Sternal Pain - Different Causes

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Search strategy

A literature search was conducted using pubmed and web of knowledge. The following search terms were used separately and in combination: sternal pain, different causes of sternal pain, chest pain, epidemiology,….

Definition/ description

Sternal pain is an acute or chronic pain or discomfort felt in the region of sternum and the associated structures.¹

Clinical relevant anatomy

The sternum is a flat bone, located in the center of the anterior thoracic wall. It consists of three segments; the manubrium (uppermost part), the body (middle part) and the xiphoid process (lowest part).^2,7 The manubrium articulates with the right and left clavicles, the first rib of both sides and the upper part of the second costal cartilage.⁷ The manubrium is quadrangular and lies at the level of the 3rd and 4th thoracic vertebrae. The jugular notch is the thickest part of the bone and is convex along anterior and concave along the posterior side.⁷ The body of the sternum is longer and thinner. It has margins that articulates with the seven first cartilages of the ribs.^2,7 The xiphoid process is the lowest part of the sternum and also the smallest part. It doesn’t articulate with the ribs.⁷ The xiphoid process anchors several important muscles like the rectus abdominus muscle and the transversus thoracis muscle, including the abdominal diaphragm, a muscle that is necessary for normal breathing.¹⁷

The left figure (fig.1) shows the anterior surface of the sternum and the costae cartilages. The right one shows de posterior surface of the sternum.²

Epidemiology/etiology

Here is a list of the different causes of sternal pain. If they’re already discussed on Physiopedia or on other sources, click on the link for more information.

Cardiovascular causes

- Heart valve diseases
- Hypertrophic cardiomyopathy
- Coronary artery disease
- Myocarditis
- Pericarditis
- Aortic dissection
- Amyloidosis

Respiratory causes

- Asthma
- Bronchitis
- Chronic Obstructive Pulmonary Disease (COPD)
- Bronchiectasis: there is currently no text in this page
- Tracheitis: there is currently no text in this page
- Tuberculosis
- Pneumonia

Abdominal and gastrointestinal causes

- Gastroesophageal reflux disease (GERD)
- Pancreatitis
- Peptic ulcers

Musculoskeletal causes

- Sternal fractures
- Clavicula fractures is a fracture of the clavicular bone. 5 to 10 % of all fractures are clavicula fractures and the fractures are most common in children and young adults.^8,9 It happens mostly by falling on the lateral shoulder and upper arm during contact sport. It also happens by falling on an outstretched arm or elbow or by a direct trauma to the clavicle. ⁸
- Sternoclavicular joint disorders
- Tietze’s syndrome (Costochondritis) is an inflammation of rib cartilage.
- Joint pain: at the joint between the ribs and shoulder bones. Can be caused by arthritis (rare). It may also be caused by extreme exercises such as lifting of heavy weights.
- Pectoral muscle ruptures generally occur during forceful activities. ¹³
- Intercostal muscles can become strained often as a result of rapid twisting of the torso. It’s common in sports such as basketball and tennis.¹¹
- Fibromyalgie can produce persistent muscle-related chest pain.
- Osteomyelitis is an inflammation due to infection of the bone or bone marrow.
- Xiphodynia (or hypersensitive xiphoid syndrome) is a condition involving referral of pain to the chest, abdomen, throat, arms and head from an irritated xiphoid process.¹⁵ While xiphodynia is frequently insidious in onset, trauma may precipitate the syndrome. Acceleration/deceleration injuries, blunt trauma to the chest, unaccustomed heavy lifting and aerobics have been known to precipitate. ¹⁵
- Precordial catch syndrome (Texidor’s Twinge) is a common, but underrecognized cause of benign chest pain in children and adolescents. ¹⁶
- Blocked rib: There is currently no text in this page.
- Slipping rib syndrome
- Rib stress fractures

Lung-related causes

- Bronchitis
- Bronchiectasis
- Tracheitis
- Tuberculosis
- Pneumonia
- Pulmonary embolism
- Pleurisy
- Collapsed lung
- Pulmonary hypertension
- (Pulmonary) sarcoidosis

Psychological causes

- Anxiety

Cancer

- Breast cancer
- Lung cancer
- Lymphoma
- Bone cancer

Clinical presentation

The most obvious sign of a strained muscle is pain. However, the level of pain felt relates to the degree of injury. It can also cause swelling in the chest area and muscle spasms. A moderate or severe strain will also result in weakness, due to a muscle tear.¹⁴

You feel pain when your injured intercostal muscles try to move your ribs during inhalation.¹¹

Differential diagnosis

Arthritis of sternoclavicular, sternomanubrial or shoulder joints gives tenderness to palpation of specific joints of the sternum.¹⁰

Fibromyalgie gives symmetric tender points at second costochondral junction, along with characteristic tender points in the neck, back hip and extremities. It also gives widespread pain.¹⁰

Traumatic muscle pain and overuse myalgie can be caused by history of trauma to chest or recent new onset of strenuous exercise to upper body (rowing). It may be bilateral and affecting multiple costochondral areas. Muscle groups may also be tender to palpation.

Diagnostic procedures

Pain can be felt when stretching, lifting, reaching or exerting the affected chest muscles. A muscle spasm is the result of inflammation, causing the muscles to contract suddenly. ¹⁴

Medical management

Surgery is most recommended for complete tears of chest muscles. Patients who have partial tears may be able to avoid surgical treatment. ¹³

Physical therapy management

A grade 1 (strain) or a grade 2 (partial tear) of chest muscle injury could be treated with physical therapy. After the intitial treatment for managing the inflammation, the therapy is based on increasing circulation, collagen production and extensibility of connective tissues. Ultrasound therapy reduces muscle spasm. Massage and electrical stimulation treat muscle injuries by releasing tension, stimulating blood flow and promoting healing. Flexibility training after pain and swelling has diminished, will help improve range of motion and mobility. Weight training will increase muscle and tendon strength.¹²

References

1. Dr. C.A. Jenner MB BS, FRCA, Sternal Pain, Nov 2006.Level of evidence: 5
2. Gray’s Anatomy of the Human Body, fig. 115 – anterior surface of sternum and costa cartilages.Level of evidence: 5
3. Dr. Greg., causes of breast bone pain (sternum), Sept 2010.Level of evidence: 5
4. M. Anju, sternum pain, Aug 2011. Level of evidence: 1
5. Mayo Foundation for Medical Education and Research, Chest Pain, Dec 2011.Level of evidence: 5
6. N. Sandhyarani, sternum pain causes, Jan 2011.Level of evidence: 5
7. A. Iqbal, Human anatomy, sternum, 2001Level of evidence: 5 Grade of recommendation: E
8. S. Mozes, Family practice notebook, LLC, 2011.
-> D. Standley, Norris SH, Recovery fractures of clavicle treated conservatively, 1998.level of evidence: 5 
9. M. Pecci, J. Kreher, MD, Boston university, Clavicle fractures, jan. 2008.level of evidence: 1 
10. A. Proulx et al., Costochondritis; diagnosis and treatment, American family physician,Am Fam Physician, sept. 2009. Level evidence: 5 
11. Lynn Hetzler, therapy for intercostal muscles, jul. 2011.Level of evidence: 5
12. E. Ahders, therapy for an injured pectoral muscle, Apr 2012.Level of evidence: 5
13. Petilon, J, et al. “Pectoralis Major Muscle Injuries: Evaluation and Management” J Am Acad Orthop Surg, Vol 13, No 1, Jan/Feb 2005, 59-68.Level of evidence: 1
14. D. Allyson, signs of a pulled chest muscle, mart 2011.Level of evidence: 5
15. Simpson K, Hawken E; Xiphodynia: A diagnostic conundrum; Chiropractic & Osteopathy,
2007, 15:13 Level of evidence: 4
16. Gumbiner C, Precordial Catch Syndrome; Southern Medical Association, 2003.Level of evidence: 5
17. R.broyles, The location and purpose of the Xiphoid process, 2009.