Chapter 1 - Thomas Wang: A 28-Year-Old Stockbroker With Severe Anterior Chest Pain

Abstract

Many patients with noncardiogenic chest pain suffer from costosternal joint pain. Most commonly, the costosternal joints become painful in response to inflammation as a result of overuse or misuse or in response to trauma secondary to acceleration-deceleration injuries or blunt trauma to the chest wall. With severe trauma, the joints may subluxate or dislocate. The costosternal joints are susceptible to the development of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, and psoriatic arthritis. The joints are also subject to invasion by tumor from primary malignant tumors, including thymoma, or from metastatic disease. Physical examination of patients suffering from costosternal syndrome reveals that the patient vigorously attempts to splint the joints by keeping the shoulders stiffly in a neutral position. Pain is reproduced with active protraction or retraction of the shoulder, deep inspiration, and full elevation of the arm. Shrugging of the shoulder may also reproduce the pain. Coughing may be difficult, leading to inadequate pulmonary toilet in patients who have sustained trauma to the anterior chest wall. The costosternal joints and adjacent intercostal muscles may be tender to palpation. The patient may also complain of a clicking sensation with joint movement.