Chest Pain – Different Causes

Pain in the breastbone (sternum) is pain or discomfort in the part of the chest that contains the sternum and the cartilage connecting it to the ribs. Because the sternum is located close to the heart, many people experiencing sternal pain may mistakenly interpret it as more general chest pain¹. Most cases of sternal pain are not cardiac in origin, however, and are primarily caused by problems involving the breastbone itself or nearby cartilaginous structures¹.

Approximately 1–3% of annual consultations in primary care in the United States are related to chest pain². A 2009 study by Sik et al. reported that 20–30% of hospital admissions were related to chest pain³. Aalam et al. reported in a retrospective descriptive study that although emergency-department visits increased between 2006 and 2016, the admission rate fell from 19% in 2006 to 3.9% in 2016⁴.

Illustration: Chest Pain – Different Causes.

Clinically Relevant Anatomy

The sternum is a flat bone located in the center of the anterior chest wall and consists of three segments:

Manubrium (upper part)

The manubrium articulates with the clavicles, the first ribs and the superior part of the second costal cartilages⁶. It has a roughly quadrangular shape and lies at the level of the third and fourth thoracic vertebrae. The jugular (suprasternal) notch is located at its superior border; the bone is convex anteriorly and concave posteriorly⁶.

Body of the sternum (middle part)

The body of the sternum is longer and thinner than the manubrium. It articulates with the inferior part of the second costal cartilages, the third to sixth costal cartilages and the superior part of the seventh costal cartilage⁶.

Xiphoid process (lower part)

The xiphoid process is the smallest and most inferior part of the sternum. It articulates with the inferior part of the seventh costal cartilage and provides attachment for structures including rectus abdominis, the transversus abdominis aponeurosis, transversus thoracis and the diaphragm⁶,⁷.

Causes of Sternal Pain

Sternal pain is usually caused by problems involving muscles or bony structures near the sternum rather than the sternum itself. Pain felt directly behind or beneath the sternum is described as substernal pain and may sometimes be caused by gastrointestinal disorders¹.

Common causes of sternal and substernal pain include:

• Costochondritis (inflammation of the cartilage between the ribs and sternum)

• Clavicle injuries or fractures

• Sternoclavicular joint injuries

• Hernia

• Sternal fracture

• Acid reflux

• Muscle strain or contusion

Musculoskeletal Causes of Chest Pain

Condition	Information
Sternal fracture	See the separate article on sternal fracture.
Sternal stress fracture	Sternal stress fractures account for approximately 0.5% of all sternal fractures and are thought to result from repetitive contractions of muscles attached to the sternum³. Documented cases include weightlifters, golfers and military recruits performing triceps dips³.
Clavicle fracture	These fractures account for 8–15% of all skeletal injuries in children and 2–5% of all fractures in adults⁸,⁹. In adults, more than 66% occur in the shaft, while up to 90% of fractures in children occur in the midshaft⁹. Approximately 25% of all clavicle fractures occur in the lateral third and 2–3% in the medial third⁹. The mechanism often involves falling onto the arm held close to the body during contact sport¹⁰.
Rib stress fracture	The ribs are affected by stress fractures less often than bones of the lower extremity¹¹. The mechanism usually involves prolonged activity causing muscular fatigue, particularly in sports with repetitive arm movements such as tennis, baseball, javelin throwing, basketball and weightlifting³,¹¹. Coughing can also cause stress fractures, particularly in ribs 4–8¹¹.
Joint subluxations	Costovertebral subluxations can occur during activities such as rowing, gymnastics, dance and butterfly swimming³. Subluxations of the sternoclavicular and sternocostal joints are less common and are often related to trauma or congenital hypermobility³.
Sternoclavicular Joint Disorders	See the separate article on the sternoclavicular joint.
Costochondritis	An inflammatory condition affecting the costochondral or chondrosternal joints. More than 90% of patients have multiple affected sites, most commonly the second to fifth joints³,¹². Localized tenderness on palpation is typical, without swelling³,¹². It is often associated with coughing, strenuous exercise or sports such as volleyball and rowing³.
Tietze Syndrome	A rare inflammatory condition that usually affects a single costal cartilage joint, most commonly the second or third¹². Pain is accompanied by swelling without warmth or erythema³. CT may be considered to exclude malignancy or other serious pathology³.
Inflammatory Joint Disease	For example osteoarthritis, rheumatoid arthritis and psoriatic arthritis involving the sternoclavicular joint, manubriosternal joint or shoulder joint¹²,¹³.
Fibromyalgia	A rheumatological condition characterized by persistent widespread pain, including symmetrical tender points near the second costochondral joints, neck, back, hips and extremities¹².
General Myalgia	May occur after chest trauma or heavy loading of the upper body, for example rowing³. Muscle groups may be tender on palpation¹².
Xiphodynia	A condition in which irritation of the xiphoid process refers pain to the chest, abdomen, throat, arms and head²,¹⁴. Onset is often insidious but may follow trauma or strenuous exercise. It is a diagnosis of exclusion. Treatment may include analgesics, corticosteroid injections or surgical excision².
Pectoralis Major Rupture	A relatively uncommon injury that usually affects men aged 20–40 years¹⁵. It is associated with activities such as weightlifting, particularly bench pressing, wrestling and water skiing¹⁵. Anabolic steroid use may increase rupture risk.
Injuries to Other Muscles (e.g. intercostals, serratus anterior, obliques)	Usually acute injuries caused by trauma, overload or return to activity after a period of inactivity²,³.
Precordial Catch Syndrome (Texidor's Twinge)	A rare pediatric condition characterized by brief episodes of sharp, stabbing pain in the left parasternal region or near the cardiac apex²,¹⁶. Pain is worsened by deep breathing and lasts from 30 seconds to 3 minutes². Management consists of reassurance and postural education.
Slipping Rib Syndrome (Clicking Rib, 12th Rib Syndrome)	A rare pediatric condition in which increased rib mobility causes recurrent unilateral chest pain¹²,¹⁷. The 8th–10th ribs are most commonly affected. Surgical excision of the affected rib cartilage can be curative³,¹⁷. Non-surgical measures include analgesia, taping and activity modification²,³.
After Surgery	Chronic pain after thoracotomy occurs in approximately 30–60% of patients, and after sternotomy in 20–35% at three years¹⁸,¹⁹,²⁰. Poor acute pain control and preoperative pain increase the risk of persistent pain¹⁸,¹⁹. Typical procedures include coronary artery bypass grafting (CABG), heart-valve surgery and lung transplantation²⁰,²¹,²².
Osteomyelitis	A rare infection of the sternum or ribs, usually associated with surgery, immunosuppression, chest trauma or intravenous drug use²³,²⁴,²⁵,²⁶. It may require aggressive antibiotic treatment.

Cardiovascular Causes of Chest Pain

• Heart valve disease

• Hypertrophic cardiomyopathy

• Coronary artery disease

• Myocarditis: May be caused by infectious agents such as viruses or non-infectious causes such as lithium and cocaine³. About 52% of cases occur in patients aged 20–39 years³. Symptoms may include chest pain, dyspnea, fatigue and palpitations³. The patient may report recent flu-like symptoms³.

• Pericarditis: May be caused by infection, sarcoidosis, rheumatoid arthritis and systemic lupus erythematosus³. Symptoms typically include pleuritic chest pain that improves when leaning forward and worsens when lying supine³.

• Aortic dissection

• Amyloidosis

Respiratory Causes of Chest Pain

• Asthma

• Exercise-induced asthma / bronchoconstriction³

• Bronchitis

• Bronchiectasis

• Chronic obstructive pulmonary disease (COPD)

• Tracheitis

• Tuberculosis

• Pulmonary embolism

• Pleuritis

• Pneumothorax

• Pulmonary hypertension

• Pulmonary sarcoidosis

• Lower respiratory tract infections (e.g. bronchitis, influenza, pneumonia): Chest pain may result from overuse of chest-wall musculature during coughing or from pleural inflammation³. Return to intense physical activity should be cautious to reduce the risk of complications; the patient should be afebrile and any remaining symptoms should be limited to above the neck³.

Abdominal and Gastrointestinal Causes of Chest Pain

• Gastroesophageal Reflux Disease (GERD): Presents as a burning pain behind the breastbone and may occur together with asthma-like symptoms, dry cough and sore throat³.

• Pancreatitis: Causes pain in the upper abdomen and lower chest³.

• Peptic ulcer disease

• Referred pain from the esophagus²: Esophageal spasm may be triggered by anxiety or drinking cold water²³.

• Boerhaave Syndrome: A rare condition involving rupture of the esophagus due to a sudden increase in intraluminal pressure³. It may occur with forceful vomiting, heavy lifting or after spinal manipulation for back pain³. There is a strong association with alcohol-related vomiting²³. Symptoms include pleuritic chest pain and painful swallowing³.

Referred Pain as a Cause of Chest Pain

• From the following structures²:

  • Shoulders

  • Cervical spine

  • Thoracic spine, including thoracic disc herniation, which is uncommon because of limited mobility in the thoracic region², discitis or tumors involving the spinal cord or vertebral body³.

  • Structures below the diaphragm

Cancer-Related Causes of Chest Pain

• Breast cancer

• Lung cancer

• Lymphoma

• Bone cancer

• Skin cancer²

Diagnostic Investigations

A patient older than 35 years, with a relevant medical history or risk factors for coronary artery disease, or who presents with cardiovascular symptoms, should undergo electrocardiography (ECG) and potentially chest radiography²¹. Cardiac stress testing may also be required to fully exclude or confirm cardiac dysfunction².

A patient with fever, cough, chest-wall swelling or other respiratory findings on history or examination should also undergo chest radiography²¹.

Radiography is also used to identify or exclude fractures, but because X-rays may be negative in up to 60% of stress-fracture cases, bone scintigraphy may be required¹¹.

CT and MRI may be indicated when bony injury is suspected and additional information is required²,³. CT should be performed when there is strong suspicion of neoplasia²¹. Nuclear-medicine scintigraphy may be positive in costochondritis, but the test is not specific for this condition²¹.

Blood tests measuring rheumatoid factor and C-reactive protein (CRP) may be appropriate when rheumatological disease is suspected²². Elevated white blood-cell count, fever, increased heart rate and increased respiratory rate suggest an infectious process²³. MRI is considered the reference imaging modality for identifying osteomyelitis²⁵. MRI and/or ultrasound can help assess the extent of muscle rupture and whether surgical repair is required²,¹⁵.

Examination

Clinical examination should include:

• Observation of the patient, including sweating, pallor, skin redness and shortness of breath, together with respiratory rate, heart rate and blood pressure.

• Chest pain lasting more than 12 hours together with tenderness on palpation of the anterior chest wall are strong clinical indicators of a musculoskeletal cause of sternal pain²².

• Active movements such as deep inspiration to expand the thorax and elevation of the upper extremities can strengthen suspicion of a musculoskeletal diagnosis²¹,¹⁵.

• Pain during inspiration is expected with rib or sternal fractures, together with pain during movements of the chest and upper extremity and pain on palpation or gentle percussion²,³.

• With a stress fracture, pain may initially be difficult to localize but can become more prominent and limiting over time³. A bony callus may be palpable over the injury site in persistent stress fractures¹¹.

• In tuberculous osteomyelitis, a palpable abscess or draining sinus may be present in addition to chest pain and fever²⁶. Swelling from rib osteomyelitis is typically seen near the costochondral joints or costovertebral angle²⁴.

• Resisted muscle testing may reveal true muscular weakness or neurogenic weakness²,¹⁵. Altered sensation and reflexes together with neurogenic weakness may indicate nerve-root involvement from the thoracic or lower cervical spine.

• Questions about morning stiffness and pain in other regions, together with general joint observation, may increase suspicion of a rheumatological cause²¹.

• Asymmetry, swelling and bruising, either over the chest or extending toward the axilla and arm, may be seen with severe muscle rupture such as pectoralis major rupture, and the patient may report a 'pop' at the time of injury¹⁵.

Muscles, Injury Mechanisms and Clinical Findings

Muscle	Mechanism	Presentation and Examination
Intercostal Muscles	Excessive loading of untrained muscles during activities such as coughing, chopping wood or overhead painting, as well as sports involving heavy upper-body loading such as rowing.	Pain and tenderness on palpation of the intercostal muscles. Pain with deep inspiration and coughing.
Pectoralis Major and/or Minor	Direct blow. Indirect trauma, for example forceful eccentric contraction when the muscle is already fully lengthened, which is common in sports such as weightlifting and rugby, or forced abduction with external rotation or extension, as may occur during a fall or recreational resistance training.	Acute onset of pain in the arm or shoulder, sometimes with a perceived 'pop'. +/- Swelling and bruising. +/- Loss of the anterior axillary fold, asymmetry or a palpable defect in the muscle belly. +/- Reduced ability to adduct the arm.
Internal and External Obliques	Muscle lengthening followed by sudden eccentric contraction. A rare injury typically seen in swimmers, javelin throwers, rowers and ice-hockey players. It may also occur in the non-throwing arm of fast bowlers in cricket.	Pain on palpation of the four lowest costal cartilages. Increased pain with resisted lateral flexion of the trunk toward the injured side.
Serratus Anterior	Overuse during activities such as weightlifting and rowing.	Pain along the medial border of the scapula radiating anteriorly². Pain reproduced with resisted scapular protraction.

Physiotherapy Management

When taking the history of a patient with chest pain, red flags must be considered carefully.

Although sternal pain is usually not serious, some causes require immediate medical assessment. Examples include:

• Pain that began after direct trauma to the chest.

• Pain occurring together with symptoms of myocardial infarction.

• Persistent pain that does not improve over time.

• Pain accompanied by severe vomiting or hematemesis¹.

Below is a brief summary of common causes of pain in the sternal region and their management:

Rib fracture:

Treatment focuses on pain management and deep-breathing exercises to maintain adequate pulmonary function. Relative rest is recommended for the first three weeks after injury, followed by gradual return to activity, particularly overhead movements². With stress fractures, biomechanical factors and sport technique may need to be corrected to reduce recurrence risk³,¹¹. Delayed union or malunion can occur, but this is often asymptomatic³,¹¹.

Joint subluxation:

Conservative management focusing on pain control and, when appropriate, joint manipulation is recommended³. If conservative treatment fails, surgical debridement may be considered³.

Costochondritis:

Treatment includes reassurance, pain relief, mobilization or manipulation of affected regions and possibly taping³. The condition usually resolves within one year³.

Acute myalgia:

Relative rest is recommended during the acute phase¹².

Fibromyalgia:

Graded exercise programs should be implemented¹².

Muscle strain:

Acute management includes reassurance, pain relief such as analgesics or heat, and avoidance of provocative activities. During the subacute phase, a progressive strengthening program and gradual return to normal activity are introduced. If conservative treatment does not provide a satisfactory response, referral for injection treatment with lidocaine or corticosteroids may be considered².

Pectoralis major rupture:¹⁵

During the acute phase, a sling may be used for comfort together with analgesia and rest. Early shoulder mobilization and gentle stretching should begin. Once pain has decreased and normal mobility has returned, usually after six to eight weeks, strengthening can be introduced. Education on weightlifting technique is important to reduce stress on pectoralis major, for example lowering the weight to no more than 4–6 cm above the chest wall and using a narrower grip no wider than 1.5 times biacromial width¹⁵.

Slipping Rib Syndrome:

This condition is usually treated with rest, physiotherapy and intercostal nerve blocks. In chronic and severe cases, surgical excision of the hypermobile cartilage may be considered¹².

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