Right Chest Wall Pain

[lemans71]

I am a 44 year old caucasian female with a 34 year history of Type I diabetes, under good control.  I have had right chest wall (it feels deep, in the area above the right breast) over the past 2 years.  The pain became constant and severe in July 2003, shortly after a plane trip.  It also makes me feel as if I must take a deep breath after saying only a few words.  PFTs showed only mild restrictive airway disease (no change from 1997 when I first noticed SOB with singing).  

Upon initial physical exam, I had diffuse abdominal tenderness (no pain unless the abdomen is palpated).  Because of this finding and because I have had GI symptoms which worsened in late June 2003 (including nausea and anorexia without the usual gastropathy symptoms...I continue with regular BMs, no early satiety...I simply have no desire for food, but continue to eat as I'm "feeding my insulin" and can easily maintain my blood sugars).  An EGD showed gastritis/duodenitis, chemically induced (I was on piroxicam for lumbar spine arthritis symptoms)...piroxicam was d/c'd and Protonix started without resolution of symptoms after 8 weeks of treatment.  Because I have a family history of colon cancer, an abdominal CT with contrast was performed with negative results.  The GI symptoms, I can live with and adjust to, the chest wall pain, I cannot.

An ACE level was normal, CBC, chemistries, sed rate, CRP are all normal.  Aside from ophthalmologic complications (I had laser therapy last in 1998, OU cataract extractions in 2000, and have 20/20 vision corrected), I have had no other complications from my diabetes.  I take Altace 2.5mg as renal prophylaxis, and OrthoNovum 777 as birth control.  I had a PE ruled out by spiral chest CT.  The spiral CT showed an irregularotu at the sternoclavicular joint.  A repeat spiral CT with emphasis on the upper chest revealed sclerosis and degenerative changes at the right sternoclavicular joint.  A bone scan showed uptake in the area as well.  Previous chest CTs (for research studies in which I participated) showed calcified granulomas, otherwise negative.  I am unable to find any information on sternoclavicular osteoarthritis. I have no history of trauma (of any sort) whatsoever.  There is absolutley no tenderness to the area upon palpation nor to any of the costochondral areas of the right chest.  As I said earlier, the pain feels "deep".  Celebrex, up to 400mg daily, has not helped.  The pain is occasionally exacerbated by deep breathing, sometimes it worsens for no apparent reason and has never been at the sternoclavicular joint.

The rheumatologist with whom I work (I am a geriatric nurse practitioner) has suggested a Lidocaine injection to see if that gives me initial relief, and if so, would proceed with a Kenalog/Lidocaine injection into the area (since actually getting into the joint itself would be difficult).

Any thoughts or suggestions would be greatly appreciated!

[Kevin Pho, MD]

You have had a very thorough evaluation for your chest discomfort, including multiple CT scans, endoscopies and rheumatological studies amongst others.  

With the spiral CT showing DJD of the sternaclavicluar joint, as well as increased uptake in that area of the bone scan, I would work on treating this musculoskeletal cause.  

There are various treatment modalities for discomfort in this area, including the lidocaine/kenalog injections.  Antidepressants, muscle relaxants, and physical measures (i.e. work with a physical therapist) have been used in selected cases.  

There is something known as the sternalis syndrome which is a rarely described condition in which localized tenderness is found directly over the body of the sternum or overlying sternalis muscle, and palpation often causes radiation of pain bilaterally.  Bone scan often shows increased uptake in this area.

Xiphoidalgia (xiphoidynia) is another relatively rare syndrome that is characterized by localized discomfort and tenderness over the xiphoid process of the sternum.  Local injection of an anesthetic-steroid combination are frequently curative.

You may want to inquire whether an MRI to further evaluate the area would be any benefit.  In the meantime, I would suggest going with the injection and seeing if the discomfort responds.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

Bibliography
Wise.  Major causes of musculoskeletal chest pain.  UptoDate, 2003.

[tmanes]

I have suffered with chest wall pain for the past 7 years to date. I've had all kinds of test. Frome stress test to gastro test. Finally being diagnosed with acid reflux desease and anxiety disorder. Trouble is I still have the chest wall pain but the doctors I've seen think I'm crazy so they all want to push me off on a shrink. The pain had subsided for a while and now it's back. The pain is so dificult to ignore. It gets so frustrating trying to explain how I feel only for the Dr. to tell me "aaww, you got acid reflux, it will make you feel the why you describe". I knew dang good and well that wasn't it. I have family that do have reflux and the symtoms are not the same!!! One dr. turned and walked out of the office because I had written down the way my chest was hurting, and he said "I aint got time for this". I was at my wits end before going in his office so all I could was leave crying, thinking maybe it is in my head. It's to painful to be "in your head" as the dr. are so quick to say. To my experience if you try telling them what your problem is they get offended. Afterall, they get the big bucks to tell you whats wrong and they don't like it if you say otherwise!! I can't live with this forever.

[rmbracalente]

I have a similar problem as the previous post, the cause of which has thus far proven ambiguous.  I am a 39 year old male, in otherwise apparent good health.  In my particular case, the bulk of the pain appears to me to be centered in the body of the sternum, and then radiates out to both the left and right upper to mid pectoral areas.  I have had this condition for over a year.  When it first manifested, it felt like someone had hit me in the chest with a sledgehammer.  Moving or twisting my chest
"the wrong way" resulted in making the pain worse.  After about six months, the pain subsided, with only brief
re-occurances over the next five to six months.  Since then, the pain has returned to these areas and is relatively onstant...I'd say about a "3-4" on the pain scale.  My GP sent me for chest X-rays in July 2003.  The impression was that I had fractures of ribs 8 and 9, which didn't make any sense to me since there was no trauma involved.
However, my GP assured me that Radiologists don't state their impressions likely, and if they indicated fractures, then
they were in fact present.  Interestingly enough, another chest & sternum series conducted by the same Radiology group
in January 2004 indicated no fractures whatsovever.  Subsequent to these impressions, a full body bone scan with
attention to the sternum was ordered, and the impression was "Minimal symmetrical accumulation of radiotracer at the
sternoclavicular and acromioclavicular joints consistent with degenerative changes.  The remainder of the sternum
demonstrates no abnormal accumulation."  After looking up these areas in a clinical anatomy book (I'm not a medical
person), I was able to locate them on my body, and there's really no discomfort in this area...it mostly seems to be
in the area of the body of the sternum.  I notice that it hurts the most after I've been driving for a while.  I guess
this is a result of pressure from pushing on the steering wheel being exerted back into the sternum.  In the past I would frequently perform a lot of upper body exercises at the gym without ever really feeling any major discomfort.  In fact, most of the discomfort now comes at rest...there is a definite "tightness" in my chest when I
wake up in the morning, that goes away soon after I start moving around. So my question is, is "mild degeneration" of these areas something to be expected in an active, otherwise health 39 year old male, or is there something else going on here?

[xohaib]

A related discussion, right chest pain after waking up was started.

[SonnyM]

A related discussion, Right Chest Wall Pain was started.