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7—SALESPERSON WITH SEVERE KNIFELIKE PAIN AND A CLICKING SENSATION IN THE RIBS
Fig. 7.7 Ultrasound-guided injection for slipping rib syndrome.
Neuropathic pain involving the chest wall also may be confused or coexist
with slipping rib syndrome. Examples of such neuropathic pain include diabetic
polyneuropathies and acute herpes zoster involving the thoracic nerves. The
possibility of diseases of the structures of the mediastinum is ever present, and
these diseases sometimes can be difficult to diagnose. Pathologic processes that
inflame the pleura, such as pulmonary embolus, infection, and tumor, also
should be considered.
TREATMENT
Initial treatment of the pain and functional disability associated with slipping
rib syndrome should include a combination of nonsteroidal antiinflammatory
drugs or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may be beneficial. The repetitive movements that incite
the syndrome should be avoided. For patients who do not respond to these
treatment modalities, injection of the affected costochondral cartilages with a
local anesthetic and steroid may be a reasonable next step (see
servative measures are ineffective, excision of the offending cartilage may be
required (Fig. 7.8).
Fig. 7.7). If con-
7—SALESPERSON WITH SEVERE KNIFELIKE PAIN AND A CLICKING SENSATION IN THE RIBS
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Fig. 7.8 Left-sided slipping rib excision. A small incision can be made and tissues mobilized to remove
the slipping cartilage and rib. (From McMahon LE. Slipping rib syndrome: a review of evaluation, diagnosis
and treatment. Sem Pediatr Surg. 2018;27(3):183188. ISSN 1055-8586, https://doi.org/10.1053/j.
sempedsurg.2018.05.009, http://www.sciencedirect.com/science/article/pii/S1055858618300349.)
HIGH-YIELD TAKEAWAYS
• The patient’s symptomatology began after a seatbelt injury.
• The patient’s pain is localized to the costochondral junction of the eighth, ninth,
and tenth ribs.
• The patient has a positive hooking maneuver test, which is highly suggestive of
slipping rib syndrome.
(Continued)
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7—SALESPERSON WITH SEVERE KNIFELIKE PAIN AND A CLICKING SENSATION IN THE RIBS
• The patient is afebrile, making an acute infectious etiology (e.g., urosepsis)
unlikely.
• The patient’s urinalysis is normal, which makes nephrolithiasis unlikely.
Suggested Readings
Fares MY, Dimassi Z, Baydoun H, et al. Slipping rib syndrome: solving the mystery of
the shooting pain. Am J Med Sci . 2019;357(2):168173.
Hansen AJ, Toker A, Hayanga J, et al. Minimally invasive repair of adult slipped rib
syndrome without costal cartilage excision. Ann Thorac Surg. 2020;110(3):10301035.
McMahon LE. Slipping rib syndrome: a review of evaluation, diagnosis and treatment.
Sem Pediatr Surg. 2018;27(3):183188.
Turcios NL. Slipping rib syndrome: an elusive diagnosis. Paediatr Resp Rev.
2017;22:4446.
van Delft EAK, van Pul KM, Bloemers FW. The slipping rib syndrome: a case report.
Int J Surg Case Rep. 2016;23:2324.
Waldman SD. Slipping rib syndrome. In: Waldman’s Comprehensive Atlas of Diagnostic
Ultrasound of Painful Conditions. ed. 2. Philadelphia: Wolters Kluwer; 2016:561565.
Waldman SD. Ultrasound-guided injection technique for slipping rib syndrome.
In: Waldman’s Comprehensive Atlas of Ultrasound-Guided Pain Management Injection
Techniques. ed. 2. Philadelphia: Wolters Kluwer; 2020:676684.
CHAPTER
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Amy Cleaves
A 30-Year-Old Female With
Shooting Chest Pain
LEARNING OBJECTIVES
• Learn the common causes of chest pain.
• Develop an understanding of the etiology of precordial catch syndrome.
• Learn the clinical presentation of precordi al catch syndrome.
• Learn how to use physical examination to rule out pathology and other chest
pain syndromes that may mimic precordial catch syndrome.
• Develop an understanding of the treatment options for precordial catch
syndrome.
• Learn the appropriate testing options to help diagnose precordial catch
syndrome.
• Learn to identify red flags in patients who present with chest pain.
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Amy Cleaves
Amy Cleaves is a 30-year -old Web
designer with the chief complaint of,
“I think I am having a heart attack!”
Amy started to speak again, and
broke out in tears. “Doctor, I am
really scared! Who will take care of
my kids? How did this happen?
What am I going to do?” I did what I
could to calm Amy and promised her
that together, we would figure this
out. I asked Amy to describe her symptoms. Amy said, “Out of nowhere, I get
this sharp pain on the left side of my breastbone just over my heart. It really
hurts! It’s there and it goes away as quickly as it comes. It really scares me each
time it happens!” I asked, “So, Amy, what does the pain feel like, an ache, a stab,
an electric shock?” She said, “Doctor, the pain is like a sharp jab that goes right
into my heart. One second I am fine, and the next second it hits, it lasts for a second or two, and then it is gone.”“Amy, does it hurt between attacks?” She shook
her head and said maybe just a little, but she wondered if that pain was more
from her rubbing the painful spot and making it sore rather than coming from
her heart. “Amy, what are you doing when the pain comes on?”“That’s the
crazy thing, I can be sitting with the kids watching Sesame Street and it hits. The
kids can tell it’s happening. I try to hide it, but it just hurts so bad.” At that, Amy
started crying again. I again tried to calm her down and then asked if the pain
went anywhere, like down her arm, into her jaw, or somewhere else, and she
shook her head no. I continued, “Any sweating, palpations, fever, chills, shortness of breath, cough, leg pain, anything else I need to know about?” Amy
responded, “Not really, Doctor, but I read on the Internet that heart attacks in
women are different than heart attacks in men.”“That’s true,” I said, “and we
need to take this very seriously. The first step is to check out your heart and then
figure out what the exact cause of this pain is.”
I asked Amy to rate her chest pain on a 1 to 10 scale, with 10 being the worst
pain she had ever had, and she said, “This pain is a 20. Doc, this is worse than anything I have ever had. Worse than when my son Jimmie slammed my hand in the
car door, worse than having a baby. It’s killing me! I just can’t go on like this!”
I asked Amy if she had any fever or chills since her pain begin, and she shook
her head no. She admitted that she quit taking her birth control pills because of
the chest pain, as she had read on the Internet that birth control pills cause blood
clots. “But honestly, Doctor, with this chest pain, sex is out of the question. I
don’t want to have a heart attack and drop dead while I’m having sex with my
partner.”
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8—A 30-YEAR-OLD FEMALE WITH SHOOTING CHEST PAIN
I asked Amy if she ever had anything like this before, and she shook her head
no. I asked what she was doing to manage the pain, and she reported, “nothing
really works. ” She tried a heating pad, but it really didn’t seem to help. She went
on to say, “Doctor, I have nobody. I don’t know what will happen to my kids if I
have a heart attack. What can I do?” I reassured her that together, we would get
this sorted out, and I would do everything I could to get her better.
I asked Amy to point with one finger to show me where it hurt the most. She
pointed to an area to the left of her sternum. She said that she kept looking in the
mirror expecting to see something there. “Doc, you can’t see anything. There is
nothing there. It’s down deep inside. I am afraid it’s something really bad.” I
again reassured Amy that we would figure out what was going on and that I
would do everything I could to get her better. She gave me a weak smile and
said that she hoped so because she was really worn out with the whole thing.
“Amy, since this pain has been so hard on you, I have a couple of questions, and
I want you to really think before answering because the answers are very important.” She said, “Okay, Doctor, I will do my best.” I said that I knew she would. I
then asked her, “Amy, have you ever felt like life just isn’t worth living?” She
seemed shocked and then answered, “Doctor, if you are asking me if this pain
makes me want to kill myself, the answer is absolutely not. That is a sin, and
besides, I have everything to live for, my kids, my partner, my job. I love them
all. I would never even think about such a horrible thing. My kids come first,
before everyone and everything. They are such good kids.” I responded, “Okay,
that’s good, but I want you to know that you can tell me anything, no judgments,
no criticism. I’m always here to help.” She smiled and said that she really appreciated my concern, that she always knew that she could count on me. “So, next
question. Do you feel like you have an excess of worry or stress? You mentioned
that you have been really scared and worried about the pain.” Amy thought for
a moment and admitted that she had been pretty stressed out, but quickly went
on to say, “Doctor, I am not imagining this or making it up! The pain is not in my
head. It’s coming from my heart.” I reassured her, “Okay, Amy, that’s good to
know. One last question. Are you being hurt or abused, or have you been hurt or
abused in a past relationship or by a stranger or loved one?” Amy shook her
head no, and said, “Absolutely not. I have a wonderful partner who is loving
and would never hurt me. My kids’ father was a kind man, too. That relationship
just wasn’
t meant to be. He drifted out of my life when I got pregnant with our
youngest, and I have no idea where he is now. With my current partner, I feel
very blessed.” I again reassured her, “Amy, this is a place where you can always
talk. You can always come for help.” She nodded yes, and said she knew that.
She said she appreciated my concern and it meant so much to her. I felt pretty
good about that!
On physical examination, Amy was afebrile. Her respirations were 16. Her
pulse was 72 and regular. Her blood pressure was normal at 118/74. Her head,
8—A 30-YEAR-OLD FEMALE WITH SHOOTING CHEST PAIN
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eyes, ears, nose, throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination was completely negative. Specifically,
her lungs were clear, and there was no mitral valve click suggestive of mitral
valve prolapse or cardiac arrythm ia. She had mild tenderness over the left costosternal area, but there was no obvious mass, costochondritis, or swelling of the
joints suggestive of Tietze syndrome. There were no cutaneous lesions suggestive of herpes zoster or evidence of previous trauma. There was no evidence of
infection. Her breast examination was normal. Her abdominal examination
revealed no abnormal mass or organomegaly. There was no costovertebral angle
(CVA) tenderness. There was no peripheral edema or findings suggestive of
thrombophlebitis. Her low back examination was unremarkable. Her lower
extremity neurologic examination was completely normal.
I told Amy that I had good news. “I didn’t find anything bad on your examination. And more good news. There’s nothing to make me believe your pain is
from the heart, but we aren’t going to take any chances.” I had a good idea about
what was wrong and how to fix it. For the first time, Amy smiled and said,
“Thank you, Doctor. I know I can always count on you.”
Key Clinical Points—What’s Important and What’s Not
THE HISTORY
’
History of sharp, paroxysmal chest pain without a history of antecedent
trauma
’
Patient’s strong belief that she was having a heart attack
’
No classic signs of angina
’
Admits to increased anxiety related to the pain
’
Pain is localized to the left parasternal area
’
No fever or chills
’
Denies suicidal ideation
’
Denies domestic violence or abuse
THE PHYSICAL EXAMINATION
’
Patient is afebrile
’
Normal visual inspection of the chest wall
’
Normal cardiac examination
’
No mitral valve click on auscultation
’
No cardiac arrythmia noted
’
Normal pulmonary and abdominal exam
’
No evidence of thrombophlebitis
’
No evidence of Tietze syndrome
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’
No evidence of costochondritis
’
Normal breast examination
8—A 30-YEAR-OLD FEMALE WITH SHOOTING CHEST PAIN
OTHER FINDINGS OF NOTE
’
Normal blood pressure
’
Normal HEENT examination
’
No peripheral edema
’
No chest mass or evidence of infection
’
No CVA tenderness
What Tests Would You Like to Order?
The following tests were ordered:
’
Chest x-ray
’
Electrocardiogram (ECG)
’
Cardiac stress echocardiography test
TEST RESULTS
Chest x-ray is reported as normal.
ECG is completely within normal limits with no evidence of arrythmia or car-
diac ischemia.
The cardiac stress test is reported as normal with no evidence of left ventricu-
lar wall dysfunction or ischemia on ECG. The ejec tion fraction is reported
as 72%.
Clinical Correlation—Putting It All Together
What is the diagnosis?
’
Precordial catch syndrome
The Science Behind the Diagnosis
ANATOMY
The cartilage of the true ribs articulates with the sternum via the costosternal
joints (Fig. 8.1). The cartilage of the first rib articulates directly with the manubrium of the sternum and is a synarthrodial joint that allows a limited gliding
movement. The cartilage of the second through sixth ribs articulates with the
body of the sternum via true arthrodial joints. These joints are surrounded by a
thin articular capsule. The costosternal joints are strengthened by ligaments.
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Fig. 8.1 Anatomy of the anterior chest wall. (From Son MBF, Sundel RP. Musculoskeletal causes of
pediatric chest pain. Pediatr Clin N Am. 2010;57(6):13851395 [Fig. 1]. ISSN 0031-3955, https://doi.
org/10.1016/j.pcl.2010.09.011, http://www.sciencedirect.com/science/article/pii/S0031395510001586.)
Ribs 8, 9, and 10 attach to the costal cartilage of the rib directly above. The cartilages of ribs 11 and 12 are called floating ribs because they end in the abdominal
musculature (see Fig. 8.1). The muscles of the anterior chest wall may also serve
as a nidus of atypical chest pain (Fig. 8.2).
CLINICAL SYNDROME
Precordial catch syndrome, also known as Texidor twinge, is a common cause of
chest wall pain. Occurring most frequently in adolescents and young adults, precordial catch syndrome is the cause of anxiety among patients and clinicians
alike, given the intensity of the pain and its frequent attribution to the heart.
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Fig. 8.2 Muscles of the anterior chest wall. (From Son MBF, Sundel RP. Musculoskeletal causes of
pediatric chest pain. Pediatr Clin N Am. 2010;57(6):13851395 [Fig. 2]. ISSN 0031-3955, https://doi.
org/10.1016/j.pcl.2010.09.011, http://www.sciencedirect.com/science/article/pii/S0031395510001586.)
8—A 30-YEAR-OLD FEMALE WITH SHOOTING CHEST PAIN
Precordial catch syndrome almost always occurs at rest, often while the patient
is sitting in a slumped position on an old couch (
causes of chest wall pain, precordial catch syndrome is characterized by sharp,
stabbing, needlelike pain that is well localized in the precordial region
(Table 8.1). It often is perceived at the left sternal border, reinforcing the belief
that the pain is cardiac in origin. Symptoms begin without warning, only adding
to the patient’s anxiety, and they go away as suddenly as they came. The pain
lasts from 30 seconds to 3 minutes, and it is often made worse by deep inspiration. Patients suffering from precordial catch syndrome usually outgrow the
syndrome by the third decade of life.
SIGNS AND SYMPTOMS
No physical findings (e.g., flushing, pallor, diaphoresis) are associated with
the onset of pain, although some patients suffering from precordial catch
syndrome may demonstrate tenderness to palpation in the anterior intercostal
muscles overlying the painful area. Because the pain is made worse with deep
inspiration, the patient may become lightheaded from prolonged shallow
breathing.
Fig. 8.3). Distinct from other
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