Is chest soreness with palpation a symptom of pericarditis?

Chest Pain in Pericarditis: Role of Chest Wall Tenderness

Chest tenderness on palpation is not a typical feature of pericarditis, and its presence significantly reduces the probability of acute coronary syndrome rather than indicating pericarditis. 1

Clinical Presentation of Pericarditis

Pericarditis presents with characteristic symptoms that help differentiate it from other causes of chest pain:

Typical Features

• Sharp, pleuritic chest pain that:
  • Improves when sitting up or leaning forward
  • May radiate to the left shoulder
  • Often worsens when lying supine 1
• Pericardial friction rub (highly specific but transient, present in 18-84% of cases) 2
• Fever may be present, especially in infectious causes 1

Diagnostic Criteria

Diagnosis requires at least two of the following:

• Characteristic pleuritic chest pain
• Pericardial friction rub
• Electrocardiographic changes (widespread ST elevations with PR depressions)
• New or worsening pericardial effusion 2

Chest Wall Tenderness in Differential Diagnosis

The 2021 AHA/ACC guidelines specifically note that chest tenderness on palpation is a finding that helps differentiate non-cardiac causes from acute coronary syndrome:

• "Chest tenderness on palpation or pain with inspiration markedly reduce the probability of ACS" 1
• In the physical examination table from these guidelines, chest wall tenderness is listed as a characteristic finding of musculoskeletal conditions like costochondritis or Tietze syndrome, not pericarditis 1

Distinguishing Features from Other Conditions

When evaluating chest pain:

1. Pericarditis: Pain typically worsens when lying down and improves when sitting forward; associated with friction rub; not typically tender to palpation 1

2. Musculoskeletal causes (e.g., costochondritis):

   • Localized tenderness at costochondral junctions
   • Pain reproducible with palpation 1

3. Pleuritic conditions (pneumonia, pneumothorax):

   • Pain with inspiration
   • May have associated respiratory findings 1

Clinical Implications

The absence of chest wall tenderness does not rule out pericarditis, but its presence should prompt consideration of alternative diagnoses, particularly musculoskeletal causes of chest pain.

When evaluating a patient with suspected pericarditis:

• Focus on the characteristic pleuritic pain that changes with position
• Listen carefully for a pericardial friction rub
• Obtain an ECG to look for diffuse ST elevations and PR depressions
• Consider echocardiography to evaluate for pericardial effusion 1

Conclusion

Chest wall tenderness on palpation is not a typical feature of pericarditis and actually points away from this diagnosis. The hallmark physical examination finding in pericarditis is the pericardial friction rub, though it may be transient and not always present.