What other conditions can cause reproducible chest pain?

Conditions That Cause Reproducible Chest Pain

Musculoskeletal disorders are the most common cause of reproducible chest pain, with costochondritis leading the list, but critically, 7% of patients with pain reproducible on palpation still have acute coronary syndrome, so reproducibility does NOT exclude cardiac disease. 1

Musculoskeletal Causes (Most Common)

Costochondritis is the single most frequent cause of reproducible chest pain, characterized by:

• Tenderness at costochondral or chondrosternal junctions on palpation 2, 3
• Sharp or stabbing pain that worsens with movement or deep breathing 2
• Pain localized by one fingertip, particularly at the left ventricular apex or costochondral junction 1

Other chest wall syndromes include:

• Fibrositis affecting the chest wall musculature 4
• Rib fractures or trauma (identifiable on radiographs if clinically indicated) 1
• Intercostal muscle strain 2
• Pain from multiple tender sites on the chest wall 5

Key finding: Among patients with noncardiac chest pain, 69% have chest wall tenderness, but typical chest pain is reproduced by palpation in only 16% 4. In primary care, 71% of patients with chest wall syndrome have reproducible pain on palpation 6.

Pulmonary Causes

Pleuritic conditions present with sharp, knifelike pain provoked by respiration or cough:

• Pleuritis/pleurisy - sharp pain worsening with deep breathing 1, 7
• Pneumonia - localized pleuritic pain with fever, productive cough, regional dullness to percussion, egophony, and possible friction rub 1, 2
• Pneumothorax - classic triad of dyspnea, sharp pleuritic pain on inspiration, and unilateral absent breath sounds with hyperresonant percussion 2, 7
• Pulmonary embolism - pleuritic pain in 52% of cases, typically with tachycardia and dyspnea in >90% 2, 7

Critical distinction: While pleuritic pain is traditionally considered "not characteristic of myocardial ischemia," 13% of patients with pleuritic pain have acute myocardial ischemia 1.

Gastrointestinal Causes

Esophageal disorders can produce reproducible chest pain:

• Gastroesophageal reflux disease (GERD) - squeezing or burning retrosternal pain, often positional 2
• Esophageal motility disorders (achalasia, distal esophageal spasm, nutcracker esophagus) - squeezing retrosternal pain or spasm, often with dysphagia 2

Important caveat: Relief of chest pain with "GI cocktails" (antacids, viscous lidocaine, anticholinergic agents) does NOT predict the absence of acute coronary syndrome 1.

Psychological Causes

Panic disorder and anxiety are common but frequently overlooked:

• Often associated with other somatic symptoms including reproducible chest pain 2
• May present with hyperventilation and chest wall muscle tension 2
• Cognitive-behavioral therapy shows 32% reduction in chest pain frequency over 3 months 2

Life-Threatening Causes That May Present With Reproducible Features

Never assume reproducible pain is benign. The following conditions require immediate evaluation:

Acute coronary syndrome:

• Present in 7% of patients with fully reproducible pain on palpation 1
• Present in 22% of patients with sharp or stabbing pain 1
• Relief with nitroglycerin is NOT predictive (35% of ACS patients vs 41% without ACS experience relief) 1

Aortic dissection:

• Sudden onset severe "ripping" or "tearing" chest or back pain 2
• Pulse differential in 30% of cases 2

Pericarditis:

• Sharp, pleuritic pain that may improve by sitting up or leaning forward 7
• Pain may be reproducible with certain positions 7

Diagnostic Algorithm

Initial evaluation for ALL patients with reproducible chest pain:

1. Obtain ECG within 10 minutes of presentation 2
2. Measure cardiac troponin as soon as possible 2
3. Perform chest radiography to evaluate for pneumothorax, pneumonia, pleural effusion, or widened mediastinum 2

Risk stratification based on clinical features:

High-risk features requiring cardiac workup despite reproducibility:

• Age ≥35 years with cardiac risk factors 3
• History of coronary artery disease 1, 3
• Exertional component to pain 1
• Associated dyspnea, diaphoresis, nausea, or radiation to arm/jaw 1, 2

Features favoring musculoskeletal origin:

• Pain affected by palpation, breathing, turning, twisting, or bending 5
• Pain from multiple sites on chest wall 5
• Young age (<35 years) without cardiac risk factors 3
• Localized tenderness at costochondral junctions 2, 3

Consider CT chest with contrast if:

• Pulmonary embolism suspected (pleuritic pain + dyspnea + tachycardia) 2
• Aortic dissection suspected (sudden severe tearing pain) 2

Critical Pitfalls to Avoid

1. Never rely on reproducibility alone - 7% of patients with palpable tenderness have ACS 1, 2
2. Never assume pleuritic pain excludes cardiac disease - 13% with pleuritic pain have acute ischemia 1
3. Never use nitroglycerin response as a diagnostic test - it relieves symptoms equally in cardiac and noncardiac causes 1
4. Never use GI cocktail response to rule out ACS - relief does not predict absence of cardiac disease 1
5. Always consider life-threatening non-cardiac causes - pulmonary embolism, aortic dissection, and tension pneumothorax can be fatal 2

Special Population Considerations

Women:

• More frequently present with atypical symptoms including back, neck, and jaw pain 1
• Use different word descriptors ("tearing," "terrifying") 1

Older adults (≥65 years):

• Increased frequency of atypical presentations 1
• Higher risk of underlying coronary artery disease even with reproducible pain 1, 3
• Should have cardiac evaluation even with chest wall tenderness 3