I have sternal chest pain with tenderness over the paraspinal muscles; what is the likely diagnosis and how should it be managed?

Sternal Chest Pain with Paraspinal Muscle Tenderness: Likely Diagnosis and Management

This presentation is most consistent with musculoskeletal chest pain, specifically costochondritis or chest wall strain, given the reproducible tenderness and lack of features suggesting life-threatening cardiac or other serious pathology.

Initial Critical Assessment

The first priority is to exclude life-threatening causes of chest pain, particularly acute coronary syndrome (ACS), which carries the highest mortality risk 1, 2. However, several features make this presentation lower risk for cardiac ischemia:

• Pain reproducible with palpation (paraspinal muscle tenderness) is a characteristic feature of musculoskeletal pain and argues against cardiac ischemia 1, 2
• Localized tenderness on examination is specifically noted as an indicator of a less severe, non-cardiac condition 1
• True anginal pain is typically not reproducible by palpation and does not vary with body position or specific movements 1, 2

Diagnostic Approach

Immediate Evaluation Required

Despite the likely musculoskeletal etiology, an ECG should still be obtained to definitively exclude cardiac pathology 1, 3:

• If seen in an office setting and ECG is unavailable, the patient should be referred to the emergency department 1
• The ECG should be reviewed for ST-segment elevation, ST depression, T-wave inversions, or new left bundle branch block 2

Features Supporting Musculoskeletal Diagnosis

The European Society of Cardiology identifies specific characteristics that indicate a less severe, non-cardiac condition 1:

• Pain that varies with respiration or body position
• Pain that is well-localized on the chest wall
• Presence of local tenderness (as in this case with paraspinal muscle tenderness)
• Pain that worsens with specific movements 2

Red Flags That Would Change Management

If any of the following are present, immediate hospital evaluation is mandatory 1, 4:

• Pain interrupting normal activity
• Associated cold sweats, nausea, vomiting, or syncope
• Severe, prolonged pain of acute onset
• Pain radiating to jaw, neck, or left arm with gradual buildup over minutes 1
• Diaphoresis (which has 95% specificity for ACS) 2

Management Strategy

For Confirmed Musculoskeletal Pain

Once cardiac and other serious causes are excluded:

• Reassurance is therapeutic and important
• NSAIDs for pain relief (similar to management of pericarditis, high-dose aspirin 1000 mg/24h or NSAIDs can be used) 1
• Activity modification to avoid movements that exacerbate pain
• Local heat application may provide symptomatic relief

Critical Pitfalls to Avoid

• Do not rely on pain severity alone to determine urgency, as severity is a poor predictor of cardiac complications 1, 4
• Do not use nitroglycerin response as a diagnostic criterion, as relief with nitroglycerin is not specific for cardiac causes 1, 2
• Do not dismiss symptoms without proper evaluation, including at minimum an ECG and focused cardiovascular examination 1
• In elderly patients or those with diabetes, maintain heightened vigilance as they may present with atypical symptoms 4, 2

When to Escalate Care

Immediate emergency department evaluation is required if 1, 3:

• The clinical picture changes or new symptoms develop
• Pain becomes severe or sustained (>20 minutes)
• Associated symptoms of diaphoresis, nausea, or dyspnea develop
• The patient has known coronary artery disease with worsening symptoms

The physical examination finding of reproducible chest wall tenderness is the key distinguishing feature that makes this presentation consistent with musculoskeletal pain rather than cardiac ischemia 1, 2.