Sternal Pain - Different Causes

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

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

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.

The left figure (fig.1) shows the anterior surface of the sternum and the costal cartilages. The right one shows the posterior surface of the sternum.(Gray’s Anatomy of the Human Body, fig. 115 – anterior surface of sternum and costa cartilages)²

Causes of Sternal Pain

Cardiovascular causes

• Heart valve disease
• Hypertrophic cardiomyopathy
• Coronary artery disease
• Myocarditis
• Pericarditis
• Aortic dissection
• Amyloidosis

Respiratory causes

• Asthma
• Bronchitis
• Bronchiectasis
• Chronic Obstructive Pulmonary Disease (COPD)
• Bronchiectasis
• Tracheitis
• Tuberculosis
• Pneumonia
• Pulmonary embolism
• Pleurisy
• Pneumothorax
• Pulmonary hypertension
• Pulmonary sarcoidosis

Abdominal and gastrointestinal causes

• Gastroesophageal reflux disease (GERD)
• Pancreatitis
• Peptic ulcers

Musculoskeletal causes

• 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. 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
• Arthritis ( 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):432-436.; 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):122-125.)
• 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. Those affected are typically over the age of 40. Clinical signs include localized pain on palpation which may radiate on the chest wall. No swelling occurs with this condition. 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). 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.
• Osteomyelitis is an inflammation due to infection of the bone or bone marrow
• Pectoral muscle ruptures generally occur during forceful activities. **
• 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 **}
• 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.
• 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.
• Xiphodynia (or hypersensitive xiphoid syndrome): a condition involving referral of pain to the chest, abdomen, throat, arms and head from an irritated xiphoid process. 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.
• Precordial catch syndrome (Texidor’s Twinge): a common but under recognized cause of benign chest pain in children and adolescents.
• Slipping rib syndrome ***
• 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

• Anxiety

Cancer

• Breast cancer
• Lung cancer
• Lymphoma
• Bone cancer
  

Clinical presentation

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

Pain can be felt when stretching, lifting, reaching or exerting the affected chest muscles. A muscle spasm is the result of inflammation, causing the muscles to contract suddenly.(D. Allyson, signs of a pulled chest muscle, mart 2011.) ¹⁴

Outcome measures

Examination

Medical management

Surgery is most recommended for complete tears of chest muscles. Patients who have partial tears may be able to avoid surgical treatment.

Physical therapy management

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