What could be causing a pulsating sensation under the right breast fold near the sternal border?

Pulsating Sensation Under Right Breast Fold Near Sternal Border

Most Likely Diagnosis

This pulsating sensation is most likely a normal finding representing visualization or palpation of the abdominal aorta or internal mammary artery pulsations, though a mammary souffle (innocent vascular murmur) should be considered if you can auscultate a continuous murmur over the area. 1

Diagnostic Approach

Initial Clinical Assessment

Determine if this is a visible pulsation, palpable pulsation, or audible bruit:

• Visible/palpable pulsation without audible sound: Most commonly represents normal vascular pulsations from the abdominal aorta (whose pulse can be palpated at the level of the umbilicus and may transmit upward) or internal mammary artery branches 1

• Audible continuous murmur with systolic accentuation: Consider mammary souffle, which is an innocent murmur with medium or high pitched, blowing character with continuous flow and systolic accentuation heard over or above the breasts that disappears with compression of the breast tissue 1

Key Physical Examination Maneuvers

• Apply gentle compression over the pulsating area: If the pulsation/murmur disappears with compression, this confirms mammary souffle as a benign finding 1

• Assess for associated breast pain: If severe focal pain is present without visible skin changes, consider pre-eruptive herpes zoster (T4-T6 dermatomes commonly affect the breast area) and examine carefully for subtle erythema, edema, or early vesicles 2

• Check for palpable cord-like structure: If present with pain, consider Mondor disease (thrombosed thoracoepigastric vein) 2, 3

When Imaging Is NOT Needed

Do not order imaging for:

• Isolated pulsation without pain, mass, or other concerning symptoms 4, 5
• Confirmed mammary souffle that disappears with compression 1
• Cyclical breast symptoms related to menstrual cycle 4, 5

When Imaging IS Indicated

Order diagnostic imaging if:

• Focal, persistent, unilateral pain accompanies the pulsation (risk of underlying malignancy 1.2-6.7% with noncyclical focal breast pain) 2, 3

• Palpable mass is present: Ultrasound is first-line to avoid radiation exposure 3, 6

• Age-appropriate imaging protocol:

  • Women <30 years: Ultrasound alone 2, 6
  • Women ≥30 years: Diagnostic mammography with ultrasound 2, 6

• Suspected vascular abnormality with pulsatile tinnitus or bruit: CT angiography of head and neck may be warranted, though this is rare for isolated breast area findings 1

Differential Diagnoses to Exclude

Benign Vascular Causes

• Normal arterial pulsations: Abdominal aorta or internal mammary artery branches 1
• Mammary souffle: Benign vascular murmur that resolves with compression 1

Pain-Associated Conditions (If Pain Present)

• Pre-eruptive herpes zoster: Severe burning/electric pain in dermatomal pattern (T4-T6) before rash appears; start antivirals immediately if suspected 2
• Mondor disease: Sudden pain with palpable cord (thrombosed vein), visible cord develops within days 2, 3
• Costochondritis (Tietze syndrome): Chest wall pain mimicking breast pain, accounts for 10-15% of "breast pain" cases 3

Malignancy Considerations

• Invasive lobular carcinoma and anaplastic carcinoma are disproportionately associated with mastalgia compared to other cancer types 3, 7
• Advanced cancers with chest wall invasion may present with focal pain as the only symptom 3

Management Algorithm

1. Perform focused physical examination:

   • Auscultate for murmur and test compression maneuver 1
   • Palpate for masses or cord-like structures 2, 3
   • Examine skin for subtle early herpes zoster signs 2

2. If mammary souffle confirmed (disappears with compression):

   • Provide reassurance that this is benign 1
   • No imaging needed 4, 5

3. If focal pain present without clear benign cause:

   • Order age-appropriate imaging (ultrasound alone if <30 years; mammography + ultrasound if ≥30 years) 2, 6
   • If herpes zoster suspected, start antivirals immediately 2

4. If imaging shows BI-RADS 1-3 and pain persists:

   • Provide reassurance 2
   • NSAIDs (ibuprofen or naproxen) for pain relief 2
   • Supportive bra and ice/heat application 2

Critical Pitfalls to Avoid

• Never dismiss focal, unilateral breast pain without proper evaluation, as some cancers present with pain alone 3, 7
• Do not order inappropriate imaging for isolated pulsation without other symptoms, as this wastes healthcare resources 4, 5
• Always consider extramammary causes (costochondritis, cervical radiculopathy) when breast exam is normal, as these account for 10-15% of "breast pain" cases 3
• Do not miss pre-eruptive herpes zoster by waiting for rash to appear; severe dermatomal pain warrants immediate antiviral therapy 2