Causes of chest pain

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There are many possible causes of chest pain or pain that seems to be coming from the area around the ribs. They can range from conditions that are primarily uncomfortable to life-threatening conditions.

We will examine the common and unusual causes of this pain associated with the musculoskeletal system, as well as causes that may be felt in the chest, but instead occur in organs inside or outside the chest. When the cause of rib pain is unclear, a careful history and physical exam can help you and your healthcare provider choose the right lab or imaging tests.

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Anatomy and structure of the thorax.

When considering possible causes and how to assess chest pain, it helps to think about the structures in and around the chest.

Bone structure

There are 12 ribs on each side of the chest. The seven upper ribs are attached directly to the breastbone ( breastbone ) by cartilage. These are known as "royal ribs". The other five ribs are called "false ribs."

Of these, the 8th to 10th ribs are also attached to the sternum, but indirectly (they attach to the cartilage of the upper rib, which eventually attaches to the sternum). Ribs 11 and 12 are neither directly nor indirectly attached to the sternum and are called floating ribs .

This pattern can have variations – some people have an extra set of rubbing, and others have fewer ribs (mostly floating ribs).

Surrounding structures

In addition to the bones that make up the ribs, sternum, and spine, and the connecting cartilage, there are many other structures associated with the rib cage that can cause pain. This includes the intercostal muscles (the muscles between the ribs) and the diaphragm (the large muscle at the base of the chest cavity), ligaments, nerves, blood vessels, and lymph nodes .

Organs in the chest

The rib cage protects various organs while allowing movement so the lungs can expand with each breath.

Organs protected by the chest include:

  • Heart
  • Trunk vessels (thoracic aorta and part of the superior and inferior vena cava)
  • Lungs and pleura (lining of the lungs)
  • Upper digestive tract ( esophagus and stomach)
  • Liver (lower right chest)
  • Spleen (lower left chest)

The area between the lungs, called the mediastinum , also contains many blood vessels, nerves, lymph nodes, and other structures.

Organs outside the chest

Organs outside of the chest, but which can sometimes cause pain as if coming from the chest, include the gallbladder, pancreas, and kidneys. The skin covering the chest can also be affected by conditions (such as shingles) that cause chest pain.

Anatomical variations

There are a number of variations that can be found in the chest area, which in turn can cause or affect symptoms in this area.

  • Additional ribs: An additional rib is found above the first in 0.5-1% of the population and is called the cervical or cervical rib .
  • Missing ribs, most of the time one of the floating ribs.
  • Forked (bifurcated) ribs is a condition present from birth in which the sternum splits a rib in two.
  • The chest of a pigeon (pectus carinatum) is a deformity in which the ribs and sternum protrude from the body.
  • Sunken chest (pectus excatum), in which abnormal growth of the ribs makes the chest appear sunken

Causes

There are many potential causes of pain that appears to come from the chest, including trauma, inflammation, infection, cancer, and reflected pain from organs such as the heart, lungs, spleen, and liver.

In an outpatient clinic (such as a family clinic), musculoskeletal disorders are the most common cause of chest pain. However, serious conditions that mimic chest pain (such as pulmonary embolism) are more common in the emergency department .

We will examine some of the common and unusual causes of musculoskeletal or chest pain, as well as causes that can stem from organs inside or outside the chest.

Common musculoskeletal causes

Some of the more common musculoskeletal causes of chest pain include:

Trauma

Muscle sprains can occur when you injure yourself, including coughing or bending over. Rib fractures are relatively common and can sometimes cause severe pain. The ribs can also be bruised ( bruised bone ) without breaking.

The sternum breaks infrequently, but chest trauma can cause a variety of abnormalities, ranging from single fractures to chest fractures. In osteoporosis , rib fractures can sometimes occur with minor trauma.

Inflammation

Costochondritis is an inflammatory condition that affects the cartilage that connects the ribs to the breastbone. This is a common condition that can sometimes mimic a heart attack with pain.

Fibromyalgia

Fibromyalgia is a relatively common cause of chest pain and is difficult to diagnose and treat (primarily a diagnosis of exclusion). Along with morning pain and stiffness, people with this disorder often experience mental confusion, fatigue, and other bothersome symptoms.

Rheumatoid conditions

Common rheumatoid conditions that can cause chest pain include rheumatoid arthritis and psoriatic arthritis .

Intercostal neuralgia

Intercostal neuralgia is a condition in which nerve pain (neuropathic pain) occurs due to trauma, herpes, entrapment of a nerve, etc. This can be difficult to diagnose and treat.

Slipped rib syndrome

Sliding rib syndrome (also called lower rib pain syndrome, rib tip syndrome, or 12th rib syndrome) is considered underdiagnosed and can cause significant lower rib pain (floating ribs). In this condition, overly mobile floating ribs are thought to slip under the ribs above and pinch the intercostal nerves, the nerves that supply the muscles that run between the ribs.

Other

Other relatively common causes may include pain associated with conditions of the thoracic spine (which often cause chest pain in the front of the chest), sternal syndrome, and painful xiphoid syndrome (the xiphoid process is a spiky bony growth in the lower part of the chest). chest). ). breastbone).

Less common musculoskeletal causes

Less common but important musculoskeletal causes of chest pain can include:

Rib stress fractures

Rib stress fractures are overuse injuries commonly seen in activities such as rowing or hiking. They can be difficult to diagnose, so it's important to tell your doctor what kinds of exercise and sports you do.

Tietze syndrome

Tietze syndrome is similar to costochondritis, but it is less common. Unlike rib cartilage tissue, swelling occurs, which accompanies inflammation of the cartilage that connects the ribs to the sternum.

Malignant neoplasms

Some cancers can cause chest pain. Both lung and breast cancers usually spread ( metastasize ) to the bones, including the chest. It can also occur with several different types of cancer.

Pain can be caused by a tumor in the bone (bone metastases ) or fractures that weaken the bones (pathological fractures). In some cases, chest pain can be the first sign of cancer.

These tumors can also grow directly into the chest and cause pain. Multiple myeloma is a blood-related cancer that can occur in the bone marrow of the chest and other bones, and it can also cause chest pain.

Other

Sickle cell crisis (bone infarction, or essentially bone death) is a rare cause of chest pain. Rheumatoid causes, such as lupus, are less commonly associated with chest pain.

Some other potential but rare causes include infections of the chest joint (septic arthritis), polychondritis, and sternoclavicular hyperostosis.

Non-musculoskeletal causes

Sometimes it can be very difficult to determine if the pain you feel in the chest is related to the chest itself or to the structures underneath. Some possible causes of chest pain include the following.

Herpes

Shingles is a condition in which the varicella-zoster virus is reactivated (which remains in the body after the initial infection). Symptoms include fever, chills, and a rash that spreads to one side of the body, but pain (which can be severe) often occurs before these other symptoms and can make diagnosis difficult.

Heart disease

Heart disease often causes pain that feels like chest pain and, especially in women, these symptoms tend to be atypical. The possibility of a heart attack should always be considered in a person suffering from any form of chest pain. Pericarditis , an inflammation of the lining of the heart, is also a potential cause.

Aorta

An enlarged large artery (aorta) in your chest can cause chest pain. Risk factors include the condition of Marfan syndrome and cardiovascular disease.

Lung disease

Lung diseases like pneumonia or lung cancer can cause chest pain. Lung cancer, in particular, can irritate the nerves and cause pain that seems to radiate from the chest. Pulmonary embolism or blood clots in the legs (deep vein thrombosis) that break off and travel to the lungs are a serious cause of chest pain.

Pleural conditions

Inflammation of the pleura ( pleurisy ) or fluid buildup between the two layers of the pleura can cause chest pain. This can cause pain when inhaling deeply and is more painful in some positions than others.

Enlarged spleen

An enlarged spleen, as in certain blood disorders or cancers, can cause chest pain. The spleen can also become enlarged (and sometimes ruptured with minor trauma) with infectious mononucleosis.

Liver condition

Inflammation or scarring of the liver, such as hepatitis or cirrhosis, can cause chest pain.

Digestive system health

Gastroesophageal reflux disease (GERD) often causes heartburn, but it can also cause other types of pain. Other possible causes are peptic ulcer or gastritis.

Mentioned pain outside the chest.

Organs outside the chest can also cause chest pain. Some organs and medical conditions to consider include:

  • Gallbladder : gallstones or cholecystitis (infection of the gallbladder).
  • Pancreas : pancreatitis or pancreatic tumors.
  • Kidney and ureters : Kidney stones can sometimes cause reflected pain that is felt in the chest (and is often severe).

Chest pain during pregnancy.

Chest pain, especially in the upper chest, is also relatively common during pregnancy. In most cases, the pain is believed to be caused by the child's position or associated with the round ligament.

Much less often, and after the 20th week of pregnancy, right-sided pain, felt under the lower ribs, is sometimes a sign of pre-eclampsia or HELLP syndrome, a medical emergency .

When to contact a healthcare provider

If you have chest pain that has no obvious explanation, it is important to make an appointment with your doctor.

Symptoms that should tell you to call 911 and don't wait include:

  • Pressure or constriction in the chest.
  • Chest pain that radiates to the arm, back, or jaw.
  • Cardiopalmus
  • Difficulty breathing , especially when it comes on suddenly
  • Strong pain
  • Sudden sweating
  • Daze
  • A new beginning of confusion or a shift in consciousness.
  • Coughing up blood, even very little
  • Difficulty to swallow
  • Numbness or tingling in the hands or feet

Diagnostics

To determine the cause or causes of chest pain, your healthcare provider will take a careful history and may run a number of different tests based on your answers.

History

If the cause of chest pain is unknown, a complete medical history is essential to make a diagnosis. The questions above can help narrow down the possible causes and guide your survey. These will include questions not only to understand the characteristics of your pain, but also to review past medical conditions, risk factors, and family history.

To narrow down the possible causes, your healthcare provider may ask you several questions. Some of these include:

  • What is the quality of your pain? Is the pain sharp or dull?
  • How long have you had pain? Did it start gradually or suddenly?
  • Have you ever experienced similar pain in the past?
  • Where is your pain? Is it localized or diffuse? Does it affect both sides of the chest, or is it isolated on the left or right side?
  • Is there anything that makes your pain easier or worse? For example, pain when you breathe deeply (chest pain from pleurisy) may indicate pleurisy or another lung disease. Movement can increase musculoskeletal pain.
  • Is there pain at rest or just in motion?
  • Is the pain worse during the day or at night? Pain that is worse at night may indicate a serious cause, such as an infection, fracture, or cancer.
  • Is the pain worse in a particular posture (PE)?
  • Is it possible to reproduce your pain by pressing on any area of the chest?
  • If you also have neck or shoulder pain, does it radiate to your hands? Do you have weakness, tingling, or numbness in your fingers?
  • What illnesses do you have and have you had? For example, a history of early breast cancer can raise concerns about bone recurrence in the chest.
  • What medical conditions did your family members have (family history)?
  • Have you ever smoked or smoked?
  • What other symptoms did you experience (accompanying symptoms)? Symptoms such as palpitations, shortness of breath, cough, rash, jaundice (discoloration of the skin to a yellowish tinge), nausea, vomiting, itching, etc., should be reported to your healthcare professional.

Physical exam

On a physical exam, your healthcare provider will most likely begin by examining your chest (unless you have symptoms that indicate an emergency). The chest will be palpated (touched) to look for localized areas of tenderness, such as over a fracture or inflammation.

With costochondritis, pain is most often felt to the left of the sternum in a highly localized area. The swelling may be associated with Tietze syndrome or trauma such as a fracture.

In fractures, the pain is usually very localized. In sternal syndrome, the pain is often felt in the front of the chest and, on palpation, the pain may spread to both sides of the chest. In intercostal neuralgia, pain can be felt throughout the chest or in one rib, but it usually cannot be reproduced on palpation.

Range of motion tests, such as bending forward (flexion), standing straight (extension), and turning left and right, are done to see if any of these movements can simulate pain.

Your skin will be examined for signs of shingles, and an exam of your extremities may reveal signs of a rheumatoid condition, such as joint swelling or deformities. In addition to examining your chest, your doctor will likely listen to your heart and lungs, and feel your stomach for tenderness.

A pleural friction murmur is the sound of breathing that can be heard when the mucous membrane of the lungs (pleura) is inflamed. Other breath sounds may indicate pneumonia or another lung disease.

In women, a breast exam may be done to look for any growth (which may have spread to the ribs).

Laboratories and tests

Depending on your history and physical exam, various lab tests may be considered. This can include markers for rheumatoid conditions and more. A blood chemistry test, including a liver test, and a complete blood count can provide important clues.

Display

Imaging tests are often needed if trauma has occurred or if there are any signs suggesting underlying lung disease or cancer. If something is visible, a conventional X-ray can help, but it cannot rule out a fracture or lung cancer.

Rib piercing exercises are better for visualizing the ribs, but you can still easily miss rib fractures. An MRI may be needed to diagnose multiple rib fractures or stress fractures. Bone scans are another good option both for detecting fractures and for looking for possible bone metastases .

Chest computed tomography (computed tomography ) is often done if there is concern about lung cancer or pleural effusion. In cancer, positron emission tomography (PET) can be helpful in examining bone and other soft tissue abnormalities, such as mediastinal tumors.

Because abdominal conditions (such as gallbladder or pancreas conditions) can cause chest pain, an ultrasound or computer scan of the abdomen may be done.

Procedures

Some conditions that can cause reflected chest pain may require diagnostic procedures.

An electrocardiogram (EKG) may be done to look for any signs of heart damage (such as a heart attack) and to look for abnormal heart rhythms. An echocardiogram (ultrasound of the heart) can provide additional information about the heart, as well as detect pericardial effusion (fluid between the membranes that line the heart), if there is one.

If the person has had a choking episode or has risk factors for lung cancer, a bronchoscopy may be done. In this procedure, a tube is inserted through the mouth (after sedation) and inserted into the large airways. A camera at the end of the endoscope allows the healthcare professional to directly view the area within the bronchi.

Endoscopy may be done to view the esophagus or stomach for conditions associated with these organs.

Watch out

Treatment for chest pain will depend on the underlying cause. Sometimes only reassurance and advice are required to avoid actions and movements that make the pain worse.

Rib fractures are difficult to treat, and many healthcare providers only prefer conservative treatments, such as chest wraps, due to the potential complications.

For the musculoskeletal system causing chest pain, a variety of options can be considered, ranging from pain relief to stretching, physical therapy, and local injections of pain relievers.

Get the word of drug information

Chest pain can indicate a number of different diseases of the musculoskeletal system, as well as non-musculoskeletal conditions inside or outside the chest. Some of these conditions are difficult to diagnose. A careful history is often the best individual "test" to find an answer that cures the underlying cause.

It can be frustrating to ask a thousand questions (sometimes repeated more than once), but in the case of chest pain, it's worth taking the time to make sure your healthcare provider has every possible clue to ask. a diagnosis. and subsequently treat your pain.

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