Major Causes of Musculoskeletal Chest Pain, Key Symptoms and Compounded Treatments
Sudden severe chest pain can send a patient to the emergency department, where tests are run and they are monitored closely. However, several hours later, individuals may be discharged with only a pat on the back and reassurance that they did not have a heart attack. Sure, this news may be a relief, but what’s missing from the scenario? As it turns out, no one actually explained the cause of the pain.
Once hospital staff have ruled out a cardiovascular emergency, it’s up to the patient to follow-up with their doctor. Pharmacists can be sure that many of these patients will end up in their pharmacy, as musculoskeletal chest pain often requires multimodal treatment with topical and oral medications—a regimen that distinctly benefits from compounded options.
Categories of Benign Chest Pain
The vast majority of patients evaluated for chest pain—about 80 percent—have a benign condition.1 That’s a lot of people who are relieved to learn they’re not having a heart attack. But then the task of finding a proper diagnosis begins. Some will find a quick answer, others face a longer diagnostic road, but they all fall into one of these categories:
- Non-specific chest pain – The diagnosis given to patients in the hospital who have chest pain but no evidence of acute coronary syndrome or coronary ischemia. Roughly 40 percent are diagnosed with coronary heart disease. Of the remaining patients, about 70 percent are diagnosed with anxiety disorder, reported the Emergency Medicine Journal.2
- Non-cardiac chest pain – Defined as a recurring, angina-like retrosternal chest pain caused by functional gastrointestinal disorders.3 Gastroesophageal reflux disease is the most common underlying condition, but it may also be caused by esophageal dysmotility and esophageal hypersensitivity.
- Musculoskeletal chest pain – About half of all patients with benign chest pain have an underlying musculoskeletal condition.
Major Causes of Musculoskeletal Chest Pain
While cardiac patients are primarily seen in the emergency department, patients with musculoskeletal chest pain tend to visit their primary care provider. Sometimes the cause is obvious because the patient has experienced acute trauma. Lacking an obvious injury, physicians must rule out cardiac, respiratory and gastrointestinal conditions before turning their attention to the primary causes of musculoskeletal chest wall pain.4
Isolated musculoskeletal pain:
- Costochondritis – The primary cause of musculoskeletal chest pain, costochondritis is diagnosed in up to half of all patients. It’s marked by inflammation and pain in the second through fifth costosternal joints and usually self-limited, but recurrences are common and it may become chronic.
- Lower rib pain syndromes – Tenderness in lower chest with area of pain on the costal margin.
- Pain from thoracic costovertebral joints – Localized pain about 3 to 4 centimeters from midline; rib movement causes pain that may be referred.
- Sternalis syndrome – Localized pain over the sternum or sternalis muscles; palpation causes pain to radiate bilaterally.
- Fibromyalgia – Widespread musculoskeletal pain and tenderness, fatigue, disturbed sleep and cognitive disturbances.
- Rheumatoid arthritis – Swelling and tenderness of multiple synovial joints.
- Axial spondyloarthritis (including ankylosing spondylitis) – Back pain for three months or longer with diagnostic blood markers or imaging features.
- Psoriatic arthritis – Inflammation around joints that occurs in patients with psoriasis
This list only shows the most prevalent conditions responsible for musculoskeletal chest pain. Both categories also have several other causes and there’s also a third category—non-rheumatic systemic causes—which includes less common neoplasms and osteoporotic rib fractures.
Treatment Regimens Based on Underlying Condition
With such diverse causes, treatment relies on the physician’s clinical expertise. For mild cases of self-limiting costochondritis, patients may simply be advised to avoid activities that cause pain and use heat packs. Otherwise, the treatment options for costochondritis are also used for other conditions in the isolated musculoskeletal pain group.
- OTC analgesics – Ibuprofen is usually first line treatment; paracetamol or nonsteroidal anti-inflammatory agents are also considered.
- Topical pain relief – A variety of COX inhibitors can be used to treat isolated musculoskeletal disorders, including diclofenac, ketoprofen, piroxicam and ibuprofen.
- Corticosteroid injection – May be needed for persistent pain.
- Physical therapy – A structured regimen of exercise, mobilization and soft tissue therapy is beneficial in severe or chronic cases and to help athletes get back into action.
Rheumatic conditions also rely on multifaceted treatment, but the regimen and medication choices are significantly more complex than treatment for isolated musculoskeletal pain.
- Pharmacologic – Includes analgesics, anti-anxiety agents, antidepressants, muscle relaxants, anticonvulsants and trigger point injections.
- Non-pharmacologic – Exercise, psychological counseling and behavioral modification.
- Sleep management – Disrupted sleep due to pain should be treated with nonpharmacological options such as melatonin.
Rheumatic and psoriatic arthritis:
- Pharmacologic – First line treatment with nonbiologic and biologic DMARDs; other medications used include NSAIDs, immunosuppressants and corticosteroids.
- Nonpharmacologic – Structured diet, exercise, physical therapy, massage, stress reduction and counseling.
- Surgery – Surgical interventions for rheumatoid arthritis relieve pain, correct deformities and improve function.
Intervention from Compounding Pharmacists
There’s always a role for compounding pharmacists—often a vital one at that—when patients need the type of multifaceted regimen used to treat rheumatic conditions. But you can also step in to help those with isolated musculoskeletal pain.
Isolated musculoskeletal pain: Topical analgesics are often recommended to relieve pain, but patients may rely on OTC products that are ineffective due to the low dose. Individually formulated patches, creams or gels promote optimal relief with a precise dose and minimal systemic absorption.
Rheumatic diseases: Treat-to-target is the term used to highlight the importance of individualized treatment of rheumatoid arthritis (RA). Counseling RA patients takes on life-saving importance as they face a multitude of pharmaceutical options and often require trial-and-error to find the treatment that stops disease progression. About 40 percent of psoriatic arthritis patients face similar concerns as their diseases becomes erosive and deforming.
- Streamline the regimen – Compounding pharmacists can make long-term treatment easier by mixing several medications into a single dose or by developing a more palatable formula, such as liquid meds for adults who struggle to swallow pills.
- Tailored topical treatment – Patients with fibromyalgia and arthritis also benefit from topical pain analgesics, including lidocaine 5 percent. Since disease progression and severity varies, compounding pharmacists can improve quality of life by working with each patient to continually refine the dose and agents.
Significant Benefits from Pharmacist Outreach
Barring obvious trauma or the type of acute pain that sends patients to the emergency department, a lot of people are confused about their chest pain. They may need a nudge from a trusted professional, so encourage them to see a doctor. Also, urge them to come back, so you can follow-up on their diagnosis and ask how they’re doing. When symptoms persist, be sure to discuss the benefits of compounded treatments. Many individuals won’t know what’s available unless you take the time to reach out and connect.
Pharmaceutica North America supports the diverse needs of chest pain patients by providing high-quality bulk APIs, delivery bases, prescription lidocaine and diclofenac and OTC supplements such as sleep aids. Contact us today so we can answer your questions and talk about our line of pharmaceutical products.
- “Chest Pain in Focal Musculoskeletal Disorders, March 2010, https://www.researchgate.net/profile/Henrik_Christensen2/publication/43097975_Chest_pain_in_focal_musculoskeletal_disorders/links/02bfe50c9f6eb4595e000000.pdf ↩
- “Anxiety Disorder in Patients with Non-Specific Chest Pain in the Emergency Setting,” February 2006, http://www.ncbi.nlm.nih.gov/pubmed/16439735 ↩
- “The Current Treatment of Non-Cardiac Chest Pain,” January 2016, http://www.ncbi.nlm.nih.gov/pubmed/26592490 ↩
- “Musculoskeletal Chest Wall Pain,” August 2015, http://www.racgp.org.au/afp/2015/august/musculoskeletal-chest-wall-pain/ ↩