Can Upper MSK Pain Radiate to Left Chest?
Yes, upper musculoskeletal pain commonly radiates to the left chest and is a frequent cause of left-sided chest pain, accounting for 20-50% of chest pain presentations in primary care settings. 1
Key Clinical Evidence
Musculoskeletal chest pain frequently presents on the left side, with one large series documenting that 69.2% of patients with musculoskeletal chest wall pain experienced left-sided symptoms. 1 This left-sided predominance makes MSK pain a critical differential diagnosis that must be distinguished from cardiac causes.
Diagnostic Features of MSK-Related Left Chest Pain
Characteristics That Suggest MSK Origin
Pain reproducible by palpation over specific chest wall structures (ribs, costochondral joints, muscles) is the hallmark finding and provides the highest diagnostic value for confirming musculoskeletal origin. 2, 3, 4
Positional pain that worsens with specific postures or physical activities strongly suggests MSK etiology rather than cardiac ischemia. 1
Sharp, stabbing quality that can be localized to a very limited area, unlike the diffuse pressure of angina. 1
Pain that increases with inspiration or specific movements of the chest wall or upper extremities. 1
Common MSK Sources That Radiate to Left Chest
Costochondritis accounts for 42% of nontraumatic musculoskeletal chest wall pain and commonly affects the left side. 1
Cervical spine disorders with referred pain patterns extending to the chest wall. 3, 4, 5
Thoracic spine pathology including arthritis of sternoclavicular and manubriosternal joints. 1
Myofascial pain syndromes and fibromyalgia affecting chest wall muscles. 6, 3, 4
Critical Pitfall: Excluding Life-Threatening Causes First
Before attributing left chest pain to MSK causes, you must systematically exclude cardiac and other life-threatening etiologies, as this is a diagnosis of exclusion. 6, 3, 4
Red Flags Requiring Urgent Cardiac Evaluation
Gradual onset over minutes with pressure/heaviness/squeezing quality radiating to left arm, jaw, or neck suggests cardiac ischemia, not MSK pain. 1
Associated symptoms including diaphoresis, dyspnea, nausea, syncope, or palpitations indicate potential acute coronary syndrome. 1
Women, elderly patients, and diabetics may present with atypical symptoms including sharp or left-sided pain that is actually cardiac in origin—never dismiss based on "atypical" features alone. 1, 7
Pain at rest or with minimal exertion suggests acute coronary syndrome rather than stable angina or MSK pain. 1
Immediate Evaluation Required
Obtain ECG within 10 minutes of presentation for any patient with left chest pain to exclude ST-segment changes, Q waves, or T-wave inversions. 7, 8, 9
Measure cardiac troponin immediately if any suspicion of acute coronary syndrome exists, even if MSK cause seems likely. 7, 8, 9
Do NOT use nitroglycerin response as a diagnostic test—esophageal spasm and other non-cardiac conditions also respond to nitroglycerin, making this an unreliable discriminator. 1, 7
Confirming MSK Diagnosis
Once life-threatening causes are excluded, the key to confirming MSK origin is reproducing the patient's exact pain through palpation or specific movements. 2, 3, 4
Physical Examination Approach
Systematically palpate costochondral junctions, sternoclavicular joints, ribs, and chest wall muscles to reproduce pain. 2, 3, 4
Assess cervical and thoracic spine range of motion and palpate for tenderness with referred pain patterns. 3, 4, 5
Test specific movements that stress chest wall structures (arm elevation, trunk rotation, deep inspiration). 2, 4
When Imaging Is NOT Needed
Most MSK chest wall pain is diagnosed by physical examination alone without need for diagnostic imaging, particularly in cases of costochondritis. 1 Imaging should be reserved for cases where examination is inconclusive or when specific pathology (fracture, infection, inflammatory arthritis) is suspected.
Management Once MSK Origin Confirmed
Reassurance and explanation are critical to allay anxiety once cardiac causes are excluded. 2
Manual therapy and physical therapy including transcutaneous electrical stimulation and stabilization exercises. 6
Analgesia and anti-inflammatory agents (topical, oral, or injection) for symptomatic relief. 2, 6
Focal injection of local anesthetic can serve both diagnostic and therapeutic purposes. 2