Chest Wall Tenderness in Pleurisy and Pleural Effusion
Yes, the chest area can be painful to touch in patients with pleurisy or pleural effusion, though this is not a universal finding and represents chest wall tenderness rather than direct pleural pain.
Understanding the Pain Mechanism
The characteristic pain of pleurisy is pleuritic chest pain—sharp, stabbing, or "knifelike" pain that worsens with deep breathing, coughing, or respiratory movements 1. This occurs due to inflammation or irritation of the pleura itself 1.
Key Clinical Features:
- Pleuritic pain is the dominant symptom, occurring in approximately 75% of patients with pulmonary embolism and pleural effusion 2, 3
- The pain is typically localized to the affected side and described as sharp rather than dull 2, 1
- Pain intensity increases with respiratory movements, distinguishing it from cardiac or musculoskeletal causes 1
Chest Wall Tenderness on Palpation
Chest wall tenderness to palpation can occur but is not the primary manifestation of pleural disease:
- When present, reproducible pain with chest wall palpation may suggest musculoskeletal origin rather than pure pleural inflammation 1
- However, this finding does not rule out serious conditions—7% of patients with reproducible pain on palpation still have acute coronary syndrome 1
- A pleural friction rub (sounding like creaking leather or walking on fresh snow) may be audible on examination and indicates pleural inflammation 1, 4
Clinical Presentation Patterns
Pleurisy:
- Patients typically present with pleuritic chest pain and may have a friction rub on examination 4
- The pain is provoked by respiratory movements rather than external pressure 1
Pleural Effusion:
- Dyspnea is the most common presenting symptom (occurring in more than half of cases), along with pleuritic chest pain 2
- In malignant effusions, chest pain is described as dull and aching rather than pleuritic, particularly in mesothelioma 2
- Large effusions may cause less pleuritic pain as the fluid separates the inflamed pleural surfaces 5
Important Clinical Pitfalls
Do not rely on chest wall tenderness alone to diagnose or exclude pleural disease:
- The absence of tenderness does not exclude pleurisy or effusion 1
- Conversely, the presence of reproducible tenderness does not rule out serious underlying conditions 1
- Always correlate with respiratory variation of pain—true pleuritic pain worsens with breathing, while pure musculoskeletal pain may not 1, 6
Diagnostic Approach
When evaluating suspected pleural disease with chest pain:
- Assess whether pain worsens with deep breathing (pleuritic) versus external palpation (musculoskeletal) 1
- Listen for pleural friction rub, which is biphasic (heard during both inspiration and expiration) and not cleared by coughing 1
- Obtain chest radiography as the essential first-line imaging 1
- Perform thoracentesis for new and unexplained pleural effusions to determine etiology 2, 5