Diagnosis: Costochondritis
In an 11-year-old with isolated right-sided chest pain that is reproducible on palpation of the breast/chest wall area with no other findings, the diagnosis is costochondritis—a benign musculoskeletal condition that requires only reassurance and symptomatic treatment. 1, 2
Clinical Confirmation
The diagnosis is established by the following key features already present in this case:
- Reproducible tenderness on palpation of the costochondral joints is the hallmark finding that confirms costochondritis and distinguishes it from cardiac causes 1, 2
- Pain localized to a specific area that can be pointed to with palpation 1
- No other abnormal findings on examination (no fever, no respiratory distress, no abnormal heart sounds, no friction rub) 1
- Age 11 years places this patient in the pediatric population where 99% of chest pain is non-cardiac, with musculoskeletal causes being the most common identifiable etiology 3, 4
Critical Cardiac Exclusion Not Required in This Case
While cardiac evaluation is mandatory in certain populations, this 11-year-old does not require an ECG or cardiac workup because:
- Patients older than 35 years or those with cardiac risk factors require ECG to exclude cardiac causes 1, 5
- This child has no cardiac risk factors, no family history mentioned, and no cardiopulmonary symptoms (no diaphoresis, tachypnea, tachycardia, hypotension, or abnormal heart sounds) 1
- Chest wall tenderness on palpation markedly reduces the probability of acute coronary syndrome 1, 2
- In children, myocardial ischemia is rare, and routine ECG is not required on every pediatric patient with chest pain 6
No Imaging Required
No imaging studies are indicated for this presentation:
- Chest radiography is only useful when evaluating for specific etiologies like pneumonia, pneumothorax, or rib fractures—none of which are suggested by this clinical picture 1, 6
- The ACR Appropriateness Criteria confirm that imaging in isolated, reproducible chest wall pain without other findings does not increase diagnostic yield 7
- Imaging may paradoxically increase anxiety and subsequent healthcare utilization without improving outcomes 7
Recommended Management
Immediate Management:
- Reassurance that this is a benign, self-limited condition not related to the heart or breast pathology 5
- NSAIDs for 1-2 weeks (ibuprofen or naproxen at age-appropriate doses) for pain relief 2
- Acetaminophen as an alternative if NSAIDs are contraindicated 2
- Ice or heat application to the affected area 2
If Pain Persists Beyond 2 Weeks:
- Consider adding low-dose colchicine if symptoms persist despite NSAID therapy 2
- Topical lidocaine patches may provide localized relief with minimal systemic effects 2
- Reassess to rule out other potential causes of persistent pain 2
Important Counseling Points
- Advise the patient and family to avoid activities that produce chest muscle overuse until symptoms resolve 5
- Symptoms often occur more than once daily and may last weeks to months (>6 months in some cases), but this does not indicate serious pathology 1, 2
- Pain typically worsens with deep breathing, coughing, or chest wall movement—this is characteristic and expected 1
Critical Pitfall to Avoid
Do not assume this is breast-related pathology simply because the patient describes it as "around the breast." In an 11-year-old, the costochondral junctions lie directly beneath breast tissue, and what the patient perceives as breast pain is actually chest wall pain from the underlying costochondral structures. 7 Breast cancer presenting as isolated pain without a mass is extraordinarily rare even in adults (0-3% incidence) and essentially nonexistent in pediatric patients. 7