Acute Chest Discomfort
Introduction
Anytime a patient hints at “chest pain,” we focus on the heart first, then maybe the lungs. Yet in adults, musculoskeletal causes of chest pain are very common and are often related to activities such as computer work or lifting. New parents are prone to costochondritis from lifting a rapidly growing baby from a crib. Sitting with an ill-situated computer or at any workstation can induce what is called “upper crossed syndrome.”
Be aware of risk factors for cardiovascular disease or pulmonary emboli. When these conditions are ruled out, focus on other syndromes, including upper crossed syndrome, first rib syndrome, and costochondritis.
Differential Diagnosis
Angina (left side)
Alert: Left-sided symptoms need to be carefully evaluated for cardiac risk factors (including hypertension, hyperlipidemia, age older than 55 years, tobacco abuse, family history of early heart disease) and to rule out angina.
Pulmonary embolism
Alert: Chest pain associated with shortness of breath, tachycardia, hemoptysis, and recent long immobilization (such as a car or plane ride, cast, surgery, history of being bedridden) requires full evaluation to rule out pulmonary embolism.
Upper Crossed Syndrome
Tight trapezius and levator scapula in the upper back with tight pectoral muscles of the chest, leading to head shifting forward and chest shifting backward
Results in rounded shoulders; may cause posterior pelvic tilt (Figure 8-1)
Seen in those who work long hours in front of a computer screen and in women with pendulous breasts
Symptoms include headache, shoulder and neck pain, anterior chest pain, lower back pain and achiness with driving long distances
Figure 8-1 • Upper crossed syndrome. (Reprinted from Donnelly JM, et al. Travell, Simons & Simons’ Myofascial Pain and Dysfunction. Baltimore: Wolters Kluwer; 2018 with permission.)
Palpate for overactive and tender points on the trapezius, levator scapulae and pectoralis major and minor, rhomboids, steroncleidomastoids, and pectoralis muscles
Lengthened and tender muscles in upper crossed syndrome include the rhomboids, lower trapezius and neck flexors. Shortened muscles include the upper trapezius, levator scapulae, and sterocleidomastoids and pectoralis muscles.
Costochondritis
Signs and symptoms include anterior chest wall pain and tenderness of the costochondral and sternoclavicular regions, most often affecting the second to the fifth costal cartilages.
Palpate costochondral junctions; pain is usually sharp, achy, or pressure-like, involving multiple (and mostly unilateral second to fifth) costal cartilages.
Pain can be exacerbated by upper body movements and exertional activities.
First Rib Syndrome and Dysfunction
May be due to muscular dysfunction or a true subluxation (rib move out of joint)
Can be a cause of neck, shoulder, arm, and back pain
Etiology
Results from tight muscles in the neck from overuse or posture (especially in those using cell phones or pads)
May also be related to those using only the chest muscles to breathe, rather than chest and abdominals
Often associated with upper crossed syndrome (tight levator scapulae, trapezius, and pectoralis muscles)
Related to thoracic outlet syndrome: a constellation of symptoms that affect the head, neck, shoulders, and upper extremities caused by compression of the neurovascular structures (brachial plexus and subclavian vessels) at the thoracic outlet, specifically in the area superior to the first rib and posterior to the clavicle.
Symptoms and History
Discomfort with raising arm overhead/combing hair
Pain or difficulty turning your head side to side
Hand/arm paresthesia
Unsuccessful shoulder pain treatment
More common in stomach sleepers (often with arm under pillow), in racket sport players, weight lifters
Physical Examination
Rule out thoracic outlet syndrome—test for weakness of the muscles of the hand, especially the thumb.
Adson sign: radial pulse in the arm is lost throughout abduction and external rotation of the shoulder (due to subclavian artery compression).
Palpate the area behind the medial clavicle on the affected side for tenderness and asymmetry compared with the other side.
Palpate the levator scapulae, trapezius, and insertions of pectoralis minor for tenderness.
Treatment
Remember the Rules
Move the patient to a position of less pain and apply trigger point care.
Stretch the shortened muscle.
Treat the region (above and below pain).
Tape to support a neutral position.
Support definitive treatment (physical therapy, orthopedics, neurosurgery).
Treatments for Upper Crossed Syndrome and Costochondritis
Pectoralis Major Stretch
With the patient supine and the hands positioned under the head, gently stretch the elbows posteriorly to end point.
Ask the patient to resist this stretch, using 10% effort, while taking three belly breaths. Then have the patient relax.
Move the elbows further down to a new end point.
Repeat these steps for a total of three stretch-relax cycles.
Pectoralis Minor Stretch
With the patient supine and the arms at the sides, place the heels of the clinician’s hands between the distal clavicle and coracoid process.
Stretch the coracoids down toward the table to the end point.
Ask the patient to roll the shoulders forward, using 10% effort against resistance.
Have the patient take belly breathes, then relax.
Move the coracoids further down.
Repeat these steps for a total of three stretch-relax cycles.
Lateral Neck and Trapezius
Have the patient side bend the neck away from the involved side and move the involved shoulder inferiorly.
With one hand, hold the head in place. With your other hand, hold the shoulder down.
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