From the Guidelines
For this 37-year-old Filipino-American male with persistent left chest and back pain despite extensive cardiac and GI workup, I recommend pursuing evaluation for musculoskeletal causes, particularly costochondritis or intercostal neuralgia, as the most likely etiology given the negative cardiac imaging and unremarkable GI evaluation 1. The patient's symptoms, including localized left-sided chest and back pain, are consistent with musculoskeletal chest wall pain, which is estimated to affect 20% to 40% of the general population 1.
- The next steps should include a trial of NSAIDs such as ibuprofen 600mg three times daily with food for 7-10 days, as recommended for the treatment of musculoskeletal chest wall pain 1,
- along with physical therapy focusing on chest wall and thoracic spine mobilization to address potential musculoskeletal contributors to the pain. Consider a referral to pain management for possible trigger point injections if symptoms persist. Additionally, obtain an MRI of the thoracic spine to rule out subtle disc pathology or nerve impingement not visible on plain radiographs. Given the patient's history of asthma, evaluate for pleuritic components with a pulmonary function test. The patient should track pain triggers, intensity, and response to interventions to help identify patterns that might guide further management. Anxiety-related somatic symptoms should also be considered, particularly if pain worsens with stress, so a screening tool for anxiety might be appropriate. It is essential to note that the patient is already on colchicine for possible recurrent pericarditis, and the treatment approach should be adjusted accordingly, considering the potential for musculoskeletal causes of the pain 1.
From the Research
Possible Etiologies
- Costochondritis: an inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall, which is a common condition seen in patients presenting to the physician's office and emergency department 2
- Thoracic outlet syndrome: caused by compression of the neurovascular structures crossing the interscalene triangle, costoclavicular space or retropectoralis minor space, which can be diagnosed using four-dimensional computed tomography scanning 3
- Costoclavicular impingement: a cause of thoracic outlet syndrome, which can be diagnosed using four-dimensional computed tomography scanning 3
- Spasm of the pectoralis minor muscle originating from costochondritis: a rare cause of thoracic outlet syndrome in children 4
Next Steps in Evaluation
- Take a comprehensive patient history to inform diagnosis and treatment, using a structured but flexible process of gathering relevant information from patients 5
- Perform a thorough clinical examination to identify the pathology of thoracic outlet syndrome and other possible etiologies 6
- Consider further testing to rule out cardiac causes if clinically indicated by age or cardiac risk status 2
- Use appropriate clinical testing to aide in diagnosis, such as electrocardiograph and chest radiograph 2