Evaluation and Management of Anterior Chest Wall Discomfort
Initial Evaluation Priority
For any patient over 35 years or with cardiac risk factors presenting with anterior chest wall discomfort, obtain an ECG immediately to exclude acute coronary syndrome before attributing symptoms to musculoskeletal causes. 1, 2
Clinical Assessment
Reproduce the pain with palpation of the costochondral junctions (ribs 2-5 most commonly affected) - this is the hallmark finding that confirms musculoskeletal origin and specifically costochondritis, which accounts for 42% of nontraumatic chest wall pain 3, 4
Characterize the pain pattern: typically described as stinging (53%) or pressing (35%), commonly retrosternal (52%) or left-sided (69%), occurring more than once daily (63%), with chronic symptoms lasting >6 months in 55% of cases 1, 4
Examine for visible swelling at costochondral junctions to distinguish Tietze syndrome (localized inflammation with swelling) from simple costochondritis 3
Assess ribs 6-7 specifically for slipping rib syndrome if pain localizes to lower costal margin 3, 4
Imaging Algorithm
First-Line Imaging
Chest radiography is the appropriate initial imaging study after history and physical examination to evaluate for rib fractures, pneumothorax, infection, or neoplasm that may simulate chest wall pain 3, 2
- Avoid routine rib series radiography as it adds minimal diagnostic value beyond standard chest radiography (fractures detected in <5% of cases) 1, 2
Advanced Imaging - When to Consider
Ultrasound should be the next step if radiographs are normal but clinical suspicion remains high, as it has higher sensitivity than CT for detecting costochondral abnormalities not visible on plain films 3, 2
CT chest is NOT first-line for uncomplicated musculoskeletal chest wall pain without trauma, infection, or malignancy risk factors 2
MRI is indicated when:
- Suspected spondyloarthritis with anterior chest wall pain (62.5% sensitive for sternoclavicular/sternocostal involvement, superior to bone scintigraphy for disease activity) 1
- Suspected necrotizing fasciitis (hyperintense signal in deep fascial compartments is highly suggestive; absence essentially excludes disease) 1
- Differentiating infection from tumor 1
Bone scintigraphy may be useful for undifferentiated costochondral pain and swelling as a highly sensitive indicator of osseocartilaginous disease, though insufficient specificity to differentiate inflammatory processes from tumors 3
Treatment Algorithm
Pharmacological Management
Initiate a 1-2 week course of NSAIDs as first-line therapy for pleuritic-type pain or inflammatory component 4
Add low-dose colchicine if symptoms persist despite NSAID therapy 4
Alternative options:
- Acetaminophen if NSAIDs contraindicated 4
- Topical lidocaine patches for localized pain relief with minimal systemic effects 4
Non-Pharmacological Measures
Apply ice packs or heat in conjunction with drug therapy 4, 2
Follow-Up Strategy
Reassess patients with persistent symptoms beyond expected timeframe to rule out other potential causes, as >55% have chronic symptoms lasting >6 months 4, 2
Critical Pitfalls to Avoid
Never assume musculoskeletal origin without ECG in patients >35 years or with cardiac risk factors - spontaneous coronary artery dissection can occur even with activities like heavy lifting in otherwise healthy individuals 2
Consider systemic inflammatory conditions in the differential: anterior chest wall pain affects 30-60% of those with axial spondyloarthritis and may be the first manifestation in 4-6% of patients 1, 3
Evaluate for SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis) in patients with chronic relapsing symptoms involving sternoclavicular joints 3