C, Hamilton J, Kelly C. The causes of musculoskeletal chest pain in patients admitted to hospital with suspected myocardial infarction. Eur J Intern Med. 2005;16(6):432-6.
- ↑ 7.0 7.1 Simpson JK, Hawken E. Xiphodynia: A diagnostic conundrum. Chiropr Osteopat. 2007, 15:13.
- ↑ Gumbiner CH. Precordial catch syndrome. South Med J. 2003;96(1):38-41.
- ↑ Healthy Fit. What causes pain in the sternum? Available from: http://www.youtube.com/watch?v=g54IcjCq4LA[last accessed 26/01/18]
- ↑ 10.0 10.1 10.2 Spalding L, Reay E, Kelly C. Cause and outcome of atypical chest pain in patients admitted to hospital. J R Soc Med. 2003;96(3):122-5.
