Musculoskeletal Chest Wall Pain

1. Musculoskeletal Chest Wall Pain MCWP

2. What percent of chest wall pain is musculoskeletal in children?

3. General Incidence (MCWP) • In the emergency department, approximately 10 to 15 percent of adults and 20 to 25 percent of children presenting with chest pain have a musculoskeletal cause.

4. Describe some general features of MCWP?

5. General features of MCWP • Onset: often insidious, with history of minor or repetitive trauma or unaccustomed physical activity. • Pain: often sharp, nagging and localized to the affected site but may radiate widely.

6. General features of MCWP Positional component: pain brought on by changes in position, turning of the chest, deep breathing or movements of the shoulder girdle.

7. General features of MCWP • Modulating factors: duplication of pain by movements involving the painful area or chest wall palpation; relief by local application of heat or use of NSAID

8. General - MCWP • painful areas are found in zones of muscular or tendinous insertions on the bones, or on cartilage or mobile zones of bone-cartilage transitions, such as the costochondral junctions.

9. General - MCWP

10. General - MCWP • History and sensibility to palpation were the keys for diagnosis. • Pain was generally moderate, well localized, continuous or intermittent over a number of hours to days or weeks, and amplified by position or movement. • The pain however, may be acute. May be at several painful sites, and if at a single site, most frequently in the midline or a left-sided site. • Pain was a cause of anxiety and cardiac concern, especially when acute. CWS coexisted with coronary disease in 19 and neoplasm in 6. • Outcome at one year was favorable even though CWS recurred in half of patients.

11. General - MCWP • MCWP is a frequent condition with good prognosis, low morbidity and no mortality. • Evolution has only been negative in cases of misdiagnosis, mainly in the presence of malignant conditions or in cases of coincidental diseases such as heart or neoplasic disease or pneumonitis. • Nevertheless, this condition tends to recur. • It also causes real anxiety and frequently suggests to the patient the possibility of heart disease. Moreover, in a few cases, it is difficult to distinguish between coronary heart disease and CWS on a clinical basis partly because the majority of chest wall pain is left-sided.

12. What is Tietze Syndrome?

13. TietzeSyndrome is a benign inflammation of one or more of the costal cartilages. It was first described in 1921 by the German surgeon Alexander Tietze (1864–1927)

14. TietzeSyndrome • usually comes on abruptly, with chest pain radiating to your arms or shoulder and lasting several weeks. • is accompanied by a localized swelling at the painful area (the junction of the ribs and breastbone).

15. TietzeSyndrome • is differentiated from costochondritis by swelling of the costal cartilages, which does not appear in costochondritis. • It, like costochondritis, was at one time thought to be associated with, or caused by, a viral infection acquired during surgery. This is now known not to be the case, as most sufferers have not had recent surgery.

16. Tietze’s Syndrome • While the true causes of Tietze's Syndrome are not well understood, it often results from a physical strain or minor injury, such as repeated coughing, sneezing, vomiting, or impacts to the chest. • It has even been known to occur after hearty bouts of laughter. • It can occur by over exerting or by an injury in the chest and breast.

17. Tietze's Syndrome • The primary presentation of the syndrome is significant, acute pain in the chest, along with tenderness and some swelling of the cartilages affected, which is commonly palpable on examination. • Although many times it can be extremely painful, to the point of being debilitating, Tietze's Syndrome is considered to be a benign condition that generally resolves in 12 weeks. • However, it can often be a chronic condition. • The pain can be identical to a heart attack and can cause hyper ventilating, anxiety attacks, passing out, panic attacks and temporary numbness/paralysis.

18. What is costochrondritis?

19. Costochondritis • is a self-limiting condition of unknown aetiology that typically presents with pain around the second to fifth costochondral joints. • It can be differentiated from Tietze's syndrome in which there is swelling and pain of the articulation. • Both conditions eventually settle spontaneously although a corticosteroid injection may be useful in particularly troublesome cases. • The intercostal muscles may be injured causing tenderness between the ribs.

21. Costochondritis • Inflammation of the junctions where the upper ribs join with the cartilage that holds them to the breastbone or sternum. • The condition causes localized chest pain that you can reproduce by pushing on the cartilage in the front of your rib cage. • Relatively harmless condition and usually goes away without treatment. • The cause is usually unknown. • Affects females more often than males (70% versus 30%).

22. Costochondritis • (with unknown cause) is a common cause of chest pain in children and adolescents. • It accounts for 10% to 30% of all chest pain in children. • Annually, doctors evaluate about 650,000 cases of chest pain in young people 10-21 years of age. • The peak age for the condition is 12-14 years.

23. What is manubriosternal joint pain?

24. Manubriosternal Joint Pain • can serve as a source of pain that often mimics the pain of cardiac origin. • The manubrium articulates with the body of the sternum via the manubriosternal joint. • The joint articulates at an angle called the angle of Louis, which allows for easy identification.

26. Manubriosternal Joint Pain • The joint is a fibrocartilaginous joint, or synchondrosis, that lacks a true joint cavity. • The manubriosternal joint allows protraction and retraction of the thorax. Above, the manubrium articulates with the sternal end of the clavicle and the cartilage of the first rib. • Below, the body of the sternum articulates with the xiphoid process. Posterior to the manubriosternal joint are the structures of the mediastinum.

27. Manubriosternal Joint Pain • The manubriosternal joint is susceptible to the development of arthritis, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and psoriatic arthritis. The joint is often traumatized during acceleration/deceleration …

28. What is pectuscarinatum?

29. Pectuscarinatum* • incidence of 1:1000 teenagers, is oligosymptomatic. However, for aesthetic and emotional reasons, it accounts for a large number of medical appointments. Such patients are introverted and do not engage in physical activities, since they are unwilling to expose their chest, which also discourages them from going to the beach or to swimming pools. The diagnosis is clinical and visual, and details are obtained through chest X-rays

30. Dislocation

31. What is sternalis syndrome?

32. Sternalis syndrome • is a rare disorder characterized by localized tenderness found over the body of the sternum, often with tenderness that causes radiation of pain bilaterally.

33. Sternum Stress fractures • Stress fractures of the sternum reported in wrestlers cause pain and tenderness of the sternum

34. What is xiphoid syndrome?

35. Xiphoidalgia or Xiphoidynia orXiphoid Syndrome • is also a rare syndrome with localized pain and tenderness over the xiphoid

36. The word derives from the Greek word xiphos for straight sword, the tip of which the process somewhat resembles.

37. xiphoid process, or xiphisternum or metasternum • is a small cartilaginous process (extension) of the lower part of the sternum which is usually ossified in the adult human. • By age 15 to 29, the xiphoid usually fuses to the body of the sternum with a fibrous joint. • Unlike the synovial articulation of major joints, this is non-movable. • Much the way the first seven ribs articulate with the sternum, the cartilage in the celiac plexus joins on the xiphoid process, reinforcing it, and indirectly attaches the costal cartilage to the sternum.

38. Xiphoid Syndrome • Pain and discomfort that occurs in the lowest portion of the sternum called the xiphoid process. • The symptoms may occur sporadically or be associated with conditions such as heart disease, gallbladder disease and bone disease. • Certain movements (bending, lifting) or eating large meals may precipitate an attack.

39. Xiphoidalgia — Xiphoidalgia (xiphoidynia) • is another relatively rare syndrome that is characterized by localized discomfort and tenderness over the xiphoid process of the sternum • Symptoms are often aggravated by eating a heavy meal or bending or twisting movements; they may also be associated with resumption of heavy work or a recent cough, suggesting a traumatic cause in some patients. • Analgesics or local injection of an anesthetic-steroid combination are frequently curative [17,18].

40. What is slipping rib syndrome?

41. Slipping Rib Syndrome • causes intermittent costal margin pain related to posture or movement, and may be diagnosed by the 'hooking manoeuvre', which reproduces pain and sometimes a click.

43. Slipping Rib Syndrome • described by Davies Colley in 1922, slipping rib syndrome is characterized by a dull ache lasting hours or days that is punctuated by intermittent, sharp, stabbing pain and precipitated by certain postures and movements. • 128-129 The 8th, 9th, and 10th ribs (false ribs) are not attached to the sternum; they are connected anteromedially by fibrous tissue. • Pain results from inadequate stabilization of the rib tips, allowing them to move upward and posteriorly, impinging upon the superior intercostal nerve. In some cases, this disruption may be posttraumatic.

44. Slipping Rib Syndrome • “hooking” maneuver: grabbing under the costal margin and pulling anteriorly.132 Treatment consists of reassurance and NSAIDs. • Persistent symptoms may be managed with local anesthetic injections or surgical resection in recalcitrant cases. • As with many unusual conditions, the key to successful management is making the correct diagnosis.

45. What is fibromyalgia?

46. Fibromyalgia • a common chronic musculoskeletal pain syndrome that presents with diffuse myalgias, multiple tender points, sleep disturbance, and fatigue. • Many patients report tenderness over the second costochondral junctions.

47. Lower rib pain syndrome • goes by many different names such as slipping or clicking rib syndrome, rib-tip syndrome, or twelfth rib. • Pain can be diffuse or localized, and is accompanied by tenderness on the costal margin that reproduces the pain.

48. What is devils grip?

49. Devil's Grip • Symptoms may include fever and headache, but the distinguishing characteristic of this disease is attacks of severe pain in the lower chest, often on one side. • The slightest movement of the rib cage causes a sharp increase of pain, which makes it very difficult to breathe, and an attack is therefore quite a frightening experience, although it generally passes off before any actual harm occurs. • The attacks are unpredictable and strike "out of the blue" with a feeling like an iron grip around the rib cage.

50. Devil's Grip • The illness lasts about a week and is rarely fatal. • Treatment includes the administration of nonsteroidal anti-inflammatory agents or the application of heat to the affected muscles. • Relapses during the weeks following the initial episode are a characteristic feature of this disease. • Boerhaave’s Syndrome