What could be causing burning pain on the upper body under the breast that radiates from front to back?

Burning Pain Under Breast Radiating Front to Back

This burning pain radiating in a band-like distribution from front to back is most likely extramammary (non-breast) pain caused by musculoskeletal or neurological conditions, particularly intercostal nerve irritation, costochondritis, or chest wall muscle strain, rather than true breast pathology. 1

Understanding the Pain Pattern

The key distinguishing feature here is the radiating, band-like distribution wrapping from front to back, which strongly suggests:

• Intercostal nerve irritation affecting the T3-T5 nerve roots that supply sensation to the breast area and chest wall 1
• The breast receives nerve supply from anterolateral and anteromedial branches of intercostal nerves T3-T5, and irritation anywhere along their course produces this characteristic radiating pattern 1, 2
• This accounts for 10-15% of cases perceived as "breast pain" but actually originating from extramammary sources 1

Most Likely Diagnoses (In Order of Probability)

Musculoskeletal Causes

• Costochondritis (Tietze syndrome) - inflammation of the rib cartilage producing sharp, burning pain that radiates along the chest wall 1, 2
• Pectoral muscle strain or spasm - particularly if there's been recent physical activity, poor posture, or repetitive movements 1
• Intercostal nerve entrapment - specifically the lateral cutaneous branch of the third intercostal nerve 1
• Fibromyositis or myalgia affecting the chest wall muscles 1

Neurological Causes

• Thoracic or cervical nerve root syndrome - radiculopathy producing dermatomal pain distribution 1
• Shingles (herpes zoster) - especially if the pain precedes a rash, produces characteristic burning quality in a dermatomal pattern 1

Less Common but Serious Causes to Exclude

• Coronary ischemia - must be considered in appropriate risk profiles, though typically presents with exertional component 1
• Pulmonary causes including pleurisy or pulmonary embolus 1
• Esophageal disease such as gastroesophageal reflux, achalasia, or hiatal hernia 1

Immediate Evaluation Steps

Clinical Examination Focus

• Reproduce the pain by palpating the chest wall, rib margins, and costochondral junctions - if reproducible, strongly suggests musculoskeletal origin 1
• Assess for dermatomal distribution - does it follow a specific nerve pathway? 2
• Check for visible skin changes - rash, erythema, or vesicles suggesting shingles 1
• Examine breast tissue separately - true breast pathology produces focal, localizable breast tenderness, not radiating band-like pain 1, 2

When Imaging is NOT Needed

• Diffuse, non-focal pain with normal breast examination does not require breast imaging 3, 2
• Cyclical pain related to menstrual cycle requires no imaging beyond routine age-appropriate screening 2
• Extramammary pain with reproducible chest wall tenderness and normal breast exam does not warrant mammography 1, 3

When Imaging IS Indicated

• Focal, unilateral breast pain that is precisely localizable within breast tissue requires diagnostic mammogram with ultrasound (age ≥30) or ultrasound alone (age <30) 3, 4
• Any palpable mass or skin changes regardless of pain pattern 5
• Axillary lymphadenopathy accompanying the pain requires urgent imaging and possible biopsy 4

Treatment Algorithm

First-Line: Conservative Management

• NSAIDs (ibuprofen or naproxen) for anti-inflammatory effect and pain relief 3, 6, 5
• Ice or heat application to the affected chest wall area for comfort 3
• Well-fitted supportive bra to minimize breast movement that may aggravate chest wall pain 3, 7
• Posture correction and avoiding aggravating movements 7

Second-Line: Targeted Interventions

• Physical therapy with stretching exercises for musculoskeletal causes 3
• Topical NSAIDs applied directly to the painful area if oral NSAIDs insufficient 7
• Nerve blocks for persistent intercostal neuralgia (requires specialist referral) 7

Reassurance Component

• Explain that breast pain alone rarely indicates cancer - cancer risk with pain as sole symptom is 1.2-6.7%, and radiating band-like pain is even less concerning for malignancy 3, 8
• Reassurance alone resolves symptoms in 86% of mild cases and 52% of severe cases 3

Critical Red Flags Requiring Urgent Evaluation

• Cardiac risk factors with exertional component - consider acute coronary syndrome 1
• Sudden onset with dyspnea - consider pulmonary embolus 1
• Fever, productive cough - consider pulmonary infection or pleurisy 1
• Palpable breast mass or axillary adenopathy - requires imaging and possible biopsy 4, 5
• Unilateral focal breast tenderness distinct from the radiating pain - warrants breast imaging 2, 7

Common Pitfalls to Avoid

• Ordering unnecessary breast imaging for clearly extramammary pain - this increases healthcare utilization without improving outcomes and may increase patient anxiety 1, 3
• Dismissing pain without proper chest wall examination - failing to reproduce pain by palpation misses the diagnosis 1
• Assuming all chest pain in women is musculoskeletal - must exclude cardiac and pulmonary causes in appropriate clinical contexts 1
• Failing to consider shingles before rash appears - early antiviral treatment is most effective 1

Special Considerations

For Smokers

• If burning pain is specifically behind the nipple (subareolar), consider periductal inflammation and strongly advise smoking cessation 3, 2

For Postmenopausal Women

• Noncyclical pain is more common after age 50, but the radiating pattern still suggests extramammary origin 1
• Lower threshold for cardiac workup in this population 1

Duration and Follow-up

• Most extramammary breast pain resolves spontaneously within weeks with conservative management 8, 9
• If pain persists beyond 4-6 weeks despite treatment, consider specialist referral (neurology for nerve-related pain, cardiology if cardiac concerns, rheumatology for fibromyalgia) 7