What is the recommended management for acute musculoskeletal chest pain?

Management of Acute Musculoskeletal Chest Pain

Start with topical NSAIDs with or without menthol gel as first-line therapy for acute musculoskeletal chest pain, as this provides the strongest evidence for pain relief, improved physical function, and patient satisfaction while avoiding systemic side effects. 1

Diagnostic Confirmation

Before initiating treatment, confirm the musculoskeletal origin of chest pain through:

• Reproduction of pain with palpation over the affected chest wall structure (costochondral junctions, ribs, intercostal muscles, or thoracic spine) 2
• Pain provoked by specific movements or postures rather than exertion or emotional stress 2
• Absence of cardiac red flags: no radiation to arm/jaw, no diaphoresis, no dyspnea at rest, and normal ECG and cardiac biomarkers if these were obtained 3, 4

The key distinguishing feature is that musculoskeletal chest pain can be reproduced by physical examination, whereas cardiac pain cannot 2.

First-Line Pharmacologic Treatment

Topical NSAIDs (with or without menthol gel) are the strongest recommendation for initial management 1:

• This is a strong recommendation with moderate-certainty evidence from the American College of Physicians and American Academy of Family Physicians 1
• Topical formulations reduce systemic absorption and minimize gastrointestinal and cardiovascular risks compared to oral NSAIDs 1
• Apply to the affected area 3-4 times daily

Second-Line Pharmacologic Options

If topical NSAIDs provide insufficient relief, consider:

Oral NSAIDs (conditional recommendation, moderate-certainty evidence) 1:

• Ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily
• More effective than acetaminophen for improving physical function 1
• Screen for contraindications: active peptic ulcer disease, severe renal impairment, heart failure, or cardiovascular disease

Oral acetaminophen (conditional recommendation, moderate-certainty evidence) 1:

• 650-1000 mg every 6 hours as needed
• Reduces pain but less evidence for improving physical function compared to NSAIDs 1
• Maximum 4 grams per 24 hours; reduce dose in hepatic impairment

Adjunctive Pharmacologic Therapy

Muscle relaxants may be considered as adjunct therapy for muscle spasm associated with acute musculoskeletal chest pain 5:

• Cyclobenzaprine 5-10 mg three times daily is FDA-approved as an adjunct to rest and physical therapy for relief of muscle spasm 5
• Use only for short periods (2-3 weeks maximum) as evidence for prolonged use is lacking 5
• Start with 5 mg dose in elderly patients and titrate slowly; avoid in moderate-to-severe hepatic impairment 5
• Common side effect is drowsiness; warn patients about sedation 5

Non-Pharmacologic Interventions

Specific acupressure (conditional recommendation, low-certainty evidence) 1:

• May reduce pain and improve physical function
• Consider for patients preferring non-pharmacologic approaches or with contraindications to NSAIDs

Transcutaneous electrical nerve stimulation (TENS) (conditional recommendation, low-certainty evidence) 1:

• May reduce pain intensity
• Can be used as adjunct to pharmacologic therapy

Manual therapy 2, 6:

• Includes mobilization and soft tissue techniques for chest wall and thoracic spine
• Particularly useful for costochondritis and myofascial pain
• Consider referral to physical therapy or chiropractic care for persistent symptoms

Physical strategies 7:

• Ice application to affected area for 15-20 minutes every 2-3 hours during first 48 hours
• Postural correction and muscle stretching exercises 8

Critical Recommendation: Avoid Opioids

The guidelines explicitly recommend AGAINST using opioids, including tramadol, for acute musculoskeletal chest pain (conditional recommendation, low-certainty evidence) 1:

• Risk of opioid use disorder outweighs benefits for this self-limited condition
• No evidence that opioids provide superior pain relief compared to NSAIDs for musculoskeletal injuries
• Approximately 2 million persons in the US have opioid use disorder from prescription opioids 1

Common Pitfalls to Avoid

• Do not use nitroglycerin response as a diagnostic test: Relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain, as musculoskeletal pain may also respond 4
• Do not assume mild pain equals benign cause: Intensity of symptoms does not correlate with disease severity 4
• Do not overlook inflammatory causes: While costochondritis is common, consider rheumatoid arthritis, spondyloarthritis, or systemic lupus erythematosus in patients with systemic symptoms or multiple joint involvement 8
• Do not prescribe muscle relaxants long-term: Cyclobenzaprine is only indicated for 2-3 weeks maximum 5

Duration and Follow-Up

• Acute musculoskeletal chest pain typically lasts less than 4 weeks 1
• If symptoms persist beyond 4 weeks despite appropriate treatment, reassess for alternative diagnoses including inflammatory conditions 8
• Consider referral to rheumatology if inflammatory arthritis is suspected 8