What causes chest pain when bending over and how is it treated?

Chest Pain When Bending Over: Causes and Treatment

Chest pain that occurs specifically when bending over is most likely musculoskeletal in origin, particularly costochondritis, which accounts for approximately 42% of nontraumatic musculoskeletal chest wall pain and is readily diagnosed by physical examination showing reproducible tenderness at the costochondral junctions. 1, 2

Key Diagnostic Features That Point Away From Cardiac Causes

Positional chest pain is usually nonischemic and several characteristics make cardiac ischemia unlikely: 1

• Pain that increases with specific body positions (like bending forward) suggests musculoskeletal origin 1, 3
• Pain that can be localized to a very limited area is unlikely related to myocardial ischemia 1
• Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease 1
• Pain relieved immediately by lying down or brought on by bending forward strongly suggests nonanginal origin 3

Most Likely Causes

Costochondritis (Primary Consideration)

This is the most common cause of nontraumatic musculoskeletal chest wall pain and should be your first consideration. 1, 2, 4

• Pain is typically described as stinging (53%) or pressing (35.1%), commonly retrosternal (52%) or left-sided (69.2%) 4
• The hallmark diagnostic finding is tenderness to palpation of the costochondral joints 2, 4
• Pain is reproducible with palpation of affected costochondral joints 4
• Symptoms often occur more than once daily (62.9%) and may be chronic, lasting >6 months (55.4%) 4

Other Musculoskeletal Causes

• Chest wall pain syndromes, benign overuse myalgia, and fibrositis should be considered 5, 6
• Tietze syndrome involves localized inflammation with visible swelling at costochondral junctions 2
• Slipping rib syndrome causes pain with ribs subluxing from the joint 2

Gastrointestinal Causes

Gastroesophageal reflux disease can mimic cardiac pain and may worsen with bending over due to increased reflux. 1, 7

• Pain described as squeezing or burning, often occurring after meals or at night 1, 7
• May improve with antacids 7
• Duration can be minutes to hours 1

Initial Evaluation Approach

History Taking

Obtain a focused history characterizing the pain by quality, location, radiation, onset, duration, precipitating factors (specifically bending), and relieving factors. 1, 7

• Assess for associated symptoms: diaphoresis, dyspnea, nausea, vomiting, or syncope (their absence makes cardiac causes less likely) 1, 7
• Document cardiovascular risk factors 1

Physical Examination

Systematically palpate the costochondral junctions, sternoclavicular joints, and chest wall for reproducible tenderness. 2, 4

• Point tenderness suggests musculoskeletal origin rather than ischemia 7
• Assess vital signs and cardiovascular examination 7
• Evaluate for chest wall tenderness and respiratory findings 7

Diagnostic Testing

For patients older than 35 years or with cardiac risk factors, obtain an ECG within 10 minutes to rule out cardiac causes. 1, 2

• Chest radiography is useful to identify pulmonary causes and evaluate for pneumothorax, pneumonia, or mediastinal abnormalities 1, 7
• Basic laboratory tests including complete blood count and basic metabolic panel should be considered 7

Treatment Algorithm

For Confirmed Costochondritis

First-line treatment is a 1-2 week course of NSAIDs for the inflammatory component. 4

• Apply ice packs or heat as adjunctive non-pharmacological measures 4
• Consider topical analgesics like lidocaine patches for localized pain relief with minimal systemic effects 4
• Use acetaminophen as an alternative if NSAIDs are contraindicated 4

If symptoms persist despite NSAID therapy, add low-dose colchicine. 4

• Reassess to rule out other potential causes if pain persists 4

For Suspected Gastrointestinal Causes

For recurrent chest pain with no cardiac or pulmonary cause identified, evaluation for gastrointestinal causes is reasonable. 1

• Consider a trial of empiric acid suppression therapy 1
• If symptoms persist despite acid suppression and upper endoscopy is normal, consider esophageal function testing and pH monitoring 1

Critical Pitfalls to Avoid

Do not use relief with nitroglycerin as a diagnostic criterion for cardiac ischemia, as cervical root compression pain and esophageal spasm can both be relieved by nitroglycerin. 1, 8, 3

• Avoid describing chest pain as "atypical" as this can be misinterpreted as benign; instead characterize it as cardiac, possibly cardiac, or noncardiac 1, 7
• Do not delay transfer to the ED if acute coronary syndrome cannot be excluded in the office setting 1
• Always consider life-threatening causes (aortic dissection, pulmonary embolism, pneumothorax) even when musculoskeletal pain seems likely 1, 9

When to Escalate Care

Transport urgently to the ED if the patient has:

• Ripping chest pain with sudden onset (suspicious for aortic dissection) 1
• Associated severe dyspnea, diaphoresis, or hemodynamic instability 1
• ECG changes suggesting ischemia or injury 1
• Pain that is different from typical episodes or persists despite initial management 8