What is the workup for chest wall pain after heavy lifting?

Workup for Chest Wall Pain After Heavy Lifting

Begin with a focused history and ECG to exclude cardiac causes, followed by chest radiography if the physical examination suggests musculoskeletal pathology; most cases are costochondritis diagnosed clinically without imaging.

Initial Clinical Assessment

Cardiac Exclusion (Critical First Step)

• Obtain an ECG immediately for any patient over 35 years or with cardiac risk factors to rule out acute coronary syndrome, as heavy lifting can precipitate spontaneous coronary artery dissection even in healthy individuals 1, 2, 3
• Ask specifically about pain character: severe pain lasting >20 minutes, radiation to neck/jaw/left arm, or lack of response to rest suggests cardiac etiology requiring urgent intervention 1
• Note that spontaneous coronary artery dissection has been reported in healthy men after extremely heavy lifting (200-250 pounds), presenting as non-ST elevation myocardial infarction 3

Focused Physical Examination

• Palpate all costochondral junctions systematically - tenderness to palpation that reproduces the patient's pain is the hallmark finding of costochondritis 2, 4
• Pay particular attention to ribs 6 and 7 costochondral junctions, as these are commonly affected 4
• Assess for visible swelling at costochondral junctions (suggests Tietze syndrome rather than simple costochondritis) 2
• Check for autonomic signs (pallor, sweating, hypotension) that would suggest cardiac pathology 1

Imaging Strategy

Initial Imaging

• Chest radiography is the appropriate first imaging study after history and physical examination for nontraumatic chest wall pain 1
• Chest X-ray evaluates for rib fractures, pneumothorax, infection, or neoplasm that may simulate chest wall pain 1
• However, recognize that chest radiographs are insensitive for costochondral junction abnormalities, rib cartilage injuries, and chest wall soft tissues 1
• In stable outpatients, rib fractures are detected in only 4.9% of cases on chest radiography 1

When to Advance Imaging

• CT chest is NOT first-line for uncomplicated musculoskeletal chest wall pain without trauma, infection, or malignancy risk factors 1
• Reserve CT for patients requiring evaluation of other pulmonary diseases or when initial workup is unrevealing and symptoms persist 1
• Ultrasound has higher sensitivity than CT for detecting costochondral abnormalities and can be useful when radiographs are normal but clinical suspicion remains high 2

Diagnostic Considerations

Most Likely Diagnosis

• Costochondritis accounts for 42% of nontraumatic musculoskeletal chest wall pain and is readily diagnosed by physical examination without imaging 1, 2
• Pain is typically stinging or pressing, retrosternal or left-sided, occurring more than once daily 1, 4

Alternative Diagnoses to Consider

• Muscle strain or overuse myalgia from the heavy lifting episode itself 5, 6
• Stress fractures of ribs from acute overload during lifting 7
• Slipping rib syndrome if pain is associated with rib subluxation 2
• Tietze syndrome if there is visible swelling at costochondral junctions 2

Clinical Pitfalls

• Do not assume musculoskeletal origin without ECG in patients >35 years or with cardiac risk factors - spontaneous coronary artery dissection can occur with heavy lifting 2, 3
• Avoid routine rib series radiography as it adds little diagnostic value beyond chest radiography (fractures detected in <5% of cases) 1
• Do not order CT, MRI, or bone scan as initial imaging - these are not indicated without specific clinical concerns for malignancy, infection, or inflammatory conditions 1
• Recognize that >55% of patients have chronic symptoms lasting >6 months, so reassurance and appropriate treatment are essential 1, 4