Musculoskeletal Chest Pain (Costochondritis)
This is most likely musculoskeletal chest pain (costochondritis), given the patient's young age, chest wall tenderness on palpation, and pain worsening with movement—however, you must still rule out life-threatening causes before making this diagnosis.
Immediate Priority: Exclude Life-Threatening Causes
While the clinical features strongly suggest a benign musculoskeletal etiology, the 2021 AHA/ACC guidelines mandate that your initial evaluation focus on rapidly identifying potentially life-threatening conditions 1:
Perform These Steps First:
- Obtain an ECG immediately (within 10 minutes if possible) to exclude acute coronary syndrome, even though ACS is unlikely in this presentation 1
- Focused cardiovascular examination to assess for signs of ACS (diaphoresis, tachycardia, hypotension, S3 gallop), aortic dissection (pulse differential), or pulmonary embolism (tachycardia with dyspnea) 1
- Assess vital signs for tachycardia, hypotension, or respiratory distress 1
Red Flags That Would Change Management:
If any of these are present, immediate emergency referral is required 1, 2:
- Sudden onset of severe "ripping" pain (suggests aortic dissection)
- Diaphoresis, nausea, vomiting, or radiation to arm/jaw/neck (suggests ACS)
- Dyspnea with tachycardia (suggests PE)
- Hemodynamic instability
- Abnormal ECG findings
Why This Is Likely Musculoskeletal
The clinical presentation has multiple features that point away from cardiac disease 1, 2:
- Tenderness on palpation is the hallmark finding of musculoskeletal chest pain and provides the highest diagnostic information against angina 2
- Pain worsening with movement (turning, twisting, bending) is a reassuring feature that suggests musculoskeletal origin 2
- Young age (27 years) with presumably low cardiac risk factors makes ACS extremely unlikely 3
- Localized pain that can be reproduced with palpation markedly reduces the probability of ACS 1, 2
The 2021 AHA/ACC guidelines specifically identify "tenderness of costochondral joints" as consistent with costochondritis and Tietze syndrome 1, 2.
Diagnostic Approach
Physical Examination Findings to Confirm:
- Palpate the costochondral junctions systematically—tenderness at these specific points confirms costochondritis 1, 2
- Reproduce the pain with chest wall palpation or movement 2
- Assess for point tenderness in a localized area, which makes cardiac ischemia less likely 2
When ECG and Cardiac Workup Are Normal:
Once you have excluded life-threatening causes with a normal ECG and examination, the diagnosis of musculoskeletal chest pain can be made clinically 2, 3.
Treatment for Musculoskeletal Chest Pain
- NSAIDs (ibuprofen 400-600mg three times daily or naproxen 500mg twice daily) are first-line treatment 4
- Avoid aggravating movements and activities that reproduce the pain 4
- Reassurance that this is a benign condition is crucial 4, 3
- Heat or ice application to the affected area may provide symptomatic relief 4
- Symptoms typically resolve within days to weeks with conservative management 4
Critical Pitfall to Avoid
Never assume musculoskeletal pain without proper cardiac evaluation first. The 2021 AHA/ACC guidelines emphasize that despite musculoskeletal findings being reassuring, the initial evaluation must still focus on ruling out life-threatening causes 2. An uncomplicated myocardial infarction can present with a completely normal examination in a young patient 1, 5.
When to Reassess or Refer
Return immediately or seek emergency care if 2:
- Pain becomes severe or changes character
- New symptoms develop (diaphoresis, dyspnea, radiation to arm/jaw)
- Pain interrupts normal activity
- Associated tachycardia or hypotension develops