Pain in sternum

Pain in the sternum is a common clinical complaint that can arise from cardiac, musculoskeletal, respiratory, gastrointestinal, or infectious causes. Proper evaluation is essential to determine the underlying etiology and guide appropriate management.

Anatomy of the Sternum

Sternal Structure

The sternum is a flat bone located in the anterior midline of the thorax, providing protection to vital organs such as the heart and major vessels. It is divided into three parts:

• Manubrium: The broad upper portion that articulates with the clavicles and first ribs.
• Body of Sternum: The elongated middle segment that connects with the costal cartilages of ribs two to seven.
• Xiphoid Process: The small cartilaginous lower portion that may ossify in adulthood.

Articulations and Joints

The sternum forms several important joints that contribute to thoracic stability and flexibility:

• Sternoclavicular joint connecting the sternum with the clavicle
• Sternocostal joints linking the sternum to the costal cartilages of the ribs
• Xiphisternal joint between the body and xiphoid process

Muscles and Ligaments

Muscles and ligaments surrounding the sternum provide movement and support:

• Pectoralis major and minor muscles
• Sternohyoid and sternothyroid muscles
• Costal ligaments stabilizing the costochondral junctions

Etiology of Sternal Pain

Cardiac Causes

Cardiac conditions can manifest as sternal pain and may indicate serious underlying disease:

• Myocardial ischemia or infarction
• Pericarditis

Musculoskeletal Causes

Musculoskeletal disorders are common sources of anterior chest pain:

• Costochondritis, inflammation of the costal cartilage
• Sternal fractures or contusions from trauma
• Sternoclavicular joint disorders
• Muscle strain of the pectoralis or intercostal muscles

Respiratory Causes

Pulmonary conditions may produce pain that is localized to the sternum:

• Pleuritis, inflammation of the pleural lining
• Pneumothorax
• Respiratory infections such as pneumonia

Gastrointestinal Causes

Gastrointestinal disorders may cause retrosternal or sternal pain:

• Gastroesophageal reflux disease (GERD)
• Esophagitis

Infectious Causes

Infections involving the sternum can result in localized pain and tenderness:

• Sternal osteomyelitis
• Post-surgical infections following median sternotomy

Other Causes

Additional conditions may present with sternal discomfort:

• Anxiety or panic attacks
• Herpes Zoster
• Referred pain from the spine or cervical region

Risk Factors

Age and Gender

Certain age groups and genders may be more susceptible to specific causes of sternal pain. Older adults have a higher risk of cardiac events, while younger individuals involved in physical activities may be more prone to musculoskeletal injuries.

Medical History

A history of cardiovascular disease, respiratory conditions, gastrointestinal disorders, or previous chest trauma increases the likelihood of sternal pain. Prior surgeries involving the chest, such as cardiac procedures, may also predispose to post-surgical complications.

Trauma or Physical Activity

Participation in contact sports, heavy lifting, or activities with repetitive upper body movements can result in fractures, contusions, or muscle strain contributing to sternal pain.

Lifestyle Factors

Lifestyle elements such as smoking, high-fat diet, and sedentary behavior can increase the risk of cardiac disease, GERD, and musculoskeletal issues, all of which may manifest as sternal pain.

Clinical Presentation

Symptoms

Sternal pain can vary in character and intensity depending on the underlying cause. Common presenting features include:

• Sharp, dull, pressure-like, or burning pain localized to the sternum
• Associated cardiac symptoms such as shortness of breath or palpitations
• Respiratory symptoms including cough or pleuritic pain
• Gastrointestinal symptoms such as heartburn, regurgitation, or nausea
• Aggravating factors like movement, deep breathing, or palpation

Physical Examination Findings

Examination may reveal clues to the etiology of sternal pain:

• Tenderness over the sternum or costochondral junctions
• Swelling, bruising, or deformity in cases of trauma
• Restricted range of motion of the upper chest or shoulders
• Signs of systemic illness such as fever, tachycardia, or hypotension

Diagnostic Evaluation

Laboratory Tests

Laboratory investigations help identify underlying systemic, cardiac, or infectious causes of sternal pain:

• Cardiac enzymes including troponins and CK-MB to detect myocardial injury
• Inflammatory markers such as ESR and CRP for musculoskeletal or infectious causes
• Complete blood count (CBC) to assess for infection or anemia

Imaging Studies

Imaging provides structural and functional information about the sternum and surrounding tissues:

• X-ray of the sternum to detect fractures, dislocations, or deformities
• CT scan or MRI for detailed assessment of bone, cartilage, and soft tissue abnormalities
• Ultrasound for evaluation of soft tissue inflammation or fluid collections
• Echocardiography to evaluate cardiac involvement when chest pain suggests myocardial or pericardial origin

Special Tests

Additional diagnostic modalities may be required depending on suspected etiology:

• Electrocardiogram (ECG) for ischemic or arrhythmic cardiac causes
• Stress testing to assess for exercise-induced cardiac ischemia
• Endoscopy for suspected esophageal or gastroesophageal causes

Differential Diagnosis

Sternal pain can be caused by multiple conditions, and differential diagnosis should include:

• Cardiac: myocardial infarction, pericarditis
• Musculoskeletal: costochondritis, fractures, muscle strain
• Respiratory: pleuritis, pneumonia, pneumothorax
• Gastrointestinal: GERD, esophagitis
• Infectious: sternal osteomyelitis, post-surgical infection
• Neuropathic or referred pain: shingles, spinal origin

Management

Conservative Management

Initial management often involves conservative approaches aimed at symptom relief and functional restoration:

• Rest and avoidance of activities that exacerbate pain
• Pain control with analgesics or non-steroidal anti-inflammatory drugs (NSAIDs)
• Physical therapy to strengthen chest wall and improve posture

Medical Management

Targeted medical therapy depends on the underlying etiology:

• Anti-reflux medications for GERD or esophagitis
• Antibiotics for bacterial infections or osteomyelitis
• Cardiac medications such as nitrates, beta-blockers, or anti-inflammatory therapy for pericarditis

Interventional or Surgical Management

In severe or refractory cases, interventional procedures or surgery may be required:

• Sternal fixation or surgical repair for fractures or structural instability
• Drainage of abscesses or infected collections
• Cardiac interventions for ischemic or structural heart disease

Prognosis

Short-term Outcomes

The short-term prognosis for sternal pain depends largely on the underlying cause. Musculoskeletal pain, such as costochondritis or minor muscle strain, often resolves within a few weeks with conservative management. Post-traumatic pain may take longer, depending on the severity of the injury.

Long-term Outcomes

Long-term prognosis is generally favorable if the underlying etiology is identified and treated promptly. Chronic pain may develop in cases of repeated musculoskeletal injuries, untreated cardiac disease, or persistent GERD. Early intervention and adherence to treatment strategies can significantly improve long-term outcomes.

Factors Affecting Recovery

Several factors influence the recovery process:

• Timely diagnosis and appropriate management
• Severity and duration of the underlying condition
• Patient adherence to medical and lifestyle recommendations
• Presence of comorbidities such as diabetes, cardiovascular disease, or chronic gastrointestinal disorders

Prevention

Lifestyle Modifications

Preventive strategies aim to reduce the risk of recurrent sternal pain by addressing modifiable factors:

• Maintaining a heart-healthy lifestyle with balanced diet and regular exercise
• Avoiding activities that place excessive strain on the chest muscles
• Limiting alcohol and smoking to reduce risk of cardiac and gastrointestinal disorders

Physical Therapy and Exercise

Structured exercise programs can strengthen the chest wall and improve posture, reducing the risk of musculoskeletal pain:

• Core and upper body strengthening exercises
• Stretching to maintain flexibility of pectoral and intercostal muscles
• Ergonomic adjustments during work or sports activities

Early Recognition and Management of Risk Factors

Prompt identification of underlying conditions can prevent complications and recurrence:

• Regular cardiovascular and gastrointestinal check-ups
• Monitoring for early signs of trauma or infection
• Timely treatment of cardiac, musculoskeletal, or gastrointestinal disorders

References

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