Chest wall pain is pain that comes from the structures of the chest itself — the costal cartilages, ribs, thoracic spine joints, intercostal nerves, and the muscles and fascia between them — rather than from the heart. It is the most common explanation for chest pain in the outpatient setting: in a prospective study of 672 consecutive primary care patients with chest pain, musculoskeletal causes accounted for 49% of cases and chest wall syndrome alone for 43%, against 16% cardiovascular.1
Before you read further: chest pain can be an emergency
Call 911 or go to an emergency department now if your chest pain is sudden and severe, feels like pressure, crushing, squeezing or tightness, or comes with any of the following:
- Pain spreading to the arm, jaw, neck, shoulder or back
- Shortness of breath
- Sweating or clammy skin
- Nausea or vomiting
- Lightheadedness, fainting, or a racing or irregular heartbeat
- Pain that comes on with exertion and eases with rest — this pattern needs urgent assessment even when the pain itself is mild
National guidelines treat acute chest pain as a cardiac emergency until testing proves otherwise.12
A heart attack does not always cause chest pain. In women, in people with diabetes, and in older adults it can present instead as unusual fatigue, indigestion-like discomfort, breathlessness on its own, or pain felt only in the back, jaw or upper abdomen. Do not rule out your heart because the pain is not where you expected it.
How the pain feels cannot settle what is causing it. Chest wall pain is often reproduced by pressing on the chest — but tenderness does not exclude heart disease. Among adults presenting with chest pain who also had chest wall tenderness on examination, 3% to 6% still had coronary artery disease.2 Which side the pain is on does not distinguish the two either.
If you were cleared before, that clearance covered the pain you had then. A normal cardiac workup months ago does not cover a new pain, or a pain that has changed in character, timing or severity. Get a changed pain reassessed.
This article is about chest wall pain in people whose pain has already been evaluated and found not to be cardiac. It is general information, not medical advice, and it is not a substitute for being examined.
What “chest wall pain” actually means
“Chest wall syndrome” is an umbrella term, not a single diagnosis. The American College of Radiology uses it to collect the various entities that produce musculoskeletal chest wall pain, in any chest wall structure.3 That vagueness is a problem for patients, because “it’s just your chest wall” is often where the workup stops and the structure generating the pain is never named. Naming it is what makes treatment possible.
Chest pain accounts for roughly 1% of primary care visits, and 2% to 4% of those patients have unstable angina or myocardial infarction; reflux, pericarditis, pneumonia, pulmonary embolism, and aortic dissection must also be considered before the differential narrows to the chest wall.10 What follows is what remains after those exclusions, and most of it is settled on history and examination rather than imaging.11
How the diagnosis is narrowed on history and examination
Three questions do most of the sorting. They are the questions a clinician works through during an examination, after the cardiac and pulmonary causes have been excluded — not a checklist for deciding on your own that pain is benign.
Where is the pain, and how big is it?
Pain a patient can cover with one fingertip points to a discrete structure — a costochondral junction, a costotransverse joint, a rib. Pain described as a band running from the spine around toward the sternum follows an intercostal nerve and suggests a neuropathic or radicular source. A broad ache across the mid-back that radiates anteriorly suggests a thoracic facet or segmental source.
What reproduces it?
Palpation over a specific costal cartilage reproducing the exact pain suggests costochondritis. Pain reproduced by trunk rotation and extension, worse with prolonged sitting, suggests a thoracic facet source. Pain reproduced by deep breathing or coughing suggests rib, pleural, or intercostal involvement. Pain reproduced by a hooking maneuver — fingers hooked under the lower costal margin and pulled anteriorly — suggests slipping rib syndrome.4
What has it done over time?
Pain that began after a fall, a coughing illness, a new exercise program, or a thoracic operation has a mechanical or surgical explanation until proven otherwise. Pain that began with a rash has a viral explanation. Pain in an older adult that began abruptly after minor strain or no trauma, worse standing and better lying flat, raises the question of a vertebral compression fracture.
The musculoskeletal causes
Costochondritis and costosternal syndrome
Inflammation or mechanical irritation at the costochondral or chondrosternal junctions. The defining finding is tenderness on palpation of the affected junctions reproducing the presenting pain, usually at more than one level and most often unilateral.2 It is generally self-limited. Its importance is mostly diagnostic: it is common enough to be used as a default label, so genuinely different problems get filed under it.
Full article: costochondritis explained, including the inflammatory and autoimmune causes that are commonly missed.
Slipping rib syndrome
The 8th, 9th, and 10th ribs attach to each other by fibrous tissue rather than directly to the sternum. When that attachment becomes lax, the rib tip can subluxate and impinge the intercostal nerve beneath it, producing sharp lower chest or upper abdominal pain, sometimes with a palpable click.4 This is a clinical diagnosis. In a surgical series of 19 adults, the hooking maneuver was positive in every case; ultrasonography suggested the diagnosis in one.5 It is routinely missed for years, and patients accumulate normal scans first.4
Full article: slipping rib syndrome, including why it is so often missed for years.
Thoracic facet-mediated pain
The paired zygapophyseal (facet) joints of the thoracic spine can refer pain laterally and anteriorly around the chest, which is why patients describe it as chest pain rather than back pain. Physical examination and imaging cannot establish this diagnosis on their own; controlled comparative diagnostic blocks are the reference standard. In the studies reviewed in the 2020 ASIPP guidelines, thoracic facet joint pain prevalence ranged from 34% to 48%, with single-block false-positive rates of 42% to 58%.6 That is why a single positive block is weak evidence and a confirmatory block matters. See facet joint injection and facet joint radiofrequency ablation.
Rib fracture and thoracic vertebral compression fracture
Rib stress fractures follow repetitive loading — rowing, throwing, prolonged coughing — and produce focal, exquisitely reproducible tenderness.11 Thoracic vertebral compression fractures in older adults with low bone density are also a recognized non-cardiac source of chest pain, and can be felt across the front of the trunk rather than as back pain.7 When a painful fracture does not settle with time and bracing, vertebroplasty and kyphoplasty are the cement augmentation options.
The neuropathic causes
Thoracic radiculopathy
Compression or irritation of a thoracic nerve root produces pain in a dermatomal band running from the spine around the trunk. It is far less common than cervical or lumbar radiculopathy and is frequently mistaken for cardiac, pleuritic, or abdominal pain because the band ends anteriorly. Sensory change, allodynia, or numbness following the same band distinguishes it from purely musculoskeletal pain. Epidural steroid injection is one of the interventions used for inflammatory radicular pain.
Full article: thoracic radiculopathy and intercostal neuralgia.
Intercostal neuralgia
Pain generated in the intercostal nerve itself rather than at the root — from a rib fracture, a slipping rib, surgical injury, a scar, or fascial entrapment. It is burning, electric, or lancinating, follows one or two intercostal spaces, and often has a tender point along the nerve’s course.
Post-herpetic neuralgia in a thoracic dermatome
Shingles most often affects the thoracic dermatomes; in one series of 164 patients, thoracic dermatomes were involved in 45% of cases, more than any other region.8 When burning, itching, or hypersensitive pain persists in that band after the rash heals, the diagnosis is post-herpetic neuralgia, not chest wall pain — and the history of a rash in the same band is the whole diagnosis. See post-herpetic neuralgia after the shingles rash heals.
Post-thoracotomy and post-surgical chest wall pain
Persistent pain after thoracic surgery is common rather than rare: chronic pain complaints affect roughly 25% to 60% of patients, and intercostal nerve injury appears to be the dominant mechanism.9 The same reasoning applies to a sternotomy, a chest tube site, or a mastectomy scar — nerve injuries with a known cause and a known distribution, which makes them among the more tractable problems here.
What honest treatment looks like
Treatment follows the structure, not the label. Self-limited costochondritis needs an accurate diagnosis, activity modification, and time. Facet-mediated pain needs the diagnosis confirmed by block before anything is ablated. Neuropathic pain responds to neuropathic drug classes, not anti-inflammatories. Myofascial contributors may respond to trigger point injections. Where a specific peripheral nerve is suspected as the generator, a diagnostic block of that nerve is the usual way to test the hypothesis: if numbing the nerve does not change the pain, the nerve was not the source.
Two honest limits. No procedure here is a cure and none has a guaranteed result — a diagnostic block that does not relieve pain is useful information, not a failure. And opioids are a poor answer to chronic chest wall pain; the work is to find and treat the generator, and to reduce opioid burden in patients who arrive already taking them. The full list of pain treatments sets out what each procedure does and does not do.
When the diagnosis stays unclear
Some chest wall pain does not resolve into a named structure. The correct response is to say so, to keep the cardiac and pulmonary question periodically open rather than permanently closed, and to treat function rather than chase a label. Chest pain that changes character, worsens, or acquires any emergency feature listed above should be re-evaluated acutely, no matter how many previous workups were normal.
Getting evaluated in St. Louis
Padda Institute, Center for Interventional Pain Management, evaluates cardiac-cleared chest wall and thoracic pain at 4477 Woodson Rd, Suite 100, St. Louis, MO 63134 and 12174 Natural Bridge Road, Bridgeton, MO 63044, where Dr. Gurpreet Singh Padda, MD, MBA, MHP practices. See locations, request an appointment, or contact us at (314) 481-5000.
Frequently asked questions
If pressing on my chest reproduces the pain, does that mean it is not my heart?
No. It makes a chest wall source more likely, but coronary artery disease is still present in about 3% to 6% of adults who have both chest pain and chest wall tenderness.2 Cardiac evaluation comes first. Once you have been cleared, the pain treatments page outlines the options.
How long does costochondritis last?
It is usually self-limited, though it can persist for weeks to months and can recur. Duration beyond that, or pain sharply focal at the lower ribs rather than the costal cartilages, should prompt a rethink of the label rather than a repeat of the same treatment — a named structure is what the pain treatments are directed at.
Do I need an MRI or CT for chest wall pain?
Often not. Most of these diagnoses are made on history and examination,11 and slipping rib syndrome in particular is frequently not visible on standard imaging.5 Imaging is directed by the suspected structure — for example, confirming a vertebral fracture before considering kyphoplasty.
Why does my mid-back pain show up as chest pain?
Thoracic facet joints and thoracic nerve roots both refer pain forward around the trunk, so a spinal source is felt anteriorly. Establishing a facet source requires controlled comparative diagnostic blocks rather than imaging, because single-block false-positive rates in the thoracic spine run high.6 See facet joint injection.
My shingles rash healed months ago but the burning band is still there. What is that?
That is post-herpetic neuralgia, a nerve injury left behind by the virus rather than ongoing infection or chest wall inflammation. It is treated as neuropathic pain — see post-herpetic neuralgia after the shingles rash heals.
I had chest surgery a year ago and it still hurts along the incision. Is that normal?
It is common — persistent pain affects roughly 25% to 60% of patients after thoracic surgery, usually from intercostal nerve injury.9 Common is not untreatable. Because the injured nerve has a known location and a known distribution, this is one of the more tractable causes on this list, and it is worth having assessed rather than accepted; the pain treatments page describes the general approaches to neuropathic pain.
Sources
- Verdon F, Herzig L, Burnand B, et al. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly. 2008. PMID 18561039
- Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009. PMID 19817327
- Stowell JT, Walker CM, Chung JH, et al. ACR Appropriateness Criteria: Nontraumatic Chest Wall Pain. J Am Coll Radiol. 2021. PMID 34794596
- Turcios NL. Slipping Rib Syndrome: An elusive diagnosis. Paediatr Respir Rev. 2016. PMID 27245407
- Mazzella A, Fournel L, Bobbio A, et al. Costal cartilage resection for the treatment of slipping rib syndrome (Cyriax syndrome) in adults. J Thorac Dis. 2020. PMID 32055418
- Manchikanti L, Kaye AD, Soin A, et al. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: ASIPP Guidelines. Pain Physician. 2020. PMID 32503359
- Bader AS, Rubinowitz AN, Gange CP, Bader EM, Cortopassi IO. Imaging in the Evaluation of Chest Pain in the Primary Care Setting, Part 2: Sources of Noncardiac Chest Pain. Am J Med. 2020. PMID 32442508
- Goh CL, Khoo L. A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Int J Dermatol. 1997. PMID 9352407
- Wildgaard K, Ravn J, Kehlet H. Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg. 2009. PMID 19307137
- McConaghy JR, Sharma M, Patel H. Acute Chest Pain in Adults: Outpatient Evaluation. Am Fam Physician. 2020. PMID 33320506
- Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013. PMID 24209723
- Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation. 2021;144(22):e368-e454. PMID 34709879
Dr. Gurpreet Singh Padda, MD, MBA, MHP
