Medical Mystery: Intense chest pain, but not from a heart attack

Ronnie is 47 years old, very active, and exercises daily. He runs six miles four times a week, during which he has occasionally noticed mild chest pain. Recently, he experienced much more intense pain than normal on his run, prompting a visit to the ER.

He was evaluated immediately, and the full protocol for a possible heart attack was performed, which included blood work to check for elevated cardiac enzymes, an EKG to check his heart rate and electrical patterns, chest X-rays, and a CAT scan.

All tests were normal. His pain was not found to be caused by a cardiac event, such as a heart attack. He was referred to a cardiologist for further studies.

In the interim, his ER doctor mentioned his symptoms to me, a pain specialist, because Ronnie had the most pain in a specific area on one side of his chest, which was not typical of a heart attack.

I examined him and found that the pain was localized to the cartilage overlying the lower ribs (5, 6, 7 and 8) on his left side. There was minimal redness, but noticeable swelling in the area where ribs attach to the chest wall, known as the costochondral junction.

What was causing his chest pain?

Heart attacks are not normally isolated to one side, as this pain was. I had another idea so I ordered an MRI, which confirmed my theory.

I determined that our patient, Ronnie, had a condition called Tietze syndrome (also known as Chondropathia Tuberosa or costochondral junction syndrome). This occurs when the cartilage that connects a rib to the breastbone is inflamed. The swelling can be difficult to appreciate on X-rays and CAT scans, but may show up on MRIs.

Tietze syndrome can be caused by repeated pressure on the ribs in question. The back and forth swinging of his arms during his weekly runs caused the pain. Deep breathing, as would occur while jogging, can exacerbate it, as can coughing, or the pressure of a seat belt.

More typically, it affects the upper ribs (1, 2 or 3), and is first noted in patients in their 20s or 30s. It is usually diagnosed in people under 40. Men and women are equally susceptible, and those with psoriatic arthritis have an increased predisposition.

The pain may come on suddenly, or gradually, as in Ronnie’s case, although his pain was mild at first. Sometimes the pain may spread to the arms and shoulders, leading people to confuse this pain with that of a heart attack.

In addition to mimicking a heart attack, similar symptoms are seen with fibromyalgia, pneumonia, spinal root lesions, and rarely, with some forms of cancer.

Treatment includes rest, warm compresses, and anti-inflammatory medications, such as Motrin. Some patients require local lidocaine or steroid injections. Most cases resolve within 12 weeks, but the swelling may persist. It is rarely a chronically painful condition.

After three weeks of rest and Motrin, Ronnie resumed his runs, pain free.

Alfred Mauro is director emeritus of Jersey City Medical Center Anesthesia and Pain Management. He can be reached at almauro@comcast.net.