From the Guidelines
Imaging for musculoskeletal chest wall pain should start with radiography of the chest, as it is usually appropriate for the initial imaging of patients with nontraumatic chest wall pain with no history of malignancy. This approach is supported by the American College of Radiology Appropriateness Criteria for nontraumatic chest wall pain 1. The initial use of chest radiography helps to rule out obvious bony abnormalities or lung pathology, guiding further management.
When considering advanced imaging for patients with nontraumatic chest wall pain, the choice depends on the clinical context:
- For patients with known or suspected malignancy, bone scan whole body and CT chest with IV contrast or CT chest without IV contrast are usually appropriate as the next imaging study after a normal chest radiograph 1.
- For suspected infectious or inflammatory conditions, CT chest with IV contrast or CT chest without IV contrast is usually appropriate as the next imaging study after a normal chest radiograph, with these procedures being equivalent alternatives 1.
- For patients with a history of prior chest intervention, CT chest with IV contrast or CT chest without IV contrast is usually appropriate as the next imaging study after a normal chest radiograph, again with these being equivalent alternatives 1.
It's crucial to consider the potential adverse health effects associated with radiation exposure, especially in pediatric patients, and to select imaging procedures accordingly, taking into account the relative radiation level (RRL) of each examination 1. A thorough physical examination and conservative management, including NSAIDs and activity modification, should be considered before pursuing imaging, reserving it for cases with specific indications such as trauma history, suspected fracture, or persistent pain despite conservative treatment.
From the Research
Musculoskeletal Chest Wall Pain Imaging
- Musculoskeletal chest wall pain can be caused by various conditions, including costochondritis, traumatic muscle pain, trauma to the chest wall, "fibrositis" syndrome, referred pain, psychogenic regional pain syndrome, and arthritis involving articulations of the sternum, ribs, and thoracic spine 2, 3, 4.
- A thorough history, physical examination, and results of investigation are essential for precise diagnosis and effective treatment of musculoskeletal chest wall disorders 2, 3, 4.
- Imaging studies, such as multidetector CT (MDCT) scans, can be useful in evaluating musculoskeletal causes of chest pain, including those of infectious, rheumatologic, and systemic causes 5.
- However, the evidence underpinning the treatment of specific localized causes of musculoskeletal chest wall pain is very limited, and further investigations should only be used when the provisional diagnosis suggests they are needed 3.
- In the emergency department, the initial evaluation of chest pain should focus on coronary artery disease and acute coronary syndromes, but also consider other potential causes, including musculoskeletal conditions 6.
Diagnostic Approaches
- A meticulous examination of the ribs, spine, sternum, and their articulations, along with a few judiciously selected diagnostic studies, can establish the diagnosis in most patients with musculoskeletal chest wall pain 4.
- MDCT scans can be effective in evaluating musculoskeletal causes of chest pain, and anyone interpreting these images must be familiar with the MDCT-imaging appearance of common musculoskeletal causes of acute nontraumatic chest pain 5.
- High sensitivity troponin (hs-cTn) can be used to safely rule out myocardial infarction (MI), and rule-out pathways, such as the high-STEACS and the ESC 0/1 and 0/2 pathways, can be used to quickly discharge patients with low risk of MI 6.