1.Chest wall pain may be caused by:
a.Musculoskeletal disorders
b.Direct injury to the roots and nerves that supply the sensory innervation of the thorax
c.Referral from a visceral source
d.Central nervous system disorders that disrupt somatosensory input or its processing
1.The prevalence of musculoskeletal chest wall pain is unknown but has been estimated to affect 10% of patients that present with chest pain
2.Anatomy:
a.The ribs articulate posteriorly with the vertebral bodies and their transverse processes at the costovertebral and costotransverse joints which are diarthroidal synovial joints
b.The second to 10th ribs articulate with two hemifacets with two adjacent vertebra separated by an intervertebral disc
c.The joint is divided by an intra-articular ligament and attaches the head of the rib to the intervertebral disc
d.The first, eleventh and twelfth ribs articulate by a single facet with its own vertebral body
e.Ribs are attached to the costal cartilages by costochondral articulations that are synchondroses
f.The first to seventh ribs are vertebrosternal in that their costal cartilages join the sternum at the chondrosternal joints
g.The cartilages of the 8th, 9th and 10th ribs articulate with the cartilage above them and are vertebrochondral ribs; the 11th and 12th ribs are free at the cartilaginous ends.
h.The costal cartilage of the first rib attaches to the manubrium by a synchondrosis. The remaining six pairs of chondrosternal articulations are synovial lined and contain an intra-articular ligament
i.There may be synovial membrane interchondral articulations between the fifth to ninth costal cartilages. These joints may degenerate with age.
j.The medial end of the clavicle articulates with the manubrium by its costal cartilage to form the sternoclavicular joint. The joint is divided into two synovial membrane-lined cavities by an intra articular fibrocartilaginous disc
k.The manubriosternal joint attaches the manubrium with the body of the sternum. It is a synchondrosis and is composed of a fibrocartilaginous disc. In approximately 1/3 of adults, there is resorption of the central component of the disc that then forms a synovial membrane lined joint. Ossification of the disc and synostosis of the joint occurs in 10% of adults.
l.The xiphisternal joint (at the most ventral aspect of the sternum) is a synchondrosis between the body of the sternum and the xiphoid cartilage that may ossify over time.
1.The onset is usually insidious. Precipitating features may be repetitive movements, minor trauma or unusual physical exertion
2.The pain is usually localized to the affected site and may be a deep ache or lancinating; it may radiate widely
3.Exacerbating factors are positional changes such as turning of the chest, deep breathing or movement of the shoulder girdle
4.Local chest wall tenderness (mechanical hyperalgesia)
5.Duplication of pain by specific movements or by chest wall palpation
6.A small number of tender areas that are asymmetric and grouped in a single area support a referred pain
7.Widespread pain tender points that are symmetrical and are associated with diffuse aching, stiffness and sleep disruption support a diagnosis of fibromyalgia
1.Tietze’s syndrome as originally described in 1921 is characterized by painful nonsuppurative swelling of the cartilaginous articulations of the anterior chest wall
2.Costochondritis causes pain and swelling of the costochondral articulations
3.There is no ethnic or geographic predispositions but clustering of patients has been reported
1.Pain in the anterior chest wall is the primary symptom
2.The pain varies in intensity and is usually localized to the involved synchondrosis
3.The disorder has a predilection for the second and third costochondral junctions. Less frequently, the chondrosternal, manubrial, sternal sternoclavicular and xiphisternal articulations are involved
4.In more than 70% of patients, the lesions are unilateral and single. If the lesions are multiple they usually affect contiguous articulations on the same side
5.Some patients have a history of excessive coughing during the course of a prior upper respiratory infection
6.Exacerbating factors are coughing, deep breathing and lying prone
7.The affected cartilage is mechanically tender and swollen but not warm or erythematous. There are no constitutional symptoms.
8.The disorder is self-limited but has remissions and exacerbations
9.Pain may stop spontaneously within weeks or months but the cartilaginous swelling may persist
10. More common in patients <40 years of age
1.There are few pathological studies. Some specimens have demonstrated degenerated costal cartilage with minor inflammatory changes in the perichondrium with primary Tietze’s syndrome.
2.Secondary Tietze’s syndrome includes:
a.Infectious involvement of the costochondral joints
b.Chest wall tumors
c.Osteomyelitis of the sternum and ribs as a complication of median sternotomy
d.Fungal costochondritis with Candida, Aspergillus, Blastomyces and Actinomyces are the major fungal organisms
1.Appropriate studies to delineate rheumatic or autoimmune involvement of cartilage (rheumatoid arthritis, relapsing polychondritis)
2.Sedimentation rate, C-reactive protein if infection or autoimmune disorders are suspected
1.MRI:
a.Is superior to CT for detecting cartilaginous damage and bone marrow edema
b.The MRI pattern of primary Tietze’s Syndrome includes:
i.Thickened and enlarged cartilage at the affected joints
ii.Focal or widespread increased signal intensities are demonstrated in both T2-weighted and STIR or FAT SAT sequences
iii.Bone marrow edema in the subchondral bone is noted in approximately 50% of patients
iv.Gadolinium enhancement occurs in the areas of thickened cartilage, subchondral bone marrow, joint capsule and ligaments
1.Costochondritis and costosternal syndrome are used interchangeably
2.It is a not uncommon disorder and may occur as a primary disease or in combination with median sternotomy or trauma
1.Pain occurs at the costochondral or chondrosternal articulations with swelling which is a differential point from Tietze’s Syndrome
2.In 90% of patients, multiple lesions are seen. The second to fifth costal cartilages are most frequently affected
3.The major physical finding is diffuse tenderness to mechanical stimuli over the involved costal cartilages:
a.Pain may be provoked by the “crowing rooster” sign in which the cervical spine is extended and traction is placed on the posteriorly extended arms or traction is applied to an adducted arm with the head rotated to the ipsilateral side
b.The disorder is self-limited but there are recurrences during its course
c.More common in patients > 40 years of age
1.The etiology of costochondritis has not been defined
2.It has been associated with minor trauma
3.Less frequently, it has been seen in intravenous drug users from bacterial and fungus infections
4.In the course of thoracic surgery in patients who have had a median sternotomy incision
5.Costochondritis has also been described with vitamin D deficiency
1.Medical evaluation to delineate causes of atypical chest pain
1.MRI to evaluate cartilage and subchondral bone
1.Rib fractures are the most common injury from blunt chest trauma and account for > 50% of thoracic injuries from non-penetrating trauma
2.Approximately 10% of patients admitted to hospital after blunt chest trauma have one or more rib fractures
3.Rib fractures in the elderly are common from falls: in adults, motor vehicle accidents is the most frequent mechanism and in youths, sport injury and violence are frequently causative
1.Point tenderness and local swelling at the site of trauma
2.Pain is exacerbated by deep breathing and various movements
3.In elderly patients each additional rib fracture increases the odds of dying by 19% and of developing pneumonia by 27%
4.First rib fractures have an association with spinal and vascular injuries. They are the rarest of all rib fractures
5.Fracture of the lower ribs are associated with abdominal organ injury
6.Left lower rib fractures may injure the spleen; right lower rib fractures are associated with liver injury
7.Fracture of ribs 11 and 12 are associated with renal injury
1.Stress fractures of the ribs and long bones are associated with:
a.Rheumatoid arthritis
b.Osteoporosis
c.Osteomalacia
d.Paget’s disease of bone
2.Patients with long standing deforming rheumatoid arthritis with affected shoulders may have rib erosions that involve the outer areas of the second to sixth ribs that are usually painless
3.Carcinoma of the lung, breast, thyroid, kidney, and prostate are the most common tumors that metastasize to the ribs. They present with painful swelling or as a pathologic fracture
4.Primary neoplasms of the ribs are rare and include:
a.Ostechondroma
b.Multiple exostoses
c.Chondrosarcoma
d.Multiple myeloma
e.Eosinophilic granuloma
5.Rarely the ribs may be involved by bacterial, syphilitic, tuberculous or fungal infections
1.Radiographs demonstrate approximately ½ to 2/3 of fractures
2.After several weeks, a callus that forms with healing may be demonstrated
3.Bone scanning and MRI with contrast are extensively utilized if metastases or tumors are sought
1.The syndrome is caused by hypermobility of the interchondral fibrous attachments of the anterior attachments of ribs 8 to 10. This allows the costal cartilage tips to subluxate and impinge upon the intercostal nerves.
1.Some patients have a history of trauma to the chest on the affected side
2.The onset is insidious usually over several months
3.The pain is unilateral, intermittent in the anterior ends of the lower costal cartilages (the tenth is most often involved)
4.Lancinating pain may occur in the anterior costal margin and the abdominal wall
5.Specific movements may elicit a painful click over the tip of the involved costal cartilage
6.The pain may be duplicated by the “hooking” maneuver in which the fingers are placed under the anterior costal margin and then the rib cage is pulled anteriorly. The maneuver may produce a palpable click as the ribs slip over one another
7.The syndrome can occur at any age but most often is seen in middle-aged patients. Men and women are affected equally.
1.Traumatic rupture of the fibro-cartilaginous band that connects ribs 8 to 10
2.The involved cartilage is tender and hyper mobile
3.A rib tip subluxates upward to override the rib above and impinges upon the intercostal nerve
1.This is a clinical diagnosis
1.Radiographs and MRI to rule out other pathologies
2.Bone scan to evaluate for costochondritis
1.Rib fracture
2.Tietze’s Syndrome
3.Bone metastases
4.Muscle tears
5.Pleuritic disease
1.Sternoclavicular hyperostosis is a chronic inflammatory disorder that presents with erythema, swelling and pain in the sternoclavicular joint
1.Erythema, swelling and pain in the sternoclavicular joint
2.Approximately 50% of patients have acne or pustular lesions the best described of which is palmoplantar pustulosis (PPP)
3.Extrasternal articular disease is seen in approximately 25% of patients
4.The age of onset is between 24-79 years: it is usually a disorder of middle life
5.The usual presentation is pain and palpable tenderness in the sternoclavicular region that may radiate to the upper chest wall
6.The process is usually bilateral but unilateral involvement occurs
7.The process is chronic and follows a relapsing remitting course
8.Pain may radiate to the shoulder, neck, or anterior upper chest wall in association with the swelling and tenderness of the sternoclavicular joint
9.Motion of the ipsilateral shoulder is restricted due to medial clavicle involvement
10. Exacerbating factors are shrugging or retracting the ipsilateral shoulder; if severe, the shoulder girdle becomes fixed in a “squared shoulder” position
11. Extrasternal articular manifestations include:
a.The axial skeleton is involved in 50% of patients
b.Symptomatic peripheral arthritis occurs in approximately 20% of patients and primarily affects large joints. The knee and ankle are most frequently involved. Less frequently involved are the wrist and interphalangeal joints
12. SCCH is classically associated with pustulotic skin changes that include:
a.Palmar and plantar pustulosis (PPP)
b.Pustular psoriasis
c.Acne conglobata
d.Acne fulminans
e.Hidradenitis suppurativa
f.Psoriasis vulgaris
13. In 70% of patients, the interval between the onset of skeletal symptomatology and skin disease is 2 years although patients may present with PPP before or after
14. The disease follows a relapsing remitting course. Associated disorders that have been reported are subclavian vein occlusion and thoracic outlet syndrome
1.The anatomy of the sternoclavicular joint is complex:
a.It is a synovial lined articulation that is composed of the inferior medial head of the clavicle, the upper outer portion of the sternum and the cartilage of the first rib
b.The joint is divided into two compartments that are separated by an intra-articular disc
c.The articular capsule that surrounds the joint is reinforced by ligaments
d.SCCH starts as a nonspecific inflammation of the ligaments (sternoclavicular) and surrounding soft tissue
e.Perichondritis is early and then evolves to an erosive arthritis; endosteal and periosteal bone formation occurs along with the growth of fibrous tissue
f.The chronic inflammation causes a progressive hyperostosis which over time causes soft tissue ossification and fusion of the sternoclavicular joints
g.Concomitantly with disease of the sternoclavicular joint, enthesopathic and hyperostotic changes may involve the shafts of long bones, the sacroiliac joints and large peripheral joints
h.Histologically SCCH is similar to the inflammatory response seen in chronic osteomyelitis or Paget’s disease. It is an ossifying periostitis associated with general hyperostosis
1.Normal serum alkaline phosphatase and urinary hydroxyproline distinguish the process from Paget’s disease
1.Radiographs:
a.Ossification that progresses to hyperostosis of the clavicles, sternum and anterior upper ribs
b.Early in the process the joint spaces in the sternoclavicular region are preserved but develop erosive changes over time
c.Usually the first to fourth rib are involved; the seventh rib may be involved but ossification beyond the eighth rib has been described.
d.Erosive changes and exuberant bone formation can occur along the anterior aspects of the vertebral bodies. The radiographic changes may be sclerotic rather than proliferative or destructive. Any area of the cervical, thoracic or lumbar spine can be involved
e.Inflammatory enthesopathy (the attachment of a ligament or tendon to a bone) of the costoclavicular ligament and the small hyperostotic foci of at least 5 mm diameter of the sternal end of the first pair of ribs are early diagnostic signs
f.Scintigraphy may demonstrate uptake early in the course of the disorder prior to positive radiographs. Increased uptake is seen in the sternoclavicular joint, the costal cartilage of the first and second ribs and the manubrium
1.A painful expansion and sclerosis of the medial end of the clavicle
1.This is a disorder of young and middle aged women
2.There may be a history of stress of the joint from heavy lifting
3.There is unilateral or bilateral painful expansion and sclerosis of the medial end of the clavicle without sternal hyperostosis or sternoclavicular synostosis
4.There is pain on abduction of the arm which may radiate to the ipsilateral shoulder or to the subscapular region
1.Histologic examination reveals an ossifying periostitis with increased thickness of cancellous bone
1.Radiographs reveal preservation of the joint space and lack of manubrial involvement which differentiates it from osteoarthritis
2.MRI:
a.T2-weighted sequences in areas of clavicular sclerosis demonstrate varying signal intensity that ranges from low intermediate to high signal intensity putatively related to the degree of bone marrow edema
b.Contrast-enhanced T1-weighted sequences demonstrate intra-osseous and periosseous enhancement
1.Manubriosternal arthritis is a rare cause of upper sternal pain
1.The pain is localized to the joint or radiates along the upper ribs to the shoulder simulating angina
2.Localized tenderness and swelling of the joint
3.Affects young males performing heavy manual labor
1.The manubriosternal joint is a cartilaginous joint (symphysis) in which a thick layer of hyaline cartilage covers the articular surfaces with an intervening fibrocartilage disc
2.Cavitation in the disc is common which occurs in 30% of patients
3.The joint is most commonly involved in rheumatoid arthritis, gout, ankylosing spondylitis and psoriatic arthritis
4.Rarely the joint can be affected by infection (tuberculosis) or osteoarthritis
1.Appropriate studies to rule out ischemic heart or lung disease and inflammatory arthritides
1.Lateral radiographs of the chest may demonstrate erosive joint changes
2.CT scan of the chest
a.May demonstrate cyst formation in the joint
1.The xiphoid process is a small cartilaginous extension of the lower sternum. It is at the level of the 9th thoracic vertebra and the T6 dermatome. At age 15 to 29, the xiphoid fuses to the body of the sternum with a fibrous joint. The joint ossifies around 40 years of age
1.The chief complaint is usually low substernal or epigastric pain
2.The pain may radiate to the precordium or abdomen
3.The xiphoid cartilage is tender and pressure reduplicates the pain and its radiation
4.The process may run a self-limited course
5.Pain in the joint may be elicited by lifting or bending
1.Direct damage to the cartilage and joint from blunt chest trauma
2.Some consider it to be Tietze’s syndrome of the xiphisternal joint
1.Appropriate studies to rule out thoracic or abdominal pathologies
1.Radiograph of the joint
1.Intercostal and accessory thoracic muscle pain is usually traumatic or from unaccustomed or excessive muscle activity
1.The onset may be sudden or gradual with localized pain and mechanical sensitivity of the affected muscle
2.Pain is exacerbated by maneuvers that stretch the involved muscles
1.Trigger points that are areas of local mechanical hyperalgesia in muscle but also can be demonstrated in ligaments, tendons and the periosteum
2.If a trigger point is mechanically stimulated, a taut band within the muscle contracts; they may be associated with a local muscle twitch response
1.Radiograph to rule out other pathology
1.A rare benign self-limited disorder most often of children and adolescents
1.Occurs primarily in young healthy persons
2.Sharp pains are felt in the anterior chest wall (“catches” or “stitches”)
3.The pain is often at the left parasternal area or near the cardiac apex
4.Pain may occur with a forward flexed posture
5.The pain lasts for 30 seconds to 3 minutes
6.The pain may be exacerbated by deep inspiration and is relieved by a change of posture or shallow breathing
7.There is no local tenderness
1.Putative irritation of the parietal pleura
1.Chest radiograph to rule out pathology
1.An acute viral illness that causes severe pain in the chest wall and the epigastrium
1.The disorder affects the intercostal and upper abdominal wall muscles
2.Usually there is a prodrome of 1-10 days of viral illness. After that, the patient experiences severe lancinating pain in the lateral chest wall usually the size of a palm (in adults). The upper epigastrium is primarily affected in children
3.The pain is exacerbated by breathing, coughing and other chest movement
4.Paroxysms of severe lancinating pain occur between symptom free intervals
5.Involved muscles are tender
6.Patients have fever, headache and pharyngitis concomitantly and approximately 10% have pleurisy
7.The illness usually lasts for 3 to 7 days but relapses can occur. The disorder is self-limited
1.The usual viruses causing epidemic myalgia are:
a.Group B coxsackie virus
b.In sporadic cases coxsackie type A and echoviruses are more frequent. Human parechovirus type 3 has recently been described
1.Isolation of the virus from the throat or feces early in the course of the illness
2.Demonstration of a rising titer of type-specific neutralizing antibodies
1.Pain and local tenderness in the posterior chest wall may be caused by:
a.Trauma
b.Metabolic bone disease
c.Infections
d.Juvenile kyphosis (Scheuermann’s disease)
e.Thoracic disc disease
f.Costovertebral arthritis
g.Diffuse idiopathic skeletal hyperostosis
h.Ankylosing spondylitis
1.Symptomatic thoracic disc disease is rare but may be accompanied by serious spinal cord compression due to the small diameter of the spinal canal at this level
2.Precipitating factors are heavy lifting, trauma and infection (IV drug abuse)
1.Occurrence is most common at the mid to lower thoracic levels and in men in the fifth decade
2.In some patients there may be preceding back pain for weeks or months due to disc annulus degeneration
3.Thoracic disc pain may radiate anteriorly and mimic cardiac pain although in this instance it is usually lancinating and in an intercostal nerve distribution
4.Posterolateral disc herniations cause compression of nerve roots with associated unilateral chest wall pain while posterior herniations cause myelopathy
1.Annulus fibrosis degeneration and tears with disc pulp protrusion
2.An inflammatory response from the extruded nucleus pulposis with local leukocytosis, cytokine and chemokine expression from immune cells
1.MRI
1.Early ankylosing spondylitis
2.Costovertebral joint syndrome
3.Metastases
1.Costovertebral and costotransverse arthritis may be seen with osteoarthritis, ankylosing spondylitis and rarely with other inflammatory arthritides
1.The pain is usually at the first, eleventh and 12th costovertebral joints as they have the most mobility
2.The pain is exacerbated by deep inspiration, coughing or chest compression
3.The pain is characteristically a dull ache
1.The usual underlying disorders are osteoarthritis, ankylosing spondylitis and psoriatic arthritis
1.MRI:
a.A positive spinal MRI for inflammation is the presence of anterior / posterior spondylitis in >3 sites
b.Fatty deposition at several vertebral corners are an early sign of axial ankylosing spondylitis
c.Radiographs:
i.Joint space narrowing, subchondral bony sclerosis and marginal osteophytes
d.Osteophytes and disc herniations in spinal radiculopathy can be differentiated by susceptibility-weighted MRI
1.Diffuse idiopathic skeletal hyperostosis is a non-inflammatory degenerative disease that causes ossification of spinal ligaments and decreased spinal mobility
2.Possibly present in 19% of men and 4% of women that are older than 50 years of age
1.This is a disorder primarily of middle aged and elderly men
2.Pain and stiffness of the thoracolumbar spine
3.In general the pain is mild, dull and nonradiating; it is exacerbated by inactivity and cold
4.There is a slight increase in dorsal kyphosis, a minimal decrease in thoracic range of motion and chest expansion; there is occasional local tenderness
1.An increase of vertebral fractures on a hyperostotic fused spine
2.DISH is associated with an increased risk of metabolic syndrome (odds ratio of 3.88)
3.Serum levels of the natural osteogenesis inhibitor Dickkopf-1 (DKK-1) are low
4.The diagnosis requires at least two or three contiguous intervertebral bridges without severe disc changes (seen in degenerative spine disease) or ankylosis of the sacroiliac or facet joints (in contrast to spondyloarthritis)
5.Partial or complete bone bridges that consist of cortical woven bone that are accompanied by morphological changes in the adjoining part of the intervertebral disc
1.Low levels of the natural osteogenesis inhibitor Dickkopf-1 (DKK1) encoded from the HGNC gene that maps to chromosome 10q21.1
1.Radiographs:
a.Undulating anterior ossification of 2-4 or more contiguous thoracic vertebrae with space between the deposited bone and the underlying vertebral bodies with relative preservation of the intervertebral disc height. It is distinguished from ankylosing spondylitis by the absence of sacroiliitis, true syndesmophytes and apophyseal joint ankylosis
1.Spondyloarthritis (SpA) is a group of disorders that includes:
a.Ankylosing spondylitis (AS)
b.Psoriatic arthritis (PsA)
c.Inflammatory bowel disease-associated arthritis
d.Reactive arthritis
e.Undifferentiated SpA
2.All of these disorders primarily affect the axial skeleton, erosions, and new bone formation in the sacroiliac joints and in the spine.
3.Other associated clinical manifestations are:
a.Asymmetrical oligoarthritis
b.Enthesitis
c.Dactylitis
d.Extraskeletal manifestations that include:
i.Psoriasis
ii.Uveitis
iii.Chronic inflammatory bowel disease
4.Axial spondyloarthritis SpA is a subset of patients without radiographic sacroiliitis and may represent an earlier stage of anklyosing spondylitis. The criteria for AxSpA include:
a.Evidence of sacroiliitis by MRI
b.Chronic back pain
c.HLA-B27 positivity
d.Nonarticular symptoms
5.Susceptibility to ankylosing spondylitis is conferred by variations in the HLA-B27 gene allele that maps to chromosome 6p21.3:
a.Functions in antigen presentation
6.Other associated genes include:
a.2q12.1 locus
i.Modulator of inflammation
b.IL-1 gene that maps to chromosome 22q13.2
i.Metabolism of xenobiotics
c.CYP2D6 gene that maps to chromosome 5q15
i.An endoplasmic reticulum aminopeptidase
d.IL23 receptor gene that maps to chromosome 1p31.1
1.Insidious onset of thoracic and low back pain
2.Onset of signs and symptoms prior to age 40
3.Symptoms are worse in the morning or with inactivity
4.Improvement of symptoms with exercise
5.Inflammatory back pain is the most common symptom and presenting manifestation of 75% of patients; it often is dull and diffusely localized to the sacroiliac and buttock areas
6.The onset is insidious over months to years with at least three months of symptomatology prior to presentation. Most patients suffer chronic disease with intermittent exacerbations
7.The pain begins unilaterally and intermittently in the sacroiliac area, progresses and becomes bilateral and more proximal
8.Morning stiffness is common and usually lasts for 30 minutes. It may awaken the patient in the early morning
9.Nocturnal back pain during the second half of the night
10. Alternating buttock pain
11. Peripheral musculoskeletal involvement is seen in 30-50% of patients
12. Peripheral enthesitis (inflammation at the site of insertion of ligaments and tendons on bone) occurs at:
a.Achilles tendon insertion
b.The plantar fascia on the calcaneus or the metatarsal heads
c.Base of the fifth metatarsal head
d.Tibial tuberosity
e.Superior and inferior poles of the patella
f.Iliac crest
1.The initial involvement is in the S1 joint which is followed by involvement of discovertebral, apophyseal, costovertebral and costotransverse joints
2.The early lesion is subchondral granulation tissue that erodes the joint and is gradually replaced by fibrocartilage and then ossifies
3.The initial process occurs at the junction of the vertebra and the annulus fibrosus of the intervertebral discs. The outer fibers of the disc undergo ossification that forms syndesmophytes
4.Extraarticular involvement includes:
a.Acute anterior uveitis
b.Aortitis
c.Cardiac arrhythmias (generally a late manifestation)
d.Restrictive lung disease
1.Molecular genetic evaluation to delineate gene mutations particularly allelic variations of HLA-B27
1.Radiographs:
a.Early signs of enthesitis (site of tendon or ligamentous bone attachments) include squaring off of the vertebral bodies due to erosions of their superior and inferior margins which erases the normal concave contour of their anterior surface
b.Inflammatory lesions of enthuses cause sclerosis of the superior and inferior margins of the vertebral bodies
2.CT and MRI Imaging
a.Reveal early sacroiliitis, erosions and enthesitis that may not be evident on radiographs
1.Frequently utilized diagnostic criteria for fibromyalgia include:
a.Diffuse widespread musculoskeletal pain and stiffness that may affect the back, neck and shoulders
b.The pain is modulated by weather (particularly a drop of barometric pressure), activity and fatigue
c.Localized tenderness at specific sites
d.Disturbed sleep with fatigue, aching and stiffness upon awakening
e.Associated tension headache, irritable bowel syndrome
f.Normal laboratory and radiographic studies; newer information supports a small fiber neuropathy as causative in a subgroup of patients
1.The chest wall is a common localization for pain (often in the distribution of the intercostobrachial nerve)
2.The disorder is predominant in the third or fourth decades and affects women in a ratio of 5:1
3.The most common symptoms are pain, aching and stiffness throughout the body but including the chest wall and periscapular areas
4.Tender points and pain are often elicited in the foraminal exit areas of the cervical roots (C2-C4), the supraclavicular fossa (upper trunk of the brachial plexus), the infraclavicular fossa (primarily the lower trunk of the brachial plexus), and the neurovascular bundle that contains the entire plexus (activated when compressed against the upper humerus). Pain one inch from the medial scapular border (an upper trunk radiation of the brachial plexus) is common
5.It may be associated with some features of neurogenic edema (erythema and swelling) as noted in type I CRPS.
6.Exacerbating factors are:
a.Cold
b.Air conditioning
c.Poor sleep
d.Fatigue
e.Stress
f.Inactivity
g.Increased exercise
7.The pain fluctuates from day to day and in some patients by the hour
1.Trigger points and taut muscle bands within affected muscles are the hallmarks of the disorder
1.No signs of inflammation. The sedimentation rate and C-reactive protein are negative
2.There is mounting evidence for a small fiber neuropathy as causative in a subgroup of patients
1.Neuroimaging with MRI is to rule out other pathologies
1.Costochondritis:
a.Costochondral or costosternal junction tenderness
b.Affects the second to fifth ribs
c.No swelling
2.Lower rib pain syndrome:
a.Pain over the 10th to 12th rib or the upper abdomen
b.A tender area over the costal margin that reproduces the pain when palpated
3.Sternalis syndrome:
a.Localized tenderness of the body of the sternum or the sternalis muscle
b.Mechanical pressure may cause bilateral pain radiations
4.Thoracic costovertebral joint dysfunction:
a.Pain 3-4 cm from the midline that is localized
b.Referred pain from the posterior midline to the lateral and anterior chest wall
5.Fibromyalgia:
a.Widespread musculoskeletal (a subgroup with neuropathic) pain and tenderness
b.Many tender points are cervical and brachial plexus areas
c.Fatigue, anxiety and sleep disturbance
1.Rheumatoid arthritis:
a.Swelling and tenderness primarily of multiple small joints although large synovial joints are affected
b.Thoracic costovertebral joints and costoclavicular joints may be affected
c.Positive rheumatoid factor, anticitrullinated protein antibody and abnormal C-reactive protein and sedimentation rate are documented
2.Axial Spondyloarthropathy:
a.Back pain of insidious onset and of at least 3 months duration
b.Onset < than 45 years of age
c.Imaging studies that demonstrate sacroiliitis by MRI, radiographs (one other feature of SpA)
d.HLA-B27 and 2 other features of SpA
3.Psoriatic Arthritis:
a.Inflammatory articular disease of joints, the spine or entheseal areas with three out of five of the following:
i.Current psoriasis, a past history or a family history of psoriasis
ii.Psoriatic nail changes
iii.Negative for rheumatoid factor
iv.History of dactylitis (inflammation of an entire finger or toe)
v.X-ray evidence of juxta-articular new bone formation in the hands or feet
1.Osteoporotic fracture:
a.Acute back pain
b.Insidious loss of height and or kyphosis with thoracic fractures
c.Acute localized pain over the fracture site
d.Often underlying risk factors
2.Neoplasms with pathologic fractures or bone pain:
a.Severe boring pain often most severe at night
b.Mechanically sensitive areas of metastases or pathologic fracture
c.Radiographic evidence of posterior element involvement (facet) or vertebral body involvement)
d.Not very responsive to opioids. If responsive to NSAIDs possible osteoid osteoma