What is the cause of chest pain in a 9-year-old male that occurred after physical activity?

From the Guidelines

This 9-year-old boy likely has costochondritis, which is inflammation of the cartilage connecting the ribs to the sternum, and I recommend reassurance that this is likely a musculoskeletal issue rather than cardiac in nature. The presentation of chest pain after physical activity in a 9-year-old male is most likely due to a musculoskeletal cause, with costochondritis being a common condition in children and adolescents 1. The key points to consider in this case are:

• The clear relationship between physical activity and pain
• The absence of concerning symptoms like shortness of breath, dizziness, or syncope
• The lack of family history of cardiac disease
• The pain pattern—occurring with specific movements, improving with rest, and being reproducible with certain positions—strongly suggests a musculoskeletal cause rather than cardiac 1. Treatment should include rest from activities that exacerbate the pain, application of heat to the affected area, and over-the-counter pain relievers such as ibuprofen (10mg/kg/dose every 6-8 hours with food, not exceeding 40mg/kg/day) or acetaminophen (15mg/kg/dose every 4-6 hours, not exceeding 75mg/kg/day) for pain management. While diagnostic tests such as chest x-ray and EKG may be considered, they are likely unnecessary in this case given the clear musculoskeletal nature of the pain. If symptoms persist beyond 1-2 weeks despite conservative management, worsen significantly, or if new concerning symptoms develop (such as fever, difficulty breathing, or palpitations), follow-up evaluation would be warranted. Costochondritis is common in children and adolescents and typically resolves with conservative management within a few weeks 1.

From the Research

Causes of Chest Pain

The cause of chest pain in a 9-year-old male that occurred after physical activity can be attributed to several factors. Some possible causes include:

• Musculoskeletal chest pain, such as costochondritis or chest wall muscle injuries 2
• Cardiac causes, although less likely in a 9-year-old, such as acute coronary syndrome (ACS) or myocardial infarction 3, 4, 5
• Other less common causes, such as pneumonia, heart failure, pulmonary embolism, or acute thoracic aortic dissection 4, 5

Evaluation and Diagnosis

To determine the cause of chest pain, a thorough evaluation and diagnosis are necessary. This may include:

• A combination of age, sex, and type of chest pain to predict the likelihood of coronary artery disease as the cause of chest pain 4
• Twelve-lead electrocardiography to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions 3, 4
• Exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging for patients at low or intermediate risk of ACS 4
• Manual therapy and exercises as needed for musculoskeletal causes of chest pain 2

Triage and Management

The optimal triage of patients with acute chest pain is a clinical and healthcare necessity. This may involve:

• Risk scores to stratify a patient's likelihood of having cardiac chest pain 5
• Rapid protocols based on serial high-sensitivity cardiac troponin assays within one or two hours to identify candidates for early discharge 5
• Transthoracic echocardiography as the first-line imaging modality for evaluating patients with ACP 5