What are the treatment options for musculoskeletal (muscle and skeletal) chest pain?

From the Guidelines

Treatment for musculoskeletal chest pain should prioritize non-pharmacological approaches, such as physical therapy, heat/cold therapy, and orthotics, before considering pharmacological treatments, as recommended by the American Heart Association 1. When it comes to managing musculoskeletal chest pain, it's essential to consider the underlying cause and tailor treatment accordingly.

• Non-pharmacological approaches, such as physical therapy, can help alleviate symptoms and improve quality of life.
• Heat or cold therapy can be applied to the affected area to reduce inflammation and relax tight muscles.
• Orthotics may also be beneficial in some cases, particularly if the pain is related to poor posture or musculoskeletal imbalances.

If non-pharmacological approaches are insufficient, pharmacological treatments may be considered.

• According to the 2021 ACR Appropriateness Criteria for nontraumatic chest wall pain, acetaminophen or aspirin at the lowest efficacious dose may be used for short-term pain relief 1.
• However, it's crucial to weigh the potential benefits and risks of any medication, particularly in patients with a history of cardiovascular disease or other comorbidities.
• The 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes also recommends a stepped-care approach for selecting treatments, starting with acetaminophen, nonacetylated salicylates, tramadol, or small doses of narcotics if necessary 1.

In terms of specific medications,

• acetaminophen (500-1000mg every 6 hours) may be a suitable alternative for patients who cannot take NSAIDs.
• Gentle stretching exercises and physical therapy can help maintain flexibility and promote healing once acute pain subsides.
• Adequate rest, avoiding activities that worsen symptoms for at least 3-5 days, is also essential for recovery. It's essential to note that if pain is severe, worsening, or accompanied by shortness of breath, fever, or radiating pain, medical evaluation is necessary to rule out more serious conditions like cardiac issues.

From the FDA Drug Label

Cyclobenzaprine hydrochloride tablets are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions Improvement is manifested by relief of muscle spasm and its associated signs and symptoms, namely, pain, tenderness, limitation of motion, and restriction in activities of daily living

Treatment for musculoskeletal chest pain may include cyclobenzaprine hydrochloride tablets as an adjunct to rest and physical therapy. The key benefits of using cyclobenzaprine hydrochloride tablets are:

• Relief of muscle spasm
• Relief of associated signs and symptoms, such as pain and tenderness It is recommended to use cyclobenzaprine hydrochloride tablets only for short periods (up to two or three weeks) 2.

From the Research

Treatment Options for Musculoskeletal Chest Pain

• The treatment of musculoskeletal chest pain can be managed through various methods, including manual therapy, exercises, and physiotherapeutic measures 3, 4.
• Non-inflammatory diseases such as costochondritis and fibromyalgia are frequent causes of chest pain, and their treatment often involves interdisciplinary approaches 4.
• Physiotherapeutic and physical treatment measures, including manual therapy, transcutaneous electrical stimulation, and stabilization exercises, are particularly important for functional myofascial disorders 4.

Pharmacological Treatment

• The use of oral opioids does not result in more pain relief than non-opioid alternatives when administered to patients as first-line treatment for acute musculoskeletal pain 5.
• A study comparing the efficacy of oxycodone/acetaminophen to that of acetaminophen alone as second-line treatment for patients with acute musculoskeletal pain found that oxycodone/acetaminophen resulted in slightly greater pain relief, but with more medication-related adverse events 5.
• Another study found that the combination of ibuprofen and acetaminophen did not reduce pain scores or the need for rescue analgesics compared with either agent alone in ED patients with pain secondary to acute musculoskeletal injuries 6.

Diagnostic Approach

• Musculoskeletal chest wall pain can be diagnosed from a thorough history and examination, and further investigations are often unnecessary unless systemic or rheumatological causes are suspected 7.
• It is critical to rule out non-musculoskeletal causes of chest pain, particularly those requiring urgent intervention such as ischaemic heart disease 7.