Introduction
- Paul F. Reuteman, PT, DPT, MHS, OCS, ATC
- Scott A. Escher, MD
Epidemiology
Age, Sex, Sport, and Position
Thoracic Pain
- •
Musculoskeletal thoracic pain is not as common as cervical or lumbar pain; however, it is typically more prevalent in the athletic population.
- •
Musculoskeletal sources of pain have been linked to both the costovertebral joints and the facet joints of the thoracic vertebrae. Little data exist on the frequency of pain associated with these structures.
- •
Thoracic disc injuries are quite rare because of the relative hypomobility of the thoracic spine. They account for only 0.15% to 4% of symptomatic disc herniations of the spine.
- •
Even though thoracic pain is less prevalent, evolving evidence indicates that manual therapy interventions addressing impairments of the thoracic spine may be associated with enhanced outcomes of individuals with neck, shoulder, and upper extremity pain.
Chest Wall Pain
- •
The anatomical structures that can cause chest wall pain are quite varied. A thorough examination is required to consider all the sources of pain.
- •
In athletes with chest pain, the first priority is to consider potentially life-threatening causes. Structures of the cardiovascular and gastrointestinal system must be considered.
- •
In the primary care setting, the cause of chest pain is benign in approximately 80% of cases, of which musculoskeletal chest pain accounts for almost 50%.
- •
Musculoskeletal sources of chest wall pain in athletes can occur in the ribs, sternum, articulations of the ribs and sternum, and myofascial structures. Injury to these structures is commonly a result of direct trauma or overuse. The incidence of these conditions is 13% to 30% in patients seeking care in an emergency department with a primary complaint of chest pain.
- •
Sports associated with musculoskeletal sources of chest pain include golf, baseball, and wrestling.
- •
Female rowers are especially susceptible to chest and rib injuries.
- •
Overhead athletes participating in sports such as basketball, tennis, or weightlifting have been found to be susceptible to first rib injuries.
Pathophysiology
Intrinsic Factors
Thoracic Pain
- •
An association between hypomobility of the thoracic spine and the presence of neck pain has been well documented in the literature. It is generally accepted that a similar association exists between thoracic pain but, ironically, evidence is less compelling for this association.
- •
Postural conditions that create an accentuated thoracic kyphosis and forward head posture have been found to correlate with thoracic and periscapular pain.
- •
A hyperkyphosis of the nonpostural type (nonreversible) is often associated with Scheuermann’s disease. To date, there has not been any correlation between pain and the presence of Scheuermann’s disease. It has been hypothesized from a biomechanical perspective that intense athletic exercise and training regimens may lead to further progression of hyperkyphosis conditions of either postural or nonpostural types.
Chest Wall Pain
- •
It is difficult to isolate common underlying impairments associated with pathologies such as costochondritis, stress fractures of the ribs or sternum, and strains of the intercostal muscles. Hypomobility of the thoracic spine and ribs may be associated with these conditions. Muscle tightness, especially of the pectoralis minor and serratus anterior, may also contribute to abnormal mechanical stresses to the anterior-lateral structures.
- •
Athletes are especially susceptible to stress fractures of the rib. The first rib is the most common rib to sustain a stress fracture. It has a point of relative weakness where a deep groove exists for the subclavian artery. Strong contractions of the anterior scalene muscles while a traction force applied to the arm during forceful overhead motion may exceed the bone’s loading capacity.
- •
Ribs 4 through 8 are also susceptible to stress fractures. These stress fractures are commonly associated with a strong contraction of the serratus anterior as the athlete moves forcefully into a side-bending and flexion motion, as in golf and softball pitching.
Extrinsic Factors
- •
A majority of extrinsic factors associated with musculoskeletal thoracic and chest wall pain deals with training errors. A study that sampled 2270 adolescents between 8 and 18 years of age found that increased angles of thoracic kyphosis were associated with greater cumulative training times. Of all the athletes studied, gymnasts trained the most each year and showed the largest thoracic curve. Lack of sports participation was associated with the smallest curve. Age and sex did not significantly have an effect on the degree of curvature.
- •
Other correlations exist between muscle activity and the prevalence of rib stress fractures and costochondritis. Rowers and golfers are especially prone to rib stress fractures and costochondritis.
- •
In rowers, the co-contraction of the serratus anterior and external obliques exerting opposite forces on the ribs may lead to rib failure. In golfers, the swing mechanics appear to have an influence on the prevalence of stress fractures. Of 19 golfers diagnosed with a rib stress fracture, 16 had stress fractures on their leading side. Electromyography of the serratus anterior on the lead side has shown the muscles to be active during the entire swing.
Traumatic Factors
- •
As mentioned, musculoskeletal injury to the chest wall and thoracic region are commonly associated with overuse activity.
- •
However, trauma is also associated with injuries to the chest and thorax. Athletes participating in high collision sports such as football, rugby and wrestling are most susceptible to injuries such as rib fractures. Traumatic rib fractures are quite painful but commonly respond to rest and conservative management. The immediate concern associated with rib fractures is the potential for injury to the underlying tissue.
- •
Any trauma to the chest may result in a pneumothorax (puncture of the lung and pleura and deflating of the lung) or a laceration of the spleen, liver, or kidney. All of these are considered life-threatening emergencies.
- •
Complaints of shortness of breath, pain with deep breathing, severe chest or abdominal pain, and asymmetrical chest expansion associated with direct trauma to the chest requires immediate medical attention.
- •
Another indicator of injury is Kehr’s sign, which is pain in the left scapular region referred from the peritoneal cavity. This is considered a classic sign of a ruptured spleen.
- •
Blood in the urine is considered a sign associated with trauma to the kidney.
Classic Pathological Findings
- •
It is uncommon for overuse conditions of the thoracic spine and chest wall to present with pathological findings.
- •
Costochondritis, rib stress fractures, and thoracic musculoskeletal pain rarely present with cardinal signs of inflammation (localized swelling, increased tissue temperature, redness).
- •
Traumatic fractures to the ribs, sternum or thoracic spine are often accompanied by localized swelling, increased tissue temperature, ecchymosis, and point tenderness.
Clinical Presentation
History
- •
A thorough subjective examination and history is critical for any person that has primary complaints of either thoracic or chest wall pain.
- •
Professional responsibilities require the practitioner to especially ask questions regarding the cardiovascular system. Specific concern is if the athlete complains of chest pain and tightness or shortness of breath with activity or a general decrease in exercise tolerance.
- •
Once cardiovascular conditions have been ruled out, common subjective complaints associated with musculoskeletal sources of thoracic and chest pain may be addressed.
Thoracic Pain
- •
Common complaints associated with musculoskeletal thoracic pain include pain along the spine, either bilaterally or unilaterally. Pain in the thoracic region may be very specific to the level of the dysfunction or it may be vague because of the referral patterns associated with the thoracic facet joints.
- •
The onset of pain may correlate with an increase in the athlete’s training volume and intensity.
- •
Pain is commonly aggravated with movement of the thoracic spine, especially with rotation and/or extension. Deep breathing and coughing will often exacerbate the pain as well.
Chest Wall Pain
- •
As with thoracic pain, musculoskeletal causes of chest wall pain are often associated with a change in activity or from direct trauma.
- •
Pain is localized to the costosternal or costochondral joints or along the ribs. Pain is usually exacerbated with upper extremity motions such as horizontal adduction or trunk rotation and/or extension.
- •
Athletes may report symptoms with increased activity or repetitions of a specific motion (e.g., trunk rotation with flexion) or with deep breathing.
- •
In the presence of costochondritis, pain may be associated with a popping sensation in the vicinity of the costochondral joint. This popping sensation may be quite painful when it occurs but may provide a temporary reduction of symptoms.
- •
In the presence of stress fractures, athletes commonly complain of specific pain at the region of the fracture. This pain may be present at rest but is certainly aggravated with activity.
- •
First rib stress fractures often produce dull, aching pain in the neck and shoulder complex.
- •
Stress fractures to the middle ribs (usually 4 to 8) are accompanied with complaints of mid-costal pain especially with deep breathing or rolling over in bed.
- •
In the presence of a traumatic fracture of a rib, the athlete can usually recall a single event in which the chest wall suffered a direct blow.
Physical Examination
Abnormal Findings
- •
A standardized protocol to assess chest and thoracic pain has been proposed by several authors. It consists of three parts: a structured interview, a general health examination, and a specific manual examination of the muscles and joints of the neck, thoracic spine, and chest wall. The use of a standardized protocol to evaluate for musculoskeletal chest pain has been found to have substantial interobserver reliability.
- •
Once it has been deemed from the interview and general health examination that the source of pain is stemming from the musculoskeletal system, the examination attempts to reproduce the patient’s pain by implying mechanical stresses to the anatomical structures.
- •
Assessment of the following is necessary: Active motion of the trunk, palpation, mobility assessment of the thoracic spine, and assessment of flexibility of the muscles in the thoracic region. A thorough examination will identify impairments necessary to address in the intervention plan.
- •
For musculoskeletal conditions of both the thorax and chest, common findings include pain and/or limited motion during active range of motion (ROM) of the thoracic region. Range of motion of the thoracic region is commonly assessed in standing and/or sitting and specific attention is paid to flexion, extension, and rotation ( Figures 21-1 to 21-4 ). Provocation of symptoms is deemed a more valuable finding during motion assessment because it is challenging to measure exact degrees of motion. To further elicit symptoms, overpressure may be applied at the end range of motion ( Figures 21-5 to 21-7 ).
FIGURE 21-1
Assessment of active thoracic flexion.
FIGURE 21-2
Assessment of active thoracic extension.
FIGURE 21-3
Assessment of active thoracic right rotation.
FIGURE 21-4
Assessment of active thoracic left rotation.
FIGURE 21-5
Assessment of thoracic extension with overpressure.
FIGURE 21-6
Assessment of thoracic right rotation with overpressure.
FIGURE 21-7
Assessment of thoracic left rotation with overpressure.
- •
Determination of palpable tenderness provides more specific detail of the location of the patient’s symptoms. Palpation of posterior structures includes the erector spinae muscles, the spinous and transverse processes, and the posterior and lateral ribs. Palpation of anterior structures includes the sternum, sternocostal joints, costochondral joints, anterior ribs, pectoralis minor/major, subclavius, and intercostal muscles.
- •
Many authors have identified aberrant or decreased mobility of the thoracic spine as a contributing factor in many of the overuse injuries of the thorax and chest.
- •
Assessment of thoracic mobility is commonly performed by applying a posterior to anterior (PA) pressure to different levels of the thoracic spine when the patient is in a prone position ( Figure 21-8 ). The clinician assesses the magnitude of motion with respect to the force applied and qualitatively determines joint stiffness. In addition to assessing joint stiffness, the clinician also inquires about pain during the application of force. Both intra- and inter-assessment reliability was found to be moderate to very good for both joint mobility and pain provocation assessment.
FIGURE 21-8
Assessment of posterior-anterior mobility of the thoracic spine.
Pertinent Normal Findings
- •
As described, a thorough evaluation must be performed to rule out non-musculoskeletal causes of chest and thoracic pain. It is important to take a clear history of the present symptoms and a general health history of the athlete.
- •
In the presence of musculoskeletal pain, normal findings should be found during the assessment of vital signs, auscultation of the heart, lung, and neck, abdominal palpation, and a neurological examination of the extremities.
- •
If the patient does not present with any significant signs or symptoms associated with the gastrointestinal and cardiovascular system, the clinician should proceed onto assessment of the musculoskeletal structures.
Imaging
Thoracic Pain
- •
If the athlete has sustained a traumatic injury, it is standard practice to order a traditional series of radiographic films of the thoracic spine.
- •
Other imaging studies to assess for fractures in the thoracic region may include the use of a bone scan, CT scan, or MRI.
- •
In the absence of traumatic injuries of the thoracic region, imaging of the thoracic spine typically does not provide much benefit.
Chest Pain
- •
Again, if the athlete has sustained a traumatic injury, it is standard practice to order a traditional series of radiographic films of the chest.
- •
For overuse injuries, a bone scan may be used to diagnose the presence of a stress fracture. A CT scan or MRI may also be ordered for more detail of the bony structures. The MRI has an added benefit of visualization of the soft tissue structures of the thorax.
Differential Diagnosis
- •
Currently a diagnosis of musculoskeletal chest and thoracic pain can be difficult to establish because there is no reference standard to verify the diagnosis. Except for traumatic fractures or stress fractures of the thorax, there are no diagnostic tests to confirm a diagnosis of musculoskeletal pain.
- •
Therefore any musculoskeletal pain is often a diagnosis made when other conditions have been excluded.
- •
Some of the conditions that could be confused with chest and thoracic musculoskeletal pain include
- •
Gastroesophageal reflux diseases (GERD): Athletes often present with burning retrosternal pain and may have a dry cough and sore throat.
- •
Pancreatitis: Acute pancreatitis causes severe epigastric and lower chest pain, it may be associated with vomiting and can be life threatening. Blood tests are performed to rule out this condition.
- •
Exercise-induced asthma (EIA): Symptoms of EIA include chest tightness/pain, dyspnea, wheezing, coughing, and fatigue. Diagnosis is confirmed by stress pulmonary function testing or methacholine challenge testing.
- •
Lower respiratory infections: These can include bronchitis, influenza, and pneumonia. Inflammation of the pleura and overuse of the muscles around the chest wall from excessive coughing are often a cause of chest pain. These conditions can be accompanied by a fever and dyspnea.
- •
Spontaneous pneumothorax: This is an uncommon condition associated with severe chest pain and shortness of breath. Diagnosis is confirmed by chest films. An association with Alpha-1 antitrypsin (AAT) deficiency has been identified with this condition.
- •
Pericarditis: This is an inflammation of the pericardium usually caused by an infection. Chest pain is the primary symptom and is often worsened by lying down and relieved by sitting forward. It typically presents with characteristic ECG changes including upward-concave ST-segment elevation in all leads. A complication of pericarditis may be pericardial effusion, which may be seen on an echocardiography.
- •
Myocarditis: This is an inflammatory disease of the heart most commonly caused by a viral infection or noninfectious agents such as drugs (e.g., cocaine). Physical activity increases the inflammation seen in myocarditis and leads to complications of dilated cardiomyopathy, heart failures, arrhythmias, and death. Symptoms include chest pain, fatigue, dyspnea, reduced exercise tolerance, and/or palpitations. Diagnostic studies include an ECG, echocardiography, cardiac MRI, or an endomyocardial biopsy.
- •
Treatment
Nonoperative Management
- •
Because of the infrequent nature of musculoskeletal chest and thoracic pain in athletes, there is a lack of high-level randomized trials that assess best practice for intervention. Case reports dominate the literature on treatment options.
- •
Therefore a majority of the intervention, whether the pain is anterior or posterior, is intended to address underlying impairments of the cervical, thoracic, and lumbar region that have been identified during the examination of the athlete (e.g., thoracic hypomobility, muscular tightness, poor trunk strength and endurance, postural considerations).
- •
Special consideration must be made in the management of rib stress fractures. Treatment of first rib stress fractures involves immobilization of the upper extremity in a sling for 4 weeks with a gradual return to activity.
- •
Management of other rib stress fractures requires relative rest for 4 to 6 weeks. Light training and cardiovascular conditioning may be undertaken during this time. Return to full competition is commonly allowed around 8 weeks.
Guidelines for Choosing Among Nonoperative Treatments
- •
Manual therapy options
- •
Thoracic posterior-anterior (PA) and anterior-posterior (AP) mobilizations or thrust manipulations. Currently only one study, a nonrandomized trial with several limitations, has assessed the effectiveness of manual therapy directed at the thoracic spine to address chest and thoracic pain. In this study, approximately 75% of the patients described a self-reported improvement in pain and general health following treatment involving thrust techniques to the thoracic region.
- •
Several studies have identified a subset of patients with neck and shoulder pain that may benefit from these manual therapy interventions. It is believed that these techniques may enhance general mobility of the thoracic spine and costovertebral joints resulting in decreased pain and enhanced function.
- •
Soft tissue mobilizations to the tight and tender musculature of the thoracic and chest region
- •
- •
Self-mobilization of the thoracic spine. These exercises are prescribed as a supplement to the manual therapy interventions described above.
- •
Stretching of musculature of the trunk with special attention to the pectoralis major/minor and the latissimus dorsi.
- •
Strengthening of the musculature of the trunk with special attention to the lower/middle trapezius and serratus anterior.
Surgical Indications
- •
There are no surgical indications for the pathologies discussed in this chapter.
Evidence
Multiple Choice Questions
- QUESTION 1.
Which of the following statements is true regarding kyphosis of the thoracic spine?
- A.
Thoracic manipulation has been found to decrease the kyphosis of the thoracic spine.
- B.
A strong correlation exists between thoracic pain and kyphosis angles of the thoracic spine.
- C.
Thoracic kyphosis angles were found to increase with greater training times and intensity.
- D.
Those participating in swimming were found to have the greatest kyphosis angles.
- A.
- QUESTION 2.
Which of the following is NOT a sign or symptom associated with a pneumothorax?
- A.
Shortness of breath
- B.
Bruising of the costal region
- C.
Asymmetrical chest expansion
- D.
Pain with deep breathing
- A.
- QUESTION 3.
Which of the following statements regarding assessment of thoracic mobility is true?
- A.
Thoracic mobility is assessed in a posterior to anterior direction while the athlete is prone. It has been found to have adequate reliability.
- B.
Thoracic mobility is assessed in a posterior to anterior direction while the athlete is supine. It has been found to have adequate reliability.
- C.
Thoracic mobility is assessed in a posterior to anterior direction while the athlete is prone. It has been found to have poor reliability.
- B.
Thoracic mobility is assessed in a posterior to anterior direction while the athlete is supine. It has been found to have poor reliability.
- A.
- QUESTION 4.
Which of the following statements is inaccurate regarding myocarditis?
- A.
There are very few symptoms associated with myocarditis.
- B.
Myocarditis may be caused by a viral infection or noninfectious agents (e.g., cocaine).
- C.
A complication associated with myocarditis may be potential death.
- D.
Diagnostic studies to confirm myocarditis include ECG, echocardiography, cardiac MRI, or an endomyocardial biopsy.
- A.
- QUESTION 5.
Which statement is true regarding the use of thoracic manipulations/mobilizations?
- A.
Thoracic manipulations have been found to be very specific to a segment of the thoracic spine.
- B.
Strong evidence exists for the use of thoracic manipulation for musculoskeletal pain of the thoracic region
- C.
A subset of patients has been identified in the literature that may benefit from these techniques.
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Pathophysiology )
- QUESTION 2.
Correct answer: B (see Pathophysiology )
- QUESTION 3.
Correct answer: A (see Clinical Presentation )
- QUESTION 4.
Correct answer: A (see Differential Diagnosis )
- QUESTION 5.
Correct answer: C (see Treatment )
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Lateral Collateral Ligament and Posterolateral Ligament Injuries
Superior Labral Pathology (SLAP/Long Head Biceps)
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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