What could be causing pain that radiates up towards the left breast area when pressing under the rib cage?

Pain Under Rib Cage Radiating to Left Breast Area

This pain pattern most likely represents costochondritis (Tietze syndrome) or another musculoskeletal chest wall condition, which accounts for 10-15% of perceived "breast pain" cases, and should be evaluated clinically to exclude the less common possibility of cardiac, pulmonary, or gastrointestinal referred pain. 1, 2

Understanding the Pain Pattern

• The nerve supply to the breast comes from intercostal nerves T3-T5, meaning irritation anywhere along their course—including the rib cage—can cause pain perceived in the breast area. 1, 2

• Extramammary (non-breast) causes are responsible for 10-15% of cases where patients report "breast pain," and your description of pressing under the rib cage triggering radiation upward strongly suggests a chest wall origin rather than true breast pathology. 1, 2

Most Likely Diagnoses

Musculoskeletal Causes (Most Common)

• Costochondritis (Tietze syndrome) is the most common chest wall condition mimicking breast pain and typically presents with reproducible tenderness when pressing on the rib cage or costochondral junctions. 1, 2

• Other musculoskeletal possibilities include pectoral muscle strains or spasms, entrapment of the lateral cutaneous branch of the third intercostal nerve, fibromyositis, or rib injury. 1

Serious Causes to Exclude

• Cardiac ischemia must be considered in the differential diagnosis of left-sided chest pain radiating upward, particularly if accompanied by exertional symptoms, shortness of breath, or risk factors for coronary disease. 1

• Pulmonary causes such as pleurisy or pulmonary embolus can present with chest wall pain that worsens with pressure or breathing. 1

• Gastrointestinal sources including gastroesophageal reflux, peptic ulcer disease, or gallbladder pathology can cause referred pain to this region. 1

Clinical Evaluation Approach

Key History Elements

• Determine if the pain is reproducible with palpation of specific chest wall locations—this strongly suggests musculoskeletal origin rather than visceral pathology. 1, 2

• Ask about relationship to physical activity, breathing, arm movements, or positional changes (suggests musculoskeletal). 1

• Inquire about cardiac risk factors, exertional symptoms, or associated shortness of breath (suggests cardiac evaluation needed). 1

• Document any relationship to meals, lying down, or acid reflux symptoms (suggests gastrointestinal origin). 1

Physical Examination Findings

• Press systematically along the costochondral junctions, sternum, and rib cage to reproduce the pain—positive findings confirm chest wall origin. 1, 2

• Perform a thorough breast examination to ensure no palpable masses, skin changes, or focal breast abnormalities are present. 2, 3

• Assess for cervical or thoracic spine tenderness, as nerve root syndrome from degenerative spinal changes can cause referred breast pain. 1

Imaging Considerations

• For isolated chest wall pain with normal breast examination and no palpable mass, breast imaging is usually not appropriate and does not increase cancer detection. 1

• The incidence of breast cancer in patients with breast pain as their only symptom is extremely low (0-3%), and even lower when pain is clearly extramammary in origin. 1

• If cardiac etiology cannot be excluded clinically, ECG and cardiac evaluation take priority over breast imaging. 1

• Chest X-ray may be considered if pulmonary causes are suspected. 1

Management Strategy

First-Line Treatment

• NSAIDs such as ibuprofen or naproxen are safe and effective first-line medications for musculoskeletal chest wall pain. 4, 3

• Application of ice packs or heating pads to the affected rib cage area can provide symptomatic relief. 4

• Avoid activities that exacerbate the pain while maintaining gentle range of motion. 4

When to Escalate Care

• Any concern for cardiac ischemia based on history or risk factors requires immediate cardiac evaluation—do not dismiss left-sided chest pain without appropriate cardiac workup. 1

• Persistent or worsening pain despite conservative management warrants further investigation. 2

• Development of new symptoms such as fever, shortness of breath, or systemic symptoms requires prompt re-evaluation. 1

Critical Pitfalls to Avoid

• Never dismiss left-sided chest pain without considering cardiac causes, especially in patients with risk factors—musculoskeletal pain should be a diagnosis of exclusion when cardiac disease is possible. 1, 2

• Do not order breast imaging for clearly extramammary pain with normal breast examination, as this does not improve outcomes and may lead to unnecessary additional testing. 1

• Always rule out extramammary causes (costochondritis, cervical radiculopathy, cardiac issues) when breast examination is normal—this is where the actual pathology lies in 10-15% of "breast pain" cases. 2, 4

• Failing to reproduce the pain with chest wall palpation may mean you haven't examined thoroughly enough or that a visceral cause needs investigation. 1, 2