Chest Pain of Musculoskeletal Origin
Abstract: The Need for Structural Evaluation of Patients with Chest Pain
Patients with non-cardiac chest pain form a substantial proportion of emergency admissions. The majority is discharged without a diagnosis or as idiopathic, using the currently accepted examining techniques. A more detailed physical examination looking for asymmetry of the bones and functional impairment of the joints of the thoracic cage, as well as pain, demonstrates objective physical findings of any musculoskeletal cause arising from altered joint and muscle mechanics. Recognizing functional anatomy and biomechanics fills a gap in medical education, leads to a greater understanding of the musculoskeletal system, and solves the mystery of many acute and chronic cases of idiopathic chest pain. The treatment of choice for joint dysfunction is joint manipulation and muscular balancing, which restores joint function, eliminates musculoligamentous strain, and relieves the mechanical cause of pain. An accurate diagnosis of musculoskeletal chest wall pain can eliminate unnecessary diagnostic tests, reduce patient anxiety, and provide effective treatment options for physicians.
Keywords:
ATYPICAL CHEST PAIN
BIOMECHANICS
SOMATIC DYSFUNCTION
STRUCTURAL DIAGNOSIS
JOINT MANIPULATION
Chest Pain of Musculoskeletal Origin
Patients with atypical chest pain form a substantial proportion of emergency admissions. The most common cause is musculoskeletal, about 25%. Of the remaining cases 40-63% are discharged without a diagnosis or labeled idiopathic. (1, 2) In patients with the diagnosis of costochondritis over 30% were still suffering from chest pain at one-year follow up. (3)
When the more serious causes of chest pain – such as coronary artery disease, pericarditis, esophageal dysfunction, irritable bowel syndrome, herpes zoster, lung inflammation, rheumatic disorders, fractures, trauma, neoplasm, and disorders of the organs and structures within the thoracic cage – have been ruled out, pain arising from the chest wall is considered as a possible cause.
Diagnoses of atypical chest pain, musculoskeletal chest wall syndrome, painful xiphoid syndrome, noncardiac chest pain, painful rib syndrome, Tietze’s syndrome, and costochondritis help reduce patient anxiety associated with the more serious conditions. Tenderness of the chest wall or a sterno-costal joint may reassure the patient of the benign nature of the symptoms. The initial treatment options are analgesics, muscle relaxants, anti-inflammatories, injections, and referral to physical therapy. When these are unsuccessful, a pain management specialist is consulted.
The current examining techniques used for the diagnosis of chest wall pain are limited to palpation of the chest wall and sterno-costal joints, provocation of chest pain using arm traction, and pain provocation with pressure applied vertically to the skull. (4, 5) Treatment of chest wall syndrome is based on treating the underlying abnormality of the cervico-dorsal or chest wall regions; however, total relief of symptoms is often an unattainable goal with only one of twelve patients becoming pain-free following treatment. (6)
The “underlying abnormality” upon which the treatment is based has not been found by palpation alone, which accounts for the high incidence of idiopathic diagnoses and low incidence of success with treatment. When pain is produced, it is imperative to find out which structures are painful and the reason for the pain. An exact diagnosis is the first step toward effective treatment. A more detailed physical examination looking for functional impairment as well as pain will dramatically reduce the number of idiopathic and undiagnosed cases.
Functional anatomy, biomechanics, structural diagnosis and treatment are an integral part of Osteopathic philosophy and education. The knowledge, experience, skill, and the science of this art has never been incorporated into Allopathic education; as a result, medical doctors have little information or success in managing patients with acute or chronic pain caused by altered joint and muscular mechanics. These conditions do not exist at the cellular level even though the symptoms can be palliated medically.
In considering altered mechanics as a cause of chest pain, it is essential for the physician to put in the background, for the moment, the disease model of internal medicine and think as a mechanic or engineer would when presented with an automobile that has broken down. The component parts – all the pulleys, belts, hinges, gears, wheels, axles, bushings, connections, ball joints, motors, engine, and computers are examined, and the function of each part is tested to determine which components are creating the malfunction. These are restored, repaired, or replaced and the function is returned to working order.
The same examining process when applied to the musculoskeletal system uncovers a new dimension of information for most physicians. It is helpful to turn at this point to the science of mechanics. Everything that is made to move has a built-in factor of play to promote efficient functional movement between the two moving parts. For example: a piston in a cylinder has play between the moving parts, as does the wheel on an axle and hinge on a door. The first sign of malfunction is a squeak or noise, which gets louder as the functional efficiency deteriorates and the normal play between the moving parts is lost.
Joints, ligaments, muscles, menisci, bursae, bones, articular cartilage, and synovium are the same wherever they occur in the musculoskeletal system. They react in the same way to pathological change and traumatic stress with symptoms of limited function and pain. The normal play within a synovial joint is less than one-eighth of an inch. (8) If the play becomes too little, the joint is tight, stiff, and function is limited. If the play becomes excessive the joint is unstable and the ligaments have lost their integrity. Mechanical joint dysfunction in an otherwise normal joint is the result of a loss of play between the articulating surfaces within the joint.
Manual therapy and joint mobilization is the treatment of choice for the pain arising from altered joint mechanics. When the mechanical dysfunction is corrected and joint motion restored, the pain resolves and normal voluntary function returns. The diagnostic entity sought by structural diagnosis is somatic dysfunction ICD9 code 739.0-9. It is defined as follows:
Somatic dysfunction: impaired or altered function of related components of the somatic (body framework) system; skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements. (7)
Fortunately the muscles, bones, and joint movements can be directly palpated and are readily accessible. This is especially true in the thoracic cage, which has a dynamic motion that is easily observed when examined for positional symmetry, range of motion, and soft tissue texture changes. The combined functional movements of more than 100 articulations coordinate to allow the ribs and sternum to elevate and expand with inhalation, and lower and contract with exhalation.
Mechanical dysfunction within and around the joints does occur as a result of trauma, strain, overuse, coronary bypass surgery, and even a cough or sneeze, where a synovial joint or group of joints lose their play and capacity to fully function without pain. The patient experiences pain coming from the joint and capsule, as well as tendon strain and muscular spasm limiting movement. Presenting symptoms can be a dull heavy ache, a sharp stabbing pain, pressure, tightness, stiffness, throbbing, pulling, spasm, cramping, and soreness. The pain may be aggravated by movement and deep breathing, painful in certain positions, and relieved by rest. Patients often describe a chronic ache, tightness, and pressure in the thorax with difficulty taking a full and satisfying breath. When involving the upper ribs and the thoracic outlet, radicular symptoms mimicking myocardial infarction such as pain, numbness, and dysesthesia are not uncommon into the upper extremity.
To begin, the respiratory cycle is observed by contacting the chest wall with the hands and placing the fingers along the ribs in the intercostals spaces. Feeling the gross movement of the ribs, sternum, and thoracic spine with full respiration examines the symmetry and range of joint function and will detect any mechanical barrier restricting movement. With inhalation the sternum elevates and moves anteriorly and superiorly with the upper 6 pairs of ribs, like the handle of a water pump, while the lower 6 pairs move laterally and superiorly like the handle of a bucket. With the exhalation phase of respiration, the ribs and sternum move caudally and inferiorly. In the normal chest wall the paired ribs are level in the horizontal plane and move equally through the full range of respiration, completing the respiratory cycle at the same time .
In the chest wall with somatic dysfunction, one rib or a group of ribs stops moving in either inhalation or exhalation before the opposite side. This finding is objective evidence of mechanical dysfunction, motion restriction, and asymmetry. Additional confirmation is achieved by palpating the rib angles at the insertion of the iliocostalis muscle posteriorly. This muscle attaches to each of the rib angles and is invariably tender with rib dysfunctions, and often quite sensitive on palpation. Inequality of intercostal spaces and tenderness of the intercostal muscles are additional objective evidence of asymmetry and muscular strain. Tenderness of the anterior sterno-costal and posterior costovertebral articulations localizes the pain to the specific joints involved. This two-minute screening examination is sufficient to confirm or rule out the existence of a mechanical component as a cause for chest pain. All of the above mentioned physical findings are usually present on examination if the cause is musculoskeletal.
A more specific segmental examination of vertebral facet joints, rib position, and motion is required to form an accurate structural diagnosis and treatment plan. The goal of manual therapy is to restore maximum pain-free joint range of motion, improve function, and relieve pain. This is achieved by a variety of therapeutic manipulative techniques, which are safe, gentle, joint specific, and effective. Accurate diagnosis and therapeutic manipulation results in an improvement of symptoms, and repeat examinations and treatments demonstrate more equal symmetry and movement of the thoracic cage.
Structural diagnosis and basic treatment techniques for mechanical chest wall pain can be learned in a few days. These skills correct the cause of the chest pain and soft tissue tenderness, and bring satisfying results and gratitude from patients suffering from acute or chronic chest pain of musculoskeletal origin.
Patients with non-cardiac chest pain form a substantial proportion of emergency admissions. The majority of these cases are discharged without treatment or a diagnosis. The screening physical examination for mechanical chest wall pain is easy to learn and perform. The physical findings present objective evidence of mechanical dysfunction. Learning these examining techniques trains the physician to think like a mechanical engineer, diagnose somatic dysfunction of the thoracic cage, eliminate the cost of unnecessary diagnostic tests, and reduce physician and patient anxiety and frustration.
REFERENCES
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2. Yildrim A, Darakurt C, Karademir S, et al: Chest pain in Children. Int. Ped 2004; Vol. 19/No3:175-180
3. Disla E, Rhim H, Reddy A, et al: Costochondritis. A Prospective Analysis in an Emergency Department Setting. Arch Intern Med 1994; 154/Vol 21:2466-2469
4. Schwartz L, Bourassa M: Evaluation of Patients With Chest Pain and Normal Coronary Angiograms. Arch Intern Med 2001; 161:1825-1833
5. Wise C, Semble E, Dalton C: Musculoskeletal Chest Wall Syndromes in Patients With Noncardiac Chest Pain: A Study of 100 Patients. Arch Phys Med Rehabil 1992; 73:147-9
6. Epstein SE, Gerber LH, Borer JS: Chest Wall Syndrome. JAMA 1979; 241/No. 26: 2993-97
7. Greenman P: Principles of Manual Medicine. Lippincott Williams & Wilkins, Philadelphia, 2003; pp 1-13, pp 261-307
8. Mennell JMcM.: Joint Pain, Little, Brown Co., Boston, 1964, pp 1-11
9. Mennell JMcM.: Joint Pain, Little, Brown Co., Boston, 1960, pp 14-30
Alan Abromovitz, MD, MD(H), M.Ac.
1725 E. Osborn Rd.
Phoenix, AZ 85016
602-274-9302
www.drabromovitz.com
