Lower rib pain syndrome (also termed painful rib syndrome, rib-tip syndrome, slipping rib, twelfth rib and clicking rib) typically presents with lower chest or upper abdominal pain. 4 It differs from the rarer Tietze’s disease, which typically involves only one area with associated painful, localised swelling. 5 Patients with costochondritis typically present with multiple areas of tenderness without swelling over the costochondral or costosternal junctions, palpation of which reproduces their pain. In one general practice sample, costochondritis, also known as costosternal syndrome and anterior chest wall syndrome, was the most common specific cause of anterior musculoskeletal chest pain, with a prevalence of 13%. Axial spondyloarthritis (including ankylosing spondylitis).Spontaneous sternoclavicular subluxation.Pain from thoracic spine/costovertebral joints.Musculoskeletal causes of chest wall pain systemic non-rheumatological conditions.conditions causing isolated musculoskeletal pain.It has been suggested that causes of MCWP can be grouped into three categories 4 and individual conditions can be broadly considered as more and less common conditions ( Table 1): This also makes it difficult to estimate prevalence of individual conditions accurately. In other cases, identifying the cause of isolated MCWP can be problematic because even if general clinical characteristics are described, there is no clear and consistent definition and usually no gold standard diagnostic test to confirm a diagnosis.

Sometimes this is obvious, as in the case of acute trauma or injuries including rib fracture or contusion and muscular strains in, for example, pectoral or intercostal muscles. More commonly, general practitioners (GPs) seek to determine the specific cause. As a result, it has been proposed that disorders causing anterior chest wall pain should be grouped as an entity called ‘chest wall syndrome’, 3 but this is not widely accepted and the clinical implications of this approach are unclear. It may be difficult, therefore, to pinpoint the exact source of pain in an individual patient. The chest wall contains a range of bony and soft tissue structures, including the spine. 1 This article focuses on musculoskeletal chest wall pain (MCWP), particularly its causes, assessment and management of the most common causes.

2 By contrast, musculoskeletal conditions were diagnosed in only 6.2% of patients presenting to the hospital emergency department with chest pain 1 but in this setting, serious causes such as cardiovascular disease were far more common. Estimates of their prevalence in the general practice setting range from 20.6% 1 to 46.6%. Although it is critical to rule out potentially life-threatening conditions, in the general practice/primary care setting, musculoskeletal conditions are the most common causes of chest pain. Chest pain is a common general practice presentation, which, because of its diverse and potentially serious causes, requires careful and often urgent assessment.

Pain in middle of chest