Diagnostic steps to differentiate musculoskeletal chest pain from cardiac causes

Chest pain evaluation often prioritizes ruling out cardiac causes, but many cases originate from the chest wall. A careful history, targeted physical exam and selected investigations can separate musculoskeletal conditions such as costochondritis from cardiac ischemia. Understanding patterns of inflammation around the sternum, ribs and cartilage and using reproducible bedside tests reduces unnecessary alarm while ensuring patients with cardiac risk receive timely assessment. This article explains stepwise diagnostic features and conservative management options used in clinical practice.

This article is for informational purposes only and should not be considered medical advice. Please consult a qualified healthcare professional for personalized guidance and treatment.

What clinical signs suggest musculoskeletal pain?

Patients with chest wall inflammation typically describe sharp, localized pain that varies with movement, posture or respiration. Pain that changes with body position or activity and lacks classic exertional features (such as radiation to the jaw or arm, or associated diaphoresis) is more likely musculoskeletal. A recent history of coughing, physical strain, or trauma can point to rib or costal cartilage irritation. Assessing baseline cardiac risk factors remains important because overlap can occur.

How does sternum, rib, and cartilage involvement present?

Costochondral or sternal inflammation commonly causes focal tenderness over the sternum or along the costochondral junctions where rib cartilage meets the rib. Pain is often reproducible at specific points and may intensify with deep breathing or coughing. Local swelling or palpable nodules can occasionally be felt. Recognizing the anatomic distribution helps distinguish localized cartilage or rib problems from diffuse or visceral chest pain.

What role do palpation and reproducing pain play?

Palpation is a key bedside maneuver: direct pressure over a tender sternum or costochondral junction that reproduces the patient’s pain supports a musculoskeletal origin. Reproducible pain with provocative maneuvers — such as arm movement, trunk rotation, or chest wall compression — further increases the likelihood of a chest wall source. Absence of reproducible tenderness does not exclude musculoskeletal causes, but reproducibility is a specific finding and guides initial management.

When to consider cardiac evaluation?

Cardiac causes should be considered when pain is associated with exertion, syncope, shortness of breath out of proportion to chest wall findings, diaphoresis, nausea, or concerning ECG or biomarker changes. If history or exam is unclear, basic tests such as ECG and cardiac enzymes are appropriate to exclude acute coronary syndromes. Persistent uncertainty or high-risk features warrant urgent cardiology review and imaging rather than assuming a benign musculoskeletal diagnosis.

Management: nsaids, analgesics and physiotherapy

Initial conservative care for confirmed musculoskeletal chest pain focuses on symptom control and addressing inflammation. Short courses of NSAIDs or other analgesics can reduce inflammation around the cartilage and provide pain relief. Local heat, activity modification, and brief rest from aggravating movements are common adjuncts. Referral for physiotherapy can introduce manual therapy techniques and guided rehabilitation to restore function and reduce recurrent inflammation.

Rehabilitation, exercises, posture, ergonomics and manual therapy

Structured rehabilitation emphasizes posture correction, breathing mechanics and progressive exercises to strengthen the thoracic and scapular muscles. Manual therapy and soft tissue techniques can relieve localized tightness around the sternum and ribs. Ergonomics advice for work and daily activities reduces repetitive strain. Breathing retraining helps when pain is linked to altered respiratory patterns. A tailored exercise program and gradual return to activity support long-term recovery.

Conclusion

A stepwise approach — focused history, careful palpation, reproducible provocation tests and appropriate use of cardiac screening — helps differentiate musculoskeletal chest pain from cardiac etiologies. When exam findings clearly indicate sternum, rib or cartilage involvement, conservative management with NSAIDs, analgesics, physiotherapy, manual therapy and rehabilitation exercises often alleviates symptoms. Maintain vigilance for red flags and use diagnostic testing when cardiac risk or atypical features are present to ensure safe, effective care.