Chest Pain: Is It Muscles?

Though chest pain can be very serious, most of the time it's not. One of the most common cause of chest pain is related to the musculoskeletal system.

Generally, chest pain involving the muscles, ligaments, bones & joints is usually localized to a specific area. It is also reproducible by applying pressure on the pain area. The pain is usually sharp and aggravated by moving the affected area such as when moving the body/arm or taking a deep breath (chest wall moves up and out).

There are a few reasons for musculoskeletal chest pain:

- muscle strain or ligament sprain : after strenuous exercise or work (carry heavy things etc), trauma, after heavy coughing, even after one night of improper sleeping posture etc.

- bone: fracture (obvious severe trauma), cancer (rare)

- ribs cartilages or joints (costochondritis): trauma, infection, unknown cause

Chest pain with musculoskeletal origin is usually harmless and will resolve by itself in a few days. Some pain-killer and anti-inflammatory medicine may help to relieve the pain.

Click here for clues on how to differentiate chest pain.

Chest Pain: How To Differentiate?

When we have chest pain, almost all of us will ask: Am I having a heart attack?

Of course there are lots of causes for chest pain. The pain around the chest can originate from any organs or structures beneath the chest wall such as:

- heart/aorta

- lungs/trachea

- esophagus/stomach

- muscle/bone/ligament/skin

- gallbladder/pancreas/liver

There are many types of chest pain, such as dull, sharp, tight, stabbing, pressing, burning etc. It is not easy to determine the cause of chest pain in most circumstances. However, doctors will ensure that the chest pain is at least not the type which is life-threatening and require immediate medical attention, such as heart attack, pneumothorax, aortic dissection, pulmonary embolism, acute pancreatitis etc.

When assessing chest pain, there are a few information which are important:

Location of chest pain:

- center of chest: heart, trachea, esophagus, musculoskeletal
- left or right of chest: lungs, musculoskeletal
- lower chest: stomach, gallbladder, pancreas, liver

The location of pain alone is not the only criteria to diagnose a chest pain. The pain of heart attack although commonly occurs in the center, but it may also be felt at the side of chest wall or the epigastric area (lower chest/upper abdomen).

Distribution of chest pain:

- radiate to the left chest/left arm/jaw: heart (angina, heart attack)
- radiate to the back: aorta (dissection), pancreas
- radiate to right shoulder: gallbladder

      Typical angina pain distribution

Nature of the pain:

- tight, gripping, pressing: heart (angina, heart attack)
- sharp, stabbing: lungs (pneumothrax, pulmonary embolism), aorta (dissection), musculoskeletal
- colicky: gallbladder (stone)
- burning: stomach (ulcer, gastritis), esophagus (reflux)

Onset of pain:

- sudden: heart (angina, heart attack), aorta (dissection), lungs (pneumothorax, pulmonary embolism), musculoskeletal
- gradual: any other causes

Duration of pain:

- comes and goes and infrequent and well in between: usually not so serious condition (musculoskeletal, gallstone, gastritis etc)
- continuous but mild: may indicate more serious condition (pneumonia, cancer etc)
- continuous and severe or worsening: may indicate more serious conditions that require medical attention immediately (heart attack, pneumothorax, pulmonary embolism, perforated gastric ulcer)

Pain aggravation:

- aggravated during inspiration: lungs (pleural), heart (pericardium), muscoloskeletal

- aggravated by food: stomach, gallbladder, esophagus

- aggravated by moving the arms: musculoskeletal

- aggravated by cough: lungs (pleural), heart (pericardium), muscoloskeletal

- aggravated by laying flat (supine): pericardium, pancreas

- aggravated by pressing: musculoskeletal, pleural

Severity of pain:

- Severity of pain is very subjective and varies from each individual. Generally the more severe the pain, the more serious the condition, such as in heart attack, aortic dissection, perforated gastric ulcer etc. However, some gastritis, gallstone, musculoskeletal pain may give rise to severe pain, even though they are not life-threatening.

Associated signs & symptoms:

This may be the most important information in determining the cause of chest pain.

- cough: lungs (infection, pneumothorax, cancer, embolism)

- shortness of breath: lungs (any cause), heart (heart attack)

- fever: infection, inflammation

- indigestion: stomach, esophagus, gallbladder

- nausea/vomiting: stomach, esophagus, heart (heart attack)

- palpitation: heart, lungs (pulmonary embolism)

The information above is not intended for self-diagnosing of chest pain. Please seek medical attention if you have a chest pain.

Chest Pain: Is It Lungs Problem?

Chest Pain: Is It Lungs?

Chest pain arising from lungs/respiratory tract usually will be accompanied by symptoms such as shortness of breath & cough.

Lungs infection (pneumonia/lung abscess)

In the case of lung infection, chest pain is usually not the main complaint. Initially fever and cough are the likely problems. When the infection gets worse, shortness of breath may occur as more lung volume is involved.

       Pneumonia: common lungs pathology but chest pain not common

Pneumothorax

This is a condition where air gets into the pleural cavity (space between the outer lungs and inner chest wall), causing the lung to collapse. This can occur during trauma/injury to the chest or spontaneously. 

In pneumothorax, shortness of breath is usually the first and most prominent symptom. In trauma case, of course the sufferer will have obvious chest injury and pain. In spontaneous case (without trauma), chest pain may be felt which may be worse when breathing in.

Pneumothorax is potentially fatal and sufferer should get immediate medical attention.

Pleuritis

Pleuritis is inflammation of the pleural which line the lungs and inner chest wall. Typically the pain is felt more when taking a deep breath in, as the pleural rub against the chest wall more during a deep breath.

       Pathology involving pleural will cause pleuritic pain (pain aggravated by breathing)

Lung cancer

Depends on the size and site of the cancer, lung cancer can give rise to chest pain but not very common. Other associated symptoms are cough, cough out blood, shortness of breath, loss of weight/appetite.

Pulmonary embolism

Pulmonary embolism occurs when a blood clot from the veins of lower part of body travel to the lungs and block the blood supply to a portion of the lung. This can cause sudden sharp chest pain, accompanied by shortness of breath. If the clot is large, it is potentially life-threatening.

Asthma

Obviously in asthma, sufferer will have shortness of breath and wheezing, and they may feel tightness in the chest as well.

Click here for clues on how to differentiate chest pain.

Chest Pain: Is It Heart Problem?

Chest Pain: Is It Heart?

Angina - precursor to "heart attack"

Angina is caused by narrowing of the coronary artery (which supply blood to heart muscle) which leads to temporary lack of blood/oxygen supply to the heart muscle when the demand for oxygen increases (during exertion). Thus, it is a condition of increased demand but limited supply of blood/oxygen.

     Narrowing of coronary artery causing angina

Typical angina is described as "pressing", "gripping", "tight" chest pain located at the center of chest which may radiate to the neck/jaw/left upper arm. This pain usually comes on exertion (physically or emotionally) and disappears during rest, and usually last <5min. This is referred as "stable angina".

If this is the first time you encounter this type of pain, you should see a doctor to have further evaluation on the pain. Doctor will usually arrange an appointment for exercise stress test / CT angiogram / percutaneous angiogram depends on your risk factors & preference.

If you are already known to have coronary heart disease, you can take the medicine under the tongue (nitroglycerin). If the pain is not relieved by the medicine, or last longer, or is more severe or more frequent than it used to be, you should go to hospital immediately for treatment as this may indicate more advance artery occlusion. This is referred as "unstable angina".

Myocardial infarction - true heart attack

Heart attack means that the already-narrowed coronary artery is suddenly blocked 100% (usually by a clot) causing heart muscle to die. In this case, more & more heart muscles are dying every second and that's why time is very crucial. The faster the sufferer gets treatment to open up the blockage, the higher the chance of survival and the better the outcome.

     Total occlusion of coronary artery causing heart attack

The nature of chest pain of heart attack is similar to angina but it is usually more severe and is commonly associated with other symptoms such as sweating, shortness of breath, dizziness, fainting, nausea etc. It can occur during exertion or even suddenly at rest (eg during sleep). However, sometimes the pain can be atypical and some elderly or diabetic patients may not feel the pain at all.

If you suspect yourself to have heart attack, please get someone else to drive you to nearest hospital as soon as possible, as every seconds count.

Aortic dissection

Another rare but important cause of chest pain is aortic dissection. It is important as it is life-threatening. In aortic dissection, the wall of aorta (which transport blood out of the heart to other body parts) is torn or seperated. Thus, it is usually described as severe "sharp" & "tearing" chest pain which may radiate to the back.

     Tearing of aortic wall

If the chest pain you experience is not the same as described above, it doesn't mean that it is not originating from the heart. When you are in doubt, always seek for medical attention.

There are other causes of chest pain related to the heart, such as infection or inflammation of the 3 layers of heart wall - endocarditis, myocarditis & pericarditis.

Click here for clues on how to differentiate chest pain.