Chapter 28: Thoracic and chest pain

INTRODUCTION

THORACIC PAIN

As with neck pain (Chapter 23) and low back pain (Chapter 29), it is frequently difficult for the clinician to make a precise diagnosis in patients with pain in the region of the thoracic spine given the interplay between the thorax, upper limb, neck, low back, and the cardiorespiratory and visceral systems. The most common musculoskeletal problems are disorders of the thoracic intervertebral joints and the numerous rib articulations as this region of the spine contributes stability to the axial skeleton. The thorax never sleeps as, even at rest, this complex interplay of joints, ligaments and muscles moves with respiration.

Injury to the intervertebral disc, the facet joints (also named zygapophyseal joints) or other nociceptive structures (Chapters 5 and 6) of the thoracic spine may lead to local or referred pain. Clinical presentation of these often articular problems is varied. Pain and altered motion are the dominant features when one or more intervertebral segments or rib joints are involved. There may be associated abnormalities of the paraspinal and periscapular muscles as well as increased neural mechanosensitivity (Chapter 6). Thoracic intervertebral joint problems frequently refer pain to the lateral or anterior chest wall. Prolapse of a thoracic intervertebral disc is rare in athletes; however, it may be under-reported given the often diffuse symptoms that arise.^{1, 2} Appropriate imaging studies are often necessary to rule out this diagnosis. The astute clinician keeps all diagnostic options open when considering the thoracic region.

In adolescents, the most common cause of thoracic region pain is Scheuermann’s disease (Chapter 44), a disorder of the growth plates of the thoracic vertebral endplates associated with an accentuated lower thoracic kyphosis. A list of the causes of pain in the region of the thoracic spine is shown in Table 28.1. The surface, muscle and cross-sectional anatomy of this area are shown in Figure 28.1.