What are the causes and treatments of chest pain that worsens with deep breathing or raising arms above the head?

Chest Pain with Deep Breathing or Arm Elevation: Diagnostic Approach and Management

Chest pain that worsens with deep breathing or raising arms above the head strongly suggests a benign musculoskeletal or pleuritic cause rather than cardiac ischemia, but life-threatening conditions must still be excluded through systematic evaluation. 1

Key Diagnostic Features

Indicators of Less Severe (Non-Cardiac) Conditions

The European Heart Journal guidelines explicitly identify pain characteristics that argue against serious cardiac pathology 1:

• Pain that varies with respiration (your primary symptom)
• Pain that changes with body position (such as raising arms)
• Pain well localized on the chest wall
• Pain accompanied by local tenderness to palpation

These features have the highest diagnostic value for ruling out angina in patients without prior coronary disease history 1.

Differential Diagnosis by Physical Examination

The 2021 AHA/ACC guidelines provide specific examination findings to distinguish causes 1:

Musculoskeletal causes:

• Costochondritis/Tietze syndrome: Tenderness of costochondral joints on palpation 1
• Chest wall pain syndromes: Pain reproduced by palpation, turning, twisting, or bending 1

Pleuritic causes (respiratory-related):

• Pneumothorax: Dyspnea with inspiration, unilateral absence of breath sounds 1
• Pneumonia: Fever, localized pleuritic pain, friction rub, regional dullness to percussion, egophony 1
• Pulmonary embolism: Tachycardia (>90% of patients), dyspnea, pain with inspiration 1

Cardiac causes (less likely with your symptoms):

• Pericarditis: Fever, pleuritic chest pain that increases in supine position (not with arm elevation), friction rub 1

Immediate Triage Algorithm

Step 1: Exclude Life-Threatening Conditions

Even with pleuritic features, certain presentations require immediate emergency evaluation 1:

Call 9-1-1 immediately if pain is accompanied by 1:

• Cold sweats, nausea, vomiting
• Fainting or near-syncope
• Severe anxiety or sense of impending doom
• Interruption of normal activities due to severity
• Sudden onset with severe intensity

Specific red flags requiring urgent hospital care 1:

• Pneumothorax (sudden onset, unilateral breath sound absence)
• Pulmonary embolism (tachycardia, dyspnea, risk factors)
• Aortic dissection (ripping pain radiating to back, pulse differential)
• Esophageal rupture (emesis, subcutaneous emphysema)

Step 2: Office-Based Evaluation

For stable patients presenting to office with pleuritic chest pain 1:

1. ECG must be performed unless a clearly noncardiac cause is evident 1

   • If ECG unavailable, refer to ED for evaluation 1
   • ECG should be obtained within 10 minutes if acute presentation 1

2. Physical examination priorities 1:

   • Palpate costochondral joints for tenderness
   • Assess breath sounds bilaterally
   • Check for chest wall tenderness with palpation
   • Attempt to reproduce pain with movement/positioning

3. If clinical evidence suggests ACS or life-threatening cause, transport urgently to ED by EMS (not personal vehicle) 1

Most Likely Diagnoses

Costochondritis (Most Common)

This is the most prevalent diagnosis for chest wall pain in primary care, accounting for the majority of musculoskeletal chest pain cases 1:

• Tenderness at costochondral junctions 1
• Pain reproduced by palpation 1
• Worsens with deep breathing, coughing, arm movements 2, 3
• No specific diagnostic test required; clinical diagnosis 2

Treatment approach 2, 3:

• NSAIDs for pain relief
• Local heat application
• Avoidance of aggravating movements
• Reassurance about benign nature

Pleurisy/Pleuritis

Sharp, localized pain that worsens with inspiration 4:

• May be associated with viral infection, pneumonia, or autoimmune conditions 4
• Friction rub may be present on auscultation 1
• Chest X-ray indicated if fever, cough, or systemic symptoms present 4

Critical Pitfalls to Avoid

Do not assume benign cause without proper evaluation 1:

• Musculoskeletal pain is most common, but cardiac problems account for 10-34% of chest pain episodes 1
• Physical examination "contributes almost nothing" to diagnosing myocardial infarction in uncomplicated cases 1
• Pain severity is a poor predictor of serious conditions 1

Delayed transfer for suspected ACS is harmful 1:

• Patients with suspected ACS initially evaluated in office should NOT have delayed transfer to ED for troponin testing 1
• Time-to-treatment directly impacts mortality (23 lives saved per 1000 per hour of delay) 1

Age and gender modify risk assessment 1:

• Likelihood of angina increases dramatically with age (men: 67% at age 30-39 to 94% at age 60-69) 1
• Women may underestimate their coronary disease risk 5

When Cardiac Workup Is Still Indicated

Despite pleuritic features, obtain ECG and consider cardiac evaluation if 1:

• Age >40 years with cardiovascular risk factors
• Prior history of coronary artery disease
• Associated symptoms: diaphoresis, nausea, radiation to arm/jaw
• Pain that interrupts normal activities despite pleuritic quality