Screening the Chest, Breasts, and Ribs

Chapter 17

Screening the Chest, Breasts, and Ribs

Clients do not present in a physical therapy clinic with chest or breast pain as the primary symptom very often. The therapist is more likely to see the individual with an orthopedic or neurologic impairment who experiences chest or breast pain during exercise or during other intervention by the therapist.

In other situations, the client reports chest or breast pain as an additional symptom during the screening interview. The pain may occur along with (or alternating with) the presenting symptoms of jaw, neck, upper back, shoulder, breast, or arm pain. When chest pain is the primary complaint, it is often an atypical pain pattern (possibly in a young athlete) that has misled the client and/or the physician.1

On the other hand, it is also possible for clients to have primary chest pain from a human movement system impairment, particularly spinal referred pain.2 Symptoms persist or recur, often with months in between when the client is free of any symptoms. Countless medical tests are performed and repeated with referral to numerous specialists before a physical therapist is consulted (see Case Example 1-7).

Finally, so many of today’s aging adults with movement system impairments have multiple medical comorbidities that the therapists must be able to identify signs and symptoms of systemic disease that can mimic neuromuscular or musculoskeletal dysfunction. Systemic or viscerogenic pain or symptoms that can be referred to the chest or breast include the cardiovascular, pulmonary, and upper gastrointestinal (GI) systems, as well as other causes such as cancer, anxiety, steroid use, and cocaine use (Table 17-1).3 Various neuromusculoskeletal (NMS) conditions, such as thoracic outlet syndrome, costochondritis, trigger points, and cervical spine disorders, can also affect the chest and breast.4

When faced with chest pain, the therapist must know how to assess the situation quickly and decide if medical referral is required and whether medical attention is needed immediately. As experts in understanding and assessing the human movement system, we are the most capable health care professional when it comes to differentiating NMS from systemic origins of symptoms.

The therapist must especially know how and what to look for to screen for cancer, cancer recurrence, and/or the delayed effects of cancer treatment. Cancer can present as primary chest pain with or without accompanying neck, shoulder, and/or upper back pain/symptoms. Basic principles of cancer screening are presented in Chapter 13; specific clues related to the chest, breast, and ribs will be discussed in this chapter. Breast cancer is always a consideration with upper quadrant pain or dysfunction.

Using the Screening Model to Evaluate the Chest, Breasts, or Ribs

There are many causes of chest pain, both cardiac and noncardiac in origin (see Table 17-1). Two conditions may be present at the same time, each contributing to chest pain. For example, someone with cervicodorsal arthritis could also experience reflux esophagitis or coronary disease. Either or both of these conditions can contribute to chest pain.

Chest pain can be evaluated in one of two ways: cardiac versus noncardiac or systemic versus neuromusculoskeletal (NMS). Physicians and nurses assess chest pain from the first paradigm: cardiac versus noncardiac. The therapist must understand the basis for this screening method while also viewing each problem as potentially systemic versus NMS. Throughout the screening process, it is important to remember we are not medical cardiac specialists; we are just screening for systemic disease masquerading as NMS symptoms or dysfunction.

Paying attention to past medical history, recognizing unusual clinical presentation for a neuromuscular or musculoskeletal condition, and keeping in mind the clues to differentiating chest pain will help the therapist evaluate difficult cases.

Additionally, the woman with chest, breast, axillary, or shoulder pain of unknown origin at presentation must be questioned regarding breast self-examinations. Any recently discovered lumps or nodules must be examined by a physician. The client may need education regarding breast self-examination, and the physical therapist can provide this valuable information.5,6 Techniques of breast self-examination are commonly available in written form for the physical therapist or the client who is unfamiliar with these methods (see Appendix D-6).

Clinical Presentation

When the clinical presentation suggests further screening is needed, the therapist can follow the guide to pain assessment (see Chapter 3) and physical assessment for the upper quadrant as presented in Table 4-13. Assess vital signs and watch for trends in heart rate and blood pressure. Keep in mind that tachycardia may be a compensatory response to reduced cardiac output and bradycardia may be an indication of myocardial ischemia or (unreported) trauma.

The client’s general appearance, along with vital sign assessment, will offer some idea of the severity of the condition. Watch for uneven pulses from side to side, diminished or absent pulses, elevated blood pressure, or extreme hypotension. Auscultation for breath or lung sounds and chest percussion may provide additional cardiopulmonary clues.

Check to see if the pain can be reproduced or made worse by palpation or with pressure on the chest; and, of course, ask about associated symptoms such as nausea and shortness of breath. The key features that point to spinal referred pain are chest pain reproduced on movement (especially with resistive movement), tenderness and tightness of musculoskeletal structures at a spinal level supplying the painful area, and an absence or lack of symptoms suggestive of a nonmusculoskeletal cause.2

Chest Pain Patterns

From the previous discussion in Chapter 3, we know that there are at least three possible mechanisms for referred pain patterns to the soma from the viscera (embryologic development, multisegmental innervations, direct pressure on the diaphragm). Pain in the chest may be derived from the chest wall (dermatomes T1-12), the pleura, the trachea and main airways, the mediastinum (including the heart and esophagus), and the abdominal viscera. From an embryologic point of view, the lungs are derived from the same tissue as the gut, so problems can occur in both areas (lung or gut), causing chest pain and other related symptoms.

Certain chest pain patterns are more likely to point to a medical rather than musculoskeletal cause. For example, pain that is positional or reproduced by palpation is not as suspicious as pain that radiates to one or both shoulders or arms or that is precipitated by exertion. Physicians agree that the chest pain history by itself is not enough to rule out cardiac or other systemic origin of symptoms. In most cases, some diagnostic testing is needed.7

Chest pain associated with increased activity is a red flag for possible cardiovascular involvement. In such cases, the onset of pain is not immediate but rather occurs 5 to 10 minutes after activity begins. This is referred to as the “lag time” and is a screening clue used by the physical therapist to assess when chest pain may be caused by musculoskeletal dysfunction (immediate chest pain occurs with movement of the arms and/or trunk) or by possible vascular compromise (chest pain occurs 5 to 10 minutes after activity begins).

Parietal pain may appear as unilateral chest pain (rather than midline only) because at any given point the parietal peritoneum obtains innervation from only one side of the nervous system. It is usually not reproduced by palpation. Thoracic disk disease can also present as unilateral chest pain, requiring careful screening.8,9

The four types of pain discussed in Chapter 3 (cutaneous, deep somatic or parietal, visceral, and referred) also apply to the chest. Parietal (somatic) chest pain is the most common systemic chest discomfort encountered in a physical therapy practice. Parietal pain refers to pain generating from the wall of any cavity, such as the chest or pelvic cavity (see Fig. 6-5). Although the visceral pleura are insensitive to pain, the parietal pleura are well supplied with pain nerve endings. It is usually associated with infectious diseases but is also seen in pneumothorax, rib fractures, pulmonary embolism with infarction, and other systemic conditions.

Pain fibers, originating in the parietal pleura, are conveyed through the chest wall as fine twigs of the intercostal nerves. Irritation of these nerve fibers results in pain in the chest wall that is usually described as knifelike and is sharply localized close to the chest wall, occurring cutaneously (in the skin).

Pain from the thoracic viscera and true chest wall pain are both felt in the chest wall, but visceral pain is referred to the area supplied by the upper four thoracic nerve roots. Report of pain in the lower chest usually indicates local disease, but upper chest pain may be caused by disease located deeper in the chest.

There are few nerve endings (if any) in the visceral pleurae (linings of the various organs), such as the heart or lungs. The exception to this statement is in the area of the pericardium (sac enclosed around the entire heart), which is adjacent to the diaphragm (see Fig. 6-5). Extensive disease may develop within the body cavities without the occurrence of pain until the process extends to the parietal pleura. Neuritis (constant irritation of nerve endings) in the parietal pleura then produces the pain described in this section.

Pleural pain may be aggravated by any respiratory movement involving the diaphragm, such as sighing, deep breathing, coughing, sneezing, laughing, or the hiccups. It may be referred along the costal margins or into the upper abdominal quadrants. Palpation usually does not reproduce pleural pain; change in position does not relieve or exacerbate the pain. In some cases of pleurisy, the individual can point to the painful spot but deep breathing (not palpation) reproduces it.

Associated Signs and Symptoms

If the client has an underlying infectious or inflammatory process causing chest or breast pain or symptoms, there may be changes in vital signs and/or constitutional symptoms such as chills, night sweats, fever, upper respiratory symptoms, or GI distress.

Signs and symptoms associated with noncardiac causes of chest pain vary according to the underlying system involved. For example, cough, sputum production, and a recent history of upper respiratory infection may point to a pleuropulmonary origin of chest or breast pain. Anyone with persistent coughing or asthma can experience chest pain related to the strain of the chest wall muscles.

Chest or breast pain associated with GI disease is often food related in the presence of a history of peptic ulcer, gastroesophageal reflux disease (GERD), or gallbladder problems. Blood in the stool or vomitus, along with a history of chronic nonsteroidal antiinflammatory drug (NSAID) use, may point to a GI problem and so on.

Many of the conditions affecting the breast are not accompanied by other systemic signs and symptoms. Risk factors, client history, and clinical presentation provide the major clues as to a viscerogenic, systemic, or cancerous origin of chest and/or breast pain or symptoms.

Screening for Oncologic Causes of Chest or Rib Pain

Cancer can present as primary chest, neck, shoulder, and/or upper back pain and symptoms. A previous history of cancer of any kind is a major red flag (Case Example 17-1). Primary cancer affecting the chest with referred pain to the breast is not as common as cancer metastasized to the pulmonary system with subsequent pulmonary and chest/breast symptoms.

Case Example 17-1   Rib Metastases Associated with Ovarian Cancer

Referral: A 53-year-old university professor came to the physical therapy clinic with complaints of severe left shoulder pain radiating across her chest and down her arm. She rated the pain a 10 on the numeric rating scale (NRS; see explanation in Chapter 3).

Past Medical History: She had a significant personal and social history, including ovarian cancer 10 years ago, death of a parent last year, filing for personal bankruptcy this year, and a divorce after 30 years of marriage.

Clinical Presentation (First Visit): During the screening examination for vital signs, the client’s blood pressure was 220/125 mm Hg. Pulse was 88 bpm. Pulse oximeter measured 98%. Oral temperature: 98.0° F. She denied any previous history of cardiovascular problems or current feelings of stress.

Intervention: She was referred for medical attention immediately on the basis of her blood pressure readings but returned a week later with a medical diagnosis of “rib bruise.” Electrocardiography (ECG) and heart catheterization ruled out a cardiac cause of symptoms. She was put on Prilosec for gastroesophageal reflux disease (GERD) and an antiinflammatory for her rib pain.

Clinical Presentation (Second Visit): The therapist was able to reproduce the symptoms described above with moderate palpation of the eighth rib on the left side and sidebending motion to the left side. The client described the symptoms as constant, sharp, burning, and intense. She had pain at night if she slept too long on either side.

Sidelying on the involved side and slump sitting did not reproduce the symptoms. There was no obvious mechanical cause for the painful symptoms (e.g., intercostal tear, costovertebral dysfunction, neuritis from nerve entrapment).

The therapist considered the possibility of a somato-visceral reflex response (e.g., a biomechanical dysfunction of the tenth rib can cause gallbladder changes), but there were no accompanying associated signs and symptoms and the tenth rib was not painful.

Result: The therapist decided to contact the referring physician to discuss the client’s clinical presentation before initiating treatment, especially given the constancy and intensity of the pain in the presence of a past medical history of cancer.

The physician directed the therapist to have the client return for further testing. A bone scan revealed metastases to the ribs and thoracic spine. Physical therapy intervention was not appropriate at this time.

Clinical Presentation

The most common symptoms associated with metastases to the pulmonary system are pleural pain, dyspnea, and persistent cough. As with any visceral system, symptoms may not occur until the neoplasm is quite large or invasive because the lining surrounding the lungs has no pain perception. Symptoms first appear when the tumor is large enough to press on other nearby structures or against the chest wall. The presence of any skin changes, lesions, or masses should be documented using the information presented in Box 4-11. Skeletal pain from metastases to the bone or primary cancers such as multiple myeloma affecting the sternum can present much like costochondritis.

Skin Changes

Ask the client about any recent or current skin changes. Metastatic carcinoma can present with a cellulitic appearance on the anterior chest wall as a result of carcinoma of the lung (see Fig. 4-26). The skin lesion may be flat or raised and any color from brown to red or purple.

Liver impairment from cancer or any liver disease can also cause other skin changes, such as angiomas over the chest wall. An angioma is a benign tumor with blood (or lymph, as in lymphangioma) vessels. Spider angioma (also called spider nevus) is a form of telangiectasis, a permanently dilated group of superficial capillaries (or venules; see Fig. 9-3).

In the presence of skin lesions, ask about a recent history of infection of any kind, use of prescription drugs within the last 6 weeks, and previous history of cancer of any kind. Look for lymph node changes. Report all of these findings to the physician.

Palpable Mass

Occasionally, the therapist may palpate a painless sternal or chest wall mass when evaluating the head and neck region. Most mediastinal tumors are the result of a metastatic focus from a distant primary tumor and remain asymptomatic unless they compress mediastinal structures or invade the chest wall.

The primary tumor is usually a lymphoma (Hodgkin’s lymphoma in a young adult or non-Hodgkin’s lymphoma in a child or older adult; see Fig. 4-29), multiple myeloma (primarily observed in people over 60 years of age), or carcinoma of the breast, kidney, or thyroid.

When involvement of the chest wall and nerve roots results in pain, the pattern is more diffuse, with radiation of pain to the affected nerve roots (Case Example 17-2). Irritation of an intercostal nerve from rib metastasis produces burning pain that is unilateral and segmental in distribution. Sensory loss or hyperesthesia over the affected dermatomes may be noted.

Case Example 17-2   Lymphoma Masquerading as Nerve Entrapment

Referral: A 72-year-old woman was referred to physical therapy for a postural exercise program and home traction by her neurologist with a diagnosis of “nerve entrapment.” She was experiencing symptoms of left shoulder pain with numbness and tingling in the ulnar nerve distribution. She had a moderate forward head posture with slumped shoulders and loss of height from known osteoporosis.

Past Medical History: The woman’s past medical history was significant for right breast cancer treated with a radical mastectomy and chemotherapy 20 years ago. She had a second cancer (uterine) 10 years ago that was considered separate from her previous breast cancer.

Clinical Presentation: The physical therapy examination was consistent with the physician’s diagnosis of nerve entrapment in a classic presentation. There were significant postural components to account for the development of symptoms. However, the therapist palpated several large masses in the axillary and supraclavicular fossa on both the right and left sides. There was no local warmth, redness, or tenderness associated with these lesions. The therapist requested permission to palpate the client’s groin and popliteal spaces for any other suspicious lymph nodes. The rest of the examination findings were within normal limits.

Associated Signs and Symptoms: Further questioning about the presence of associated signs and symptoms revealed a significant disturbance in sleep pattern over the last 6 months with unrelenting shoulder and neck pain. There were no other reported constitutional symptoms, skin changes, or noted lumps anywhere. Vital signs were unremarkable at the time of the physical therapy evaluation.

Result: Returning this client to her referring physician was a difficult decision to make given that the therapist did not have the benefit of the medical records or results of neurologic examination and testing. With the significant past medical history for cancer, the woman’s age, presence of progressive night pain, and palpable masses, no other reasonable choice remained. When asked if the physician had seen or felt the masses, the client responded with a definite “no.”

There are several ways to approach handling a situation like this one, depending on the physical therapist’s relationship with the physician. In this case, the therapist had never communicated with this physician before. It is possible that the physician was aware of the masses, knew from medical testing that there was extensive cancer, and chose to treat the client palliatively.

Because there was no indication of such, the therapist notified the physician’s staff of the decision to return the client to the physician. A brief (one-page) written report summarizing the findings was given to the client to hand-carry to the physician’s office.

Further medical testing was performed, and a medical diagnosis of lymphoma was made.

Screening for Cardiovascular Causes of Chest, Breast, or Rib Pain

Cardiac-related chest pain may arise secondary to angina, myocardial infarction, pericarditis, endocarditis, mitral valve prolapse, or aortic aneurysm. Despite diagnostic advances, acute coronary syndromes and myocardial infarctions are missed in 2% to 10% of patients.7 There is no single element of chest pain history powerful enough to predict who is or who is not having a coronary-related incident. Medical referral is advised whenever there is any doubt; medical diagnostic testing is almost always required.7

Cardiac-related chest pain also can occur when there is normal coronary circulation, as in the case of clients with pernicious anemia. Affected clients may have chest pain or angina on physical exertion because of the lack of nutrition to the myocardium.

Risk Factors

Gender and age are nonmodifiable risk factors for chest pain caused by heart disease. The rate of coronary artery disease (CAD) is rising among women and falling among men. Men develop CAD at a younger age than women, but women make up for it after menopause. Many women know about the risk of breast cancer, but in truth, they are 10 times more likely to die of cardiovascular disease. While one in 30 women’s deaths is from breast cancer, one in 2.5 deaths is from heart disease.10

Women do not seem to do as well as men after taking medications to dissolve blood clots or after undergoing heart-related medical procedures. Of the women who survive a heart attack, 46% will be disabled by heart failure within 6 years.11 African-American women have a 70% higher death rate from CAD compared with Caucasian women.10 Whenever screening individuals who have chest pain, keep in mind that older men and women, menopausal women, and African-American women are at greatest risk for cardiovascular causes.

A common treatment for CAD after heart attack is angioplasty with insertion of a stent. A stent is a wire mesh tube that props open narrowed coronary arteries. Sometimes, the stent malfunctions or gets scarred over. Cardiologists have realized that such treatments, while effective at alleviating chest pain, do not reduce the risk of heart attacks for most people with stable angina.

When the client presents with chest pain, he or she often does not think it can be from the heart because there is a stent in place, but this may not be true. Anyone with a history of stent insertion presenting with chest pain should be assessed carefully. Take vital signs, and ask about associated signs and symptoms. Evaluate the effect of exercise on symptoms. For example, does the chest, neck, shoulder, or jaw pain start 3 to 5 minutes after exercise or activity? What is the effect on pain in the upper body when the individual is using just the lower extremities, such as walking on a treadmill or up a flight of stairs?

Other risk factors for CAD are listed in Table 6-3. Efforts are being made to determine evidence-based risk factors for low- versus high-risk chest pain of unknown origin. Predictive values for ischemia resulting in myocardial infarction or death include two or more episodes of chest pain typical of a heart attack in an adult 55 years old or older who has a family history of heart disease and/or a personal history of diabetes.12

Clinical Presentation

There are some well-known pain patterns specific to the heart and cardiac system. Sudden death can be the first sign of heart disease. In fact, according to the American Heart Association (AHA), 63% of women who died suddenly of cardiovascular disease had no previous symptoms. Sudden death is the first symptom for half of all men who have a heart attack. Cardiac arrest strikes immediately and without warning.

Cardiac Pain Patterns

Doctors and nurses often use “the three Ps” when screening for chest pain of a cardiac nature. The presence of any or all of these Ps suggests the client’s pain or symptoms are not caused by a myocardial infarction (MI):

Cardiac pain patterns may differ for men and women. For many men, the most common report is a feeling of pressure or discomfort under the sternum (substernal), in the midchest region, or across the entire upper chest. It can feel like uncomfortable pressure, squeezing, fullness, or pain.

Pain may occur just in the jaw, upper neck, midback, or down the arm without chest pain or discomfort. Pain may also radiate from the chest to the neck, jaw, midback, or down the arm(s). Pain down the arm(s) affects the left arm most often in the pattern of the ulnar nerve distribution. Radiating pain down both arms is also possible.

For women, symptoms can be more subtle or atypical (Box 17-1). Chest pain or discomfort is less common in women but still a key feature for some. They often have prodromal symptoms (e.g., pain in the chest, pain in the shoulder or back, radiating pain or numbness in the arms, dyspnea, and fatigue) 12 months prior and up to 1 month before having a heart attack (see Table 6-4).1315 Black women younger than 50 years are more likely to report frequent and intense prodromal symptoms.16

Fatigue, nausea, and lower abdominal pain may signal a heart attack. Many women pass these off as the flu or food poisoning. Other symptoms for women include a feeling of intense anxiety, isolated right biceps pain, or midthoracic pain. Heartburn; sudden shortness of breath or the inability to talk, move, or breathe; shoulder or arm pain; or ankle swelling or rapid weight gain are also common symptoms with MI.

Chest Pain Associated with Angina

The therapist should keep in mind that coronary disease may go unnoticed because the client has no anginal or infarct pain associated with ischemia. This situation occurs when collateral circulation is established to counteract the obstruction of the blood flow to the heart muscle. Anastomoses (connecting channels) between the branches of the right and left coronary arteries eliminate the person’s perception of pain until challenged by physical exertion or exercise in the physical therapy setting.

Chest pain caused by angina is often confused with heartburn or indigestion, hiatal hernia, esophageal spasm, or gallbladder disease, but the pain of these other conditions is not described as sharp or knifelike. The client often says the pain feels like “gas” or “heartburn” or “indigestion.” Referred pain from a trigger point in the external oblique abdominal muscle can cause a sensation of heartburn in the anterior chest wall (see Fig. 17-7).

Episodes of stable angina usually develop slowly and last 2 to 5 minutes. Discomfort may radiate to the neck, shoulders, or back (Case Example 17-3). Shortness of breath is common. Symptoms of angina may be similar to the pattern associated with a heart attack. One primary difference is duration. Angina lasts a limited time (a few minutes up to a half hour) and can be relieved by rest or nitroglycerin. When screening for angina, a lack of objective musculoskeletal findings is always a red flag:

Case Example 17-3   Adhesive Capsulitis

Referral: A 56-year-old man returned to the same physical therapist with his third recurrence of left shoulder adhesive capsulitis of unknown cause.

Past Medical History: There was no reported injury, trauma, or repetitive motion as a precipitating factor in this case. The client was a car salesman with a fairly sedentary job. He reported a past history of prostatitis, peptic ulcers, and a broken collarbone as a teenager. He reported being a “social” drinker at work-related functions but did not smoke or use tobacco products. He was taking ibuprofen for his shoulder but no other over-the-counter or prescription medications or supplements.

The two previous episodes of shoulder problems resolved with physical therapy intervention. The client had a home program to follow to maintain range of motion and normal movement. At the time of his most recent discharge 6 months ago, he had attained 80% of motion available on the uninvolved side with some continued restricted glenohumeral movement and altered scapulohumeral rhythm. The client reported that he did not continue with his exercise routine at home and “that’s why I got worse again.”

Clinical Presentation

Shoulder flexion and abduction Left: 105/100 Right: 170/165
Shoulder medial (internal) rotation 0-70 0-90
Shoulder lateral (external) rotation 0-45 0-80

Accessory motions: Reduced inferior and anterior glide on the left; within normal limits on the right. The client reports pain during glenohumeral flexion, abduction, and medial and lateral rotations.

Clinical impressions: Decreased physiologic motion with capsular pattern of restriction and compensatory movements of the shoulder girdle; humeral superior glide syndrome.

Associated Signs and Symptoms: When asked if there were any symptoms of any kind anywhere else in the body, the client reported “chest tightness” whenever he tried to use his arm for more than a few minutes. Previously, he was used to “working through the pain,” but he can’t seem to do that anymore.

He also reported “a few bouts of nausea and sweating” when his shoulder started aching. He denied any shortness of breath or constitutional symptoms such as fever or sweats. There were no other gastrointestinal-related symptoms.

What are the red flags in this case? How would you screen further?

Screening can begin with something as simple as vital sign assessment. The therapist can consult Box 4-19 for a list of other associated signs and symptoms and look for a cluster or pattern associated with a particular system.

Given his age, sedentary lifestyle, and particular clinical presentation, a cardiovascular screening examination seems most appropriate. The therapist can also consult the Special Questions to Ask box at the end of Chapter 6 for any additional pertinent questions based on the client’s responses to questions and examination results. A short (3- to 5-minute) bike test also can be used to assess the effect of lower extremity exertion on the client’s symptoms.

Result: The client’s blood pressure was alarmingly high at 185/120 mm Hg. Although this is an isolated (one time) reading, he was under no apparent stress, and he revealed that he had a history of elevated blood pressure in the past. The bike test was administered while his heart rate and blood pressure were being monitored. Symptoms of chest and/or shoulder pain were not reproduced by the test, but the therapist was unwilling to stress the client without a medical evaluation first.

Referral was made to his primary care physician with a phone call, fax, and report of the therapist’s findings and concerns. Although there is a known viscero-somatic effect between heart and chest and heart and shoulder, there is no reported direct cause and effect link between heart disease and adhesive capsulitis. Comorbid factors, such as diabetes or heart disease, have been shown to affect pain levels and function.73

Likewise, adhesive capsulitis is known to occur in some people following immobility associated with intensive care, coronary artery bypass graft, or pacemaker complications/revisions.

The physician considered this an emergency situation and admitted the client to the cardiology unit for immediate workup. The electrocardiogram results were abnormal during the exercise stress test. Further testing confirmed the need for a triple bypass procedure. Following the operation and phase 1 cardiac rehab in the cardiac rehab unit, the client returned to the original outpatient physical therapist for his phase 2 cardiac rehab program. Shoulder symptoms were gone, and range of motion was unimproved but regained rapidly as the rehab program progressed.

The therapist shared this information with the cardiologist, who agreed that there may have been a connection between the chest/shoulder symptoms before surgery, although he could not say for sure.

The therapist should also watch for unstable angina in a client with known angina. Unlike stable angina, rest or nitroglycerin does not relieve symptoms associated with an MI, unless administered intravenously. Without intervention, symptoms of an MI may continue without stopping. A sudden change in the client’s typical anginal pain pattern suggests unstable angina. Pain that occurs without exertion, lasts longer than 10 minutes, or is not relieved by rest or nitroglycerin signals a higher risk for a heart attack. Immediate medical referral is required under these circumstances.

Screening for Pleuropulmonary Causes of Chest, Breast, or Rib Pain

Pulmonary chest pain usually results from obstruction, restriction, dilation, or distention of the large airways or large pulmonary artery walls. Specific diagnoses include pulmonary artery hypertension, pulmonary embolism, mediastinal emphysema, asthma, pleurisy, pneumonia, and pneumothorax. Pleuropulmonary disorders are discussed in detail in Chapter 7.

Clinical Presentation

Pulmonary pain patterns differ slightly depending on the underlying pathology and the location of the disease. For example, tracheobronchial pain is referred to the anterior neck or chest at the same levels as the points of irritation in the air passages. Chest pain that tends to be sharply localized or that worsens with coughing, deep breathing, other respiratory movements or motion of the chest wall and that is relieved by maneuvers that limit the expansion of a particular part of the chest (e.g., autosplinting) is likely to be pleuritic in origin.

Symptoms that increase with deep breathing and activity or the presence of a productive cough with bloody or rust-colored sputum are red flags. The therapist should ask about new onset of wheezing at any time or difficulty breathing at night. Be careful when asking clients about changes in breathing patterns. It is not uncommon for the client to deny any shortness of breath.

Often, the reason for this is because the client has stopped doing anything that will bring on the symptoms. It may be necessary to ask what activities he or she can no longer do that were possible 6 weeks or 6 months ago. Symptoms that are relieved by sitting up are indicative of pulmonary impairment and must be evaluated more carefully.

Screening for Gastrointestinal Causes of Chest, Breast, or Rib Pain

GI causes of upper thorax pain are a result of epigastric or upper GI conditions. GERD (“heartburn” or esophagitis) accounts for a significant number of cases of noncardiac chest pain, in the young as well as older adults.3,1820 Stomach acid or gastric juices from the stomach enter the esophagus, causing irritation to the protective lining of the lower esophagus. Whether the client is experiencing GERD or some other cause of chest pain, there is usually a telltale history or associated signs and symptoms to red flag the case.

Clinical Presentation

The GI system has a broad range of referred pain patterns based on embryologic development and multisegmental innervations, as discussed in Chapter 3. Upper GI and pancreatic problems are more likely than lower GI disease to cause chest pain. Chest pain referred from the upper GI tract can radiate from the chest posteriorly to the upper back or interscapular or subscapular regions from T10 to L2 (Fig. 17-1).


Esophageal dysfunction will present with symptoms such as anterior neck and/or anterior chest pain, pain during swallowing (odynophagia), or difficulty swallowing (dysphagia) at the level of the lesion. Symptoms occur anywhere a lesion is present along the length of the esophagus. Early satiety, often with weight loss, is a common symptom with esophageal carcinoma.

Lesions of the upper esophagus may cause pain in the (anterior) neck, whereas lesions of the lower esophagus are more likely to be characterized by pain originating from the xiphoid process, radiating around the thorax to the middle of the back.

Chest pain with or without accompanying or alternating midthoracic back pain from an esophageal or other upper GI problem is usually red flagged by a suspicious history or cluster of associated signs and symptoms. The pain pattern associated with thoracic disk disease can be the same as for esophageal pathology. In the case of disk disease, there may be bowel and/or bladder changes and sometimes numbness and tingling in the upper extremities. The therapist should ask about a traumatic injury to the upper back region and conduct a neurologic screening examination to assess for this possibility as a cause of the symptoms.

Epigastric Pain

Epigastric pain is typically characterized by substernal or upper abdominal (just below the xiphoid process) discomfort (see Fig. 17-1). This may occur with radiation posteriorly to the back secondary to long-standing duodenal ulcers. Gastric duodenal peptic ulcer may occasionally cause pain in the lower chest rather than in the upper abdomen. Antacid and food often immediately relieve pain caused by an ulcer. Ulcer pain is not produced by effort and lasts longer than angina pectoris. The therapist will not be able to provoke or eliminate the client’s symptoms. Likewise, physical therapy intervention will not have any long-lasting effects unless the symptoms were caused by trigger points (TrPs).

Pain in the lower substernal area may arise as a result of reflux esophagitis (regurgitation of gastroduodenal secretions), a condition known as gastroesophageal reflux disease (GERD). It may be gripping, squeezing, or burning, described as “heartburn” or “indigestion.” Like that of angina pectoris, the discomfort of reflux esophagitis may be precipitated by recumbency or by meals; however, unlike angina, it is not precipitated by exercise and is relieved by antacids.

Hepatic and Pancreatic Systems

Epigastric pain or discomfort may occur in association with disorders of the liver, gallbladder, common bile duct, and pancreas, with referral of pain to the interscapular, subscapular, or middle/low back regions. This type of pain pattern can be mistaken for angina pectoris or myocardial infarction (e.g., hypotension occurring with pancreatitis produces a reduction of coronary blood flow with the production of angina pectoris).

Hepatic disorders may cause chest pain with radiation of pain to the shoulders and back. Cholecystitis (gallbladder inflammation) appears as discrete attacks of epigastric or right upper quadrant pain, usually associated with nausea, vomiting, and fever and chills. Dark urine and jaundice indicate that a stone has obstructed the common duct.

The pain has an abrupt onset, is either steady or intermittent, and is associated with tenderness to palpation in the right upper quadrant. The pain may be referred to the back and right scapular areas. A gallbladder problem can result in a sore tenth rib tip (right side anteriorly) as described in Chapter 9 (Case Example 17-4). Rarely, pain in the left upper quadrant and anterior chest can occur.

Case Example 17-4   Chest Pain During Pregnancy

Referral: A 33-year-old woman in her twenty-ninth week of gestation with her first pregnancy was referred to a physical therapist by her gynecologist. Her abdominal sonogram and lab tests were normal. A chest x-ray was read as negative.

Past Medical History: None. The client had the usual childhood illnesses but had never broken any bones and denied use of tobacco, alcohol, or substances of any kind. There was no recent history of infections, colds, viruses, coughs, trauma or accidents, and changes in gastrointestinal function and no history of cancer.

Clinical Presentation: Although there were no signs and symptoms associated with the respiratory system, the client’s symptoms were reproduced when she was asked to take a deep breath. Palpation of the upper chest, thorax, and ribs revealed pain on palpation of the right tenth rib (anterior).

Thinking about the role of the gallbladder causing tenth rib pain, the therapist asked further questions about past history and current gastrointestinal symptoms. The client had no red flag symptoms or history in this regard.

Knowing that transient osteoporosis can be associated with pregnancy,74-79 the therapist gave the client the Osteoporosis Screening Evaluation (see Appendix C-6). The client replied “yes” to three questions (Caucasian or Asian, mother diagnosed with osteoporosis, physically inactive), suggesting the possibility of rib fracture.75,77

Result: The therapist initiated a telephone consultation with the physician to review her findings. Although the original x-ray was read as negative, the physician ordered a different view (rib series) and identified a fracture of the tenth rib.

The physician explained that the mechanical forces of the enlarging uterus on the ribs pull the lower ribs into a more horizontal position. Any downward stress from above (e.g., forceful cough or pull from the external oblique muscles) or upward force from the serratus anterior and latissimus dorsi muscles can increase the bending stress on the lower ribs.75

An aquatics therapy program was initiated and continued throughout the remaining weeks of this client’s pregnancy.

Acute pancreatitis causes pain in the upper part of the abdomen that radiates to the back (usually anywhere from T10 to L2) and may spread out over the lower chest. Fever and abdominal tenderness may develop.

Screening for Breast Conditions that Cause Chest or Breast Pain

Occasionally, a client may present with breast pain as the primary complaint, but most often the description is of shoulder or arm or neck or upper back pain. When asked if any symptoms occur elsewhere in the body, the client may mention breast pain (Case Example 17-5).

Case Example 17-5   Breast Pain and Trigger Points

Referral: A 67-year-old woman came to physical therapy after seeing her primary care physician with a report of decreased functional left shoulder motion. She was unable to reach the top shelf of her kitchen cabinets or closets. She felt that at 5 feet 7 inches this is something she should be able to do.

Past Medical History: During the Past Medical History portion of the interview, she mentioned that she had had a stroke 10 years ago. Her referring physician was unaware of this information. She had recently moved here to be closer to her daughter, and no medical records have been transferred. There was no other significant history.

At the end of the interview, when asked, “Is there anything else you think I should know about your health or current situation that we haven’t discussed?” she replied, “Well, actually the reason I really went to see the doctor was for pain in my left breast.”

She had not reported this information to the physician.

Clinical Presentation: Examination revealed mild loss of strength in the left upper extremity accompanied by mild sensory and proprioceptive losses. Palpation of the shoulder and pectoral muscles produced breast pain. The client had been aware of this pain, but she had attributed it to a separate medical problem. She was reluctant to report her breast pain to her physician. Objectively, there were positive trigger points of the left pectoral muscles and loss of accessory motions of the left shoulder (see Fig 17-7).

Blood pressure (sitting, left arm) 142/108 mm Hg
Heart rate 72 bpm
Pulse oximeter 98%
Oral temperature 98.0° F

Intervention: Physical therapy treatment to eliminate trigger points and restore shoulder motion resolved the breast pain during the first week.

Should you make a medical referral for this client? If so, on what basis?

Despite this woman’s positive response to physical therapy treatment, given the age of this client, her significant past medical history for cerebrovascular injury (reportedly unknown to the referring physician), current blood pressure (although an isolated measurement), report of breast pain (also unreported to her physician), and the residual paresis, medical referral was still indicated.

At the first follow-up visit, a letter was sent with the client that briefly summarized the initial objective findings, her progress to date, and the current concerns. She returned for an additional week of physical therapy to complete the home program for her shoulder. A medical evaluation ruled out breast disease, but medical treatment (medication) was indicated to address cardiovascular issues.

During examination of the upper quadrant, the therapist may observe suspicious or aberrant changes in the integument, breast, or surrounding soft tissues. The client may report discharge from the nipple. Discharge from both nipples is more likely to be from a benign condition; discharge from one nipple can be a sign of a precancerous or malignant condition.

Asking the client about history, risk factors, and the presence of other signs and symptoms is the next step (see Box 4-18). Knowing possible causes of breast pain can help guide the therapist during the screening interview (see Table 17-2).

Past Medical History

A past history of breast cancer, heart disease, recent birth, recent upper respiratory infection (URI), overuse, or trauma (including assault) may be significant for the client presenting with breast pain or symptoms. Any component of heart disease, such as hypertension, angina, myocardial infarction, and/or any heart procedure such as angioplasty, stent, or coronary artery bypass, is considered a red flag.

Any woman experiencing chest or breast pain should be asked about a personal history of previous breast surgeries, including mastectomy, breast reconstruction, or breast implantation or augmentation. A past history of breast cancer is a red flag even if the client has completed all treatment and has been cancer free for 5 years or more.

On the flip side, a past history of breast cancer in a client who presents with musculoskeletal symptoms with or without a history of trauma does not always mean cancer metastases. A complete evaluation with advanced imaging may be needed to uncover the true underlying etiology as in the reported case of fibular pain in a patient with a history of breast cancer that turned out to be an incomplete nondisplaced distal fibular stress fracture with no evidence of tumor or mass (Case Example 17-6).21

Breast cancer and cysts develop more frequently in individuals who have a family history of breast disease. A previous history of cancer is always cause to question the client further regarding the onset and pattern of current symptoms. This is especially true when a woman with a previous history of breast cancer or cancer of the reproductive system appears with shoulder, chest, hip, or sacroiliac pain of unknown cause.

If a client denies a previous history of cancer, the therapist should still ask whether that person has ever received chemotherapy or radiation therapy. It is surprising how often the answer to the question about a previous history of cancer is “no” but the answer to the question about prior treatment for cancer is “yes.”

Clinical Presentation

For the most part, breast pain (mastalgia), tenderness, and swelling are the result of monthly hormone fluctuations. Cyclical pain may get worse during perimenopause when hormone levels change erratically. These same symptoms may continue after menopause, especially in women who use hormone replacement therapy (HRT). Noncyclical breast pain is not linked to menstruation or hormonal fluctuations. It is unpredictable and may be constant or intermittent, affecting one or both breasts in a small area or the entire breast.

The typical referral pattern for breast pain is around the chest into the axilla, to the back at the level of the breast, and occasionally into the neck and posterior aspect of the shoulder girdle (Fig. 17-2). The pain may continue along the medial aspect of the ipsilateral arm to the fourth and fifth digits, mimicking pain of the ulnar nerve distribution.

Jarring or movement of the breasts and movement of the arms may aggravate this pain pattern. Pain in the upper inner arm may arise from outer quadrant breast tumors, but pain in the local chest wall may point to any pathologic condition of the breast.

Nipple discharge in women is common, especially in pregnant or lactating women, and does not always signal a serious underlying condition. It may occur as a result of some medications (e.g., estrogen-based drugs, tricyclic antidepressants, benzodiazepines, and others).

The fluid may be thin to thick in consistency and various colors (e.g., milky white, green, yellow, brown, or bloody). Any unusual nipple discharge should be evaluated by a medical doctor. Injury, hormonal imbalance, underactive thyroid, infection or abscess, or tumors are just a few possible causes of nipple discharge.

Causes of Breast Pain

There is a wide range of possible causes of breast pain, including both systemic or viscerogenic and NMS etiologies (Table 17-2). Not all conditions are life threatening or even require medical attention.

Although it is more typical in women, both men and women can have chest, back, scapular, and shoulder pain referred by a pathologic condition of the breast. Only those conditions most likely to be seen in a physical therapist’s practice are included in this discussion.


Mastitis is an inflammatory condition associated with lactation (breast feeding). Mammary duct obstruction causes the duct to become clogged. The breast becomes red, swollen, and painful. The involved breast area is often warm or even hot. Constitutional symptoms such as fever, chills, and flulike symptoms are common. Acute mastitis can occur in males (e.g., nipple chafing from jogging); the presentation is the same as for females.

Risk factors include previous history of mastitis; cracked, bleeding, painful nipples; and stress or fatigue. Bacteria can enter the breast through cracks in the nipple during trauma or nursing. Subsequent infection may lead to abscess formation. Obstructive and infectious mastitis are considered as two conditions on a continuum. Mastitis is often treated symptomatically, but the client should be encouraged to let her doctor know about any breast signs and symptoms present. Antibiotics may be needed in the case of a developing infection.

Benign Tumors and Cysts

Benign tumors and cysts were once lumped together and called “fibrocystic breast disease.” With additional research over the years, scientists have come to realize that a single label is not adequate for the variety of benign conditions possible, including fibroadenomas, cysts, and calcifications that can occur in the breast.

An unchanged lump of long duration (years) is more likely to be benign. Many lumps are hormonally induced cysts and resolve within two or three menstrual cycles. Cyclical breast cysts are less common after menopause.

Other conditions can include intraductal papillomas (wartlike growth inside the breast), fat necrosis (fat breaks down and clumps together), and mammary duct ectasia (ducts near the nipple become thin-walled and accumulate secretions). Some of these breast changes are a variation of the norm, and others are pathologic but nonmalignant. A medical diagnosis is needed to differentiate between these changes.

Paget’s Disease

Paget’s disease of the breast is a rare form of ductal carcinoma arising in the ducts near the nipple. The woman experiences itching, redness, and flaking of the nipple with occasional bleeding (Fig. 17-3). Paget’s disease of the breast is not related to Paget’s disease of the bone, except that the same physician (Dr. James Paget, a contemporary of Florence Nightingale, 1877) named both conditions after himself.

Breast Cancer

The breast is the second most common site of cancer in women (the skin is first). Cancer of the breast is second only to lung cancer as a cause of death from cancer among women. Male breast cancer is possible but rare, accounting for 1% of all new cases of breast cancer (2,140 cases in 2011 for men compared with 230,480 for women).22

Although the frequency of breast cancer in men is strikingly less than that in women, the disease in both sexes is remarkably similar in epidemiology, natural history, and response to treatment. Men with breast cancer are 5 to 10 years older than women at the time of diagnosis, with mean or median ages between 60 and 66 years. This apparent difference may occur because symptoms in men are ignored for a longer period and the disease is diagnosed at a more advanced state.

Risk Factors: Despite the discovery of a breast cancer gene (BRCA-1 and BRCA-2), researchers estimate that only 5% to 10% of breast cancers are a result of inherited genetic susceptibility. Normally, BRCA-1 and BRCA-2 help prevent cancer by making proteins that keep cells from growing abnormally. Inheriting either mutated gene from a parent does increase the risk of breast cancer.23 But a much larger proportion of cases are attributed to other factors, such as advancing age, race, smoking, obesity, physical inactivity, excess alcohol intake, exposure to ionizing radiation, and exposure to estrogens (Table 17-3).24

Women who received multiple fluoroscopies for tuberculosis or radiation treatment for mastitis during their adolescent or childbearing years are at increased risk for breast cancer as a result of exposure to ionizing radiation. In the past, irradiation was used for a variety of other medical conditions, including gynecomastia, thymic enlargement, eczema of the chest, chest burns, pulmonary tuberculosis, mediastinal lymphoma, and other cancers. Most of these clients are in their 70s now and at risk for cancer because of advancing age as well.

As a general principle, the risk of breast cancer is linked to a woman’s total lifelong exposure to estrogen. The increased incidence of estrogen-responsive tumors (tumors that are rich in estrogen receptors proliferate when exposed to estrogen) has been postulated to occur as a result of a variety of factors, such as prenatal and lifelong exposure to synthetic chemicals and environmental toxins, earlier age of menarche (first menstruation), improved nutrition in the United States, delayed and decreased childbearing, and longer average lifespan.

At the same time, it should be remembered that many women diagnosed with breast cancer have no identified risk factors. More than 70% of breast cancer cases are not explained by established risk factors.23,25 There is no history of breast cancer among female relatives in more than 90% of clients with breast cancer. However, first-degree relatives (mother, daughters, or sisters) of women with breast cancer have two to three times the risk of developing breast cancer than the general female population, and relatives of women with bilateral breast cancer have five times the normal risk.23

Risk factors for men are similar to those for women, but at least half of all cases do not have an identifiable risk factor. Risk factors for men include heredity, obesity, infertility, late onset of puberty, frequent chest x-ray examinations, history of testicular disorders (e.g., infection, injury, or undescended testes), and increasing age. Men who have several female relatives with breast cancer and those in families who have the BRCA-2 mutation have a greater risk potential.

The presence of any of these factors may become evident during the interview with the client and should alert the physical therapist to the potential for neuromusculoskeletal complaints from a systemic origin that would require a medical referral. There are several easy-to-use screening tools available. In addition to screening for current risk, clients should be given this information for future use (Box 17-2).

Box 17-2   Resources for Assessing and Lowering Breast Cancer Risk

Mar 20, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Screening the Chest, Breasts, and Ribs
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