What are the treatment options for sternum pain that worsens with twisting?

Sternum Pain with Twisting: Treatment Approach

For sternum pain that worsens with twisting, the primary treatment is conservative management with NSAIDs, local heat application, and targeted stretching exercises, after first ruling out life-threatening cardiac and traumatic causes through focused physical examination and selective diagnostic testing. 1, 2

Immediate Assessment to Exclude Emergent Causes

Before initiating treatment for presumed musculoskeletal sternum pain, you must systematically exclude cardiac and other serious pathology:

• Perform a focused cardiovascular examination looking specifically for diaphoresis, tachycardia, hypotension, new murmurs, or signs of heart failure that would suggest acute coronary syndrome rather than musculoskeletal pain 1
• Palpate the costochondral joints to determine if the pain is reproducible with direct pressure over the sternum or costochondral junctions—this finding strongly supports a musculoskeletal diagnosis (costochondritis or Tietze syndrome) 1
• Obtain an ECG within 10 minutes if there is any uncertainty about cardiac origin, particularly if the patient has cardiovascular risk factors, as positional chest pain is usually nonischemic but cardiac causes must be definitively excluded 1, 3

Critical pitfall: Do not assume all reproducible chest wall pain is benign—persistent or progressive sternal swelling requires imaging to exclude malignancy (lymphoma, chondrosarcoma) or infection 4

Conservative Treatment Protocol for Confirmed Musculoskeletal Pain

Once cardiac and serious pathology are excluded through examination findings of tenderness at costochondral joints without systemic signs:

• Initiate NSAIDs as first-line pharmacologic therapy for pain relief and anti-inflammatory effect, though evidence shows this approach can be disappointing as monotherapy 2
• Prescribe structured stretching exercises as the primary therapeutic intervention, which have demonstrated progressive significant improvement compared to controls (p<0.001) in reducing costochondritis pain 2
• Apply local heat to the affected costochondral junctions to provide symptomatic relief 2
• Consider local splinting for severe cases, though this is less commonly used 2

Specific Stretching Exercise Protocol

The stretching regimen should target the anterior chest wall and costochondral junctions specifically, as this intervention has shown superior outcomes to NSAIDs alone in treating costochondritis 2

Expected Timeline and Follow-up

• Counsel patients that symptoms typically persist for a mean of 10.9 weeks following sternal injury, with significantly prolonged duration in patients over age 50 (p<0.03) 5
• Provide formal written advice regarding rehabilitation expectations and prognosis, as studies show current discharge instructions are often poor and variable 5
• Arrange follow-up at 2-4 weeks to reassess response to conservative therapy 2

Red Flags Requiring Advanced Imaging

If pain persists beyond expected timeframe or clinical features are atypical, obtain CT or MRI to exclude:

• Sternal fracture or dislocation from unrecognized trauma 6
• Sternal osteomyelitis or septic arthritis if fever, systemic symptoms, or risk factors for infection are present 6
• Primary sternal tumors (non-Hodgkin lymphoma, chondrosarcoma) if there is progressive sternal mass or swelling 4
• Post-sternotomy complications including wire suture reactions, sternal dehiscence, or nonunion in patients with prior cardiac surgery 7, 6

Important caveat: In patients 2-84 months post-sternotomy, consider sternal wire suture reaction causing nerve entrapment if pain is sharp, stabbing, or deep-seated—this requires wire removal for symptom relief 7

Special Considerations for Trauma Patients

For patients with known or suspected sternal fracture from blunt trauma:

• Recognize that manubriosternal dislocations can occur in children aged 10-11 from trampoline injuries involving thoracic hyperflexion, typically healing uneventfully but occasionally requiring surgical stabilization if pain persists 1
• Provide adequate analgesia as chest pain is the predominant persisting symptom, and current evidence shows analgesia prescribing at discharge is often inadequate 5
• Inform patients about prolonged recovery and provide written documentation to their primary care physician outlining expected prognosis 5