Sternum pain: main causes, diagnosis

Author Ольга Кияница


The pain behind the sternum are associated with various causes, and cardiovascular or pulmonary diseases are considered the most unsafe factors. With the help of modern methods of research it is possible, as a rule, to establish the correct diagnosis.

Sternum pain is a pressing, painful, extremely unpleasant sensation, localized in the center of the chest. The causes of this symptom can be very different. Some of them are considered minor (stress, indigestion), others are associated with the development of life-threatening diseases (myocardial infarction, rapidly progressive pneumonia, pulmonary embolism).

In studies it was noted that in the USA every year up to 3% of the population is referred to ambulance because of pain behind the sternum, whereas hospitalization on this basis is carried out in 20-30% of cases. [Sik EC, Batt ME, Heslop LM. Atypical Chest Pain in Athletes. Curr Spor Med Rep. 2009; 8 (2): 52-58.]

For the diagnosis of the disease, hiding under the pain behind the sternum, used a variety of studies. The first is performed electrocardiography, radiography of the chest, ultrasound of the internal organs. Also important are laboratory values ​​taken from general and biochemical blood tests. All such appointments allow for accurate diagnosis and appropriate therapy.

Video: Pain Below The Breastbone (Sternum) How to find out what hurts behind the sternum

Clinical anatomy

The sternum is a flat bone located in the center of the anterior part of the chest wall. It consists of three segments:

  • Handle (upper part).
  • Body (middle part).
  • Xiphoid process (lowest part).

The handle connects to the clavicle, the first ribs and the top of the second costal cartilage. The handle is quadrangular and located at the level of the 3rd and 4th thoracic vertebrae. The jugular notch is the most protruding part of the sternum grip, convex at the front and concave at the back.

The body of the sternum is longer and thinner than the grip. Its edges are connected to the lower part of the second costal cartilage, from the 3rd to the 6th costal cartilage and the upper part of the 7th costal cartilage.

The xiphoid process is the lowest and smallest part of the sternum. It articulates with the lower part of the 7th costal cartilage and provides a place for attachment of the abdominal cavity, transverse abdominal aponeurosis, transverse abdominal muscles and the abdominal diaphragm.

Together with the ribs and spine, the sternum forms the chest, which is the location of the lungs, heart and other anatomical structures. Additionally, the rib cage plays the role of protecting the internal organs. In some cases, it is their disease that can cause chest pain.

Causes of chest pain causes

There are many diseases of various organs and systems of the body that can provoke the appearance of pain behind the sternum.

Causes of the heart and blood vessels:

  • Heart valve disease.
  • Hypertrophic cardiomyopathy.
  • Cardiac ischemia.
  • Myocarditis: may be caused by infectious agents (eg, viral) and non-infectious (eg, heavy metals, cocaine). In 52% of cases occur in patients aged 20-39 years. Symptoms may include chest pain, shortness of breath, fatigue, and rapid heartbeat. Also, the patient may complain of a recent flu.
  • Pericarditis: may be caused by infection, sarcoidosis, rheumatoid arthritis and systemic lupus erythematosus.Symptoms are often presented in the form of pleural chest pain, which improves when leaning forward and worsens when lying down.
  • Aortic dissection.
  • Amyloidosis.

Causes of the respiratory system:

  • Asthma.
  • Bronchoconstriction.
  • Bronchitis.
  • Bronchiectasis.
  • Chronic obstructive pulmonary disease (COPD).
  • Tracheitis.
  • Tuberculosis.
  • Pulmonary embolism.
  • Pleurisy.
  • Pneumothorax.
  • Pulmonary hypertension.
  • Pulmonary sarcoidosis.
  • Respiratory infections of the lower respiratory tract (for example, bronchitis, influenza, pneumonia): At the same time, chest pain is caused by excessive use of the pectoral muscles during coughing or inflammation of the pleura. To return to intense physical activity with caution. To limit the risk of complications; the patient should not have a temperature, and any residual symptoms should not be determined in the region of the lungs and trachea.

Causes of the abdominal and gastrointestinal tract

  • Gastroesophageal reflux disease (GERD), which is often manifested by burning pain behind the sternum.
  • Pancreatitis - this condition causes pain in the upper abdomen and lower chest, sometimes painful sensations radiating to the sternum.
  • Peptic ulcers.
  • Surviving pain of the esophagus, which is often associated with cramps in the esophagus and can be caused by excessive anxiety or drinking very cold water.
  • Syndrome Bourhave is a rare condition associated with a rupture of the esophagus or caused by a sudden increase in intraluminal pressure. Such an increase in pressure may occur as a result of deep-sea rise. Severe inflammation associated with alcoholism is also associated with this syndrome. Symptoms include pleural chest pain and painful swallowing.

Causes of the musculoskeletal system:

Disease Description
Stress fractures of the sternum This type of fracture accounts for 0.5% of all sternum fractures and is believed to be caused by frequently repeated contractions of the muscles attached to this bone. Such injuries are most often recorded in weightlifters, golfers and military recruits committing “dips” on the triceps.
Fractures of clavicle These injuries account for 8-15% of all skeletal damage in children and 2-5% of all fractures in adults. In the latter case, more than 66% of the fractures occur in the region of the diaphysis of the clavicle, whereas in children up to 90% occur in the middle of the bone. Of all the clavicle fractures, about 25% are in the lateral part, and 2-3% in the third part of the medial part. The most common mechanism of injury is to fall on the arm when the arm is near the body, for example, during sports.
Rib stress fractures The ribs are prone to stress fractures less frequently than the bones in the lower limbs. Their occurrence is associated with prolonged fatigue caused by activities associated with the movement of the upper limb. This condition is commonly found in sports based on repetitive movements of the same type (for example, tennis, baseball, javelin throwing, basketball and weightlifting).
Subluxation of joints Defeat may occur during rowing, gymnastics, dancing and swimming. Usually leads to pain at the levels of the 6th and 7th ribs. Sterloclavicular and sternocostal subluxations are less common and may be associated with trauma or congenital hypermobility.
Costochondritis Inflammatory condition that affects the cystochondral connections or chondrosteral joints. In 90% of patients more than one area is affected, and the most commonly affected is from the second to the fifth rib. Most often people over 40 are affected. Clinical signs include localized pain during palpation, which can be transmitted to the chest wall. A recent illness associated with coughing, or performing strenuous exercise with the participation of the upper limb, can cause this type of inflammation. Such an injury is usually associated with movements of the same type in sports, including rowing and volleyball.
Tietze syndrome A rarely occurring inflammatory disease that affects one rib cartilage (usually the second or third). Suffer mainly under the age of 40 years. In this condition, localized pain and swelling are usually determined, but there is no local temperature increase or erythema. Pathology can be caused by an infection (especially against a background of chest trauma), neoplasms, or rheumatological conditions.
Inflammatory joint disease For example, the cause may be osteoarthritis, rheumatoid arthritis and psoriatic arthritis of the joints.
Fibromyalgia A rheumatologic condition that can cause persistent and widespread pain, radiating to the neck, back of the thigh and limbs.
Generalized myalgia It develops on the background of a chest injury or a recently initiated intense workout involving the upper body (for example, rowing). Myalgia can be bilateral and affect several adjacent cartilaginous areas.
Xyphodynia (or xyphoidalgia) A condition associated with the spread of pain in the chest, abdomen, throat, arms and head due to the stimulation of the xiphoid process. Blunt trauma of the chest, too active weightlifting and aerobics, as is known, lead to this disease.
Rupture of the pectoral muscle Most often occurs in male athletes aged 20 to 40 years. The most common activities associated with this injury are intense sports activities (for example, football, water skiing, wrestling) and weightlifting (especially on the bench).
Sliding Rib Syndrome A relatively rare pediatric disease in which hypermobility of the rib causes recurrent focal and unilateral pain in the chest. The hypermobile rib can migrate under the upper rib and can cause intercostal muscle tension, irritation of the intercostal nerve or stretching of the costal cartilage.
Post surgical condition Chronic pain syndrome after thoracotomy, which is determined in 30-60% of patients undergoing thoracotomy. It is reported that the frequency of post-neurotic pain is 35% within three months after surgery and about 20% with a three-year period (29% in patients older than 75 years). Sensory disturbances (for example, increased sensitivity to touch or pressure) may be more common, about 60-66%.
Osteomyelitis Infectious inflammation of the bone or bone marrow. Osteomyelitis of the sternum rarely occurs and can be caused by cardiac surgery, immunodeficiency, chest trauma (for example, compression during CPR), tuberculosis or lung abscess, although in some cases no obvious factor has been identified.

Video: What causes pain in the sternum?

Diagnostic procedures

  • Electrocardiography and, possibly, chest radiography is indicated for patients over 35 years old who have a history or risk of developing coronary artery disease. Stress testing of the heart may also be required to accurately determine or eliminate heart dysfunction.
  • A chest x-ray is necessarily prescribed to patients with fever, cough, chest edema, or other respiratory symptoms in history or on physical examination.
  • X-rays are used to identify fractures. Additionally, a computer or MRI scan of the affected bone is used (since X-rays give a negative result in 60% of all voltage fractures).
  • CT and MRI are prescribed for suspected bone injuries, especially if additional information is required.
  • CT scan should be performed if a neoplasm is suspected.
  • Nuclear scintigraphy (organ scan) may be positive with costochondritis, but the test is not specific to this condition.
  • A blood test for rheumatoid factor and C-reactive protein (CRP), which most often indicates a rheumatological condition.
  • MRI is considered the gold standard for osteomyelitis.
  • MRI and / or ultrasound may help assess the degree of muscle breakage.

It is important that after the diagnosis of acute cardiopulmonary disease is established, patients who were referred to hospital with atypical chest pain should be examined by appropriate specialists.

Criteria for evaluation

  • Cardiopulmonary observation - is to assess the general condition of the patient (eg, sweating, pale skin, redness, shortness of breath), respiratory rate, heart rate, blood pressure.
  • Preservation of chest pain for longer than 12 hours, as well as the presence of sensitivity to palpation of the anterior chest wall are important clinical indicators of a serious condition associated with musculoskeletal factors of development.
  • A history of vigorous activity associated with deep breathing (expansion of the chest), and frequent elevation of the upper limbs may indicate involvement in the pathological process of the musculoskeletal system.
  • If there is a fracture of the ribs or sternum, pain during inspiration is determined, as well as painful movements of the chest and upper limb, pain during palpation and / or weak tapping.
  • At the turn of tension, pain at the beginning may not have a localized location, but gradually becomes noticeable and more debilitating. A damaged bone can be felt above the injury site, especially if there is a permanent fracture of tension.
  • In cases of tuberculous osteomyelitis, bone abscess may be observed in addition to pain in the sternum and fever.
  • Examination may indicate true muscle weakness or neurogenic weakness. Changes in sensory tests and peripheral reflexes in addition to neurogenic weakness may indicate damage to the pectoral or lower cervical nerve root.
  • Questions regarding morning stiffness and other areas of pain or dysfunction, as well as general observation of the joints, may indicate a rheumatological factor.
  • Asymmetry, swelling and bruising (on the chest, in the armpit and on the arm) can be observed in the presence of serious muscle injuries, such as a large chest rupture.

Video: How to stop sternum pain - Popping sternum and Calisthenics Chest pain

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