chest pain

[Pain_doc]

A patient for the group... 44yo F with a couple year history of right> left anterior chest pains along the lateral sternal border. She is allergic to NSAIDs. She wound up undergoing a breast reduction surgery to see if that would help. It did not. I performed some costochondral/sternocostal injections with steroid that were really quite helpful for a month or so. But then pains returned. Topicals and various oral medications (duloxetine, pregabalin, etc) have been tried in the past and either no help or not tolerated.

Any ideas for longer term relief. Thanks

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[RoloTomassi]

Joint injection where steroid if helpful but not durable --> PRP. That's my algorithm typically. Bit of a stretch here but might be an option.

 

[willabeast]

Assume working diagnosis is Costochondritis? Got the following from UpToDate. //
A variety of diagnostic terms have been used in this group of patients, including costochondritis, costosternal syndrome, and anterior chest wall syndrome. The diagnosis is based solely upon the ability to reproduce pain by palpation of tender areas. In some studies, certain maneuvers, such as the "crowing rooster" and horizontal arm flexion maneuvers, have also been found to be useful. A study involving 1212 patients, done in an outpatient primary care setting, showed that the presence of at least two of four specific features (localized muscle tension, stinging pain, pain reproducible by palpation, and absence of cough) was associated with a diagnosis of chest wall syndrome, with 63 percent sensitivity and 79 percent specificity [17]. (See "Clinical evaluation of musculoskeletal chest pain", section on 'Physical examination'.)

Although the costosternal syndrome is a frequent diagnosis in patients with noncardiac chest pain, the causes, natural history, and treatment of this condition are poorly documented. Most prospective studies suggest that about half of these patients will continue to have chest pain for 6 to 12 months, with moderate limitation of activities in most [26].//
My thoughts.
#1. Get documentation in writing that this is not cardiac in origin from primary care. Obtain a ESR as a screen.
#2. See if turmeric helps (give it 3 weeks before you give up).
#3. Don't refer to a surgeon.
#4. Mention pneumothorax when discussing risks.
#5. PT referral. IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES - PubMed

 

[willabeast]

IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES - PubMed

Level IV.

pubmed.ncbi.nlm.nih.gov

 

[bedrock]

A patient for the group... 44yo F with a couple year history of right> left anterior chest pains along the lateral sternal border. She is allergic to NSAIDs. She wound up undergoing a breast reduction surgery to see if that would help. It did not. I performed some costochondral/sternocostal injections with steroid that were really quite helpful for a month or so. But then pains returned. Topicals and various oral medications (duloxetine, pregabalin, etc) have been tried in the past and either no help or not tolerated.

Any ideas for longer term relief. Thanks

If steroid really helped but only for a month, then I’d recommend Costo sterno injections with PRP.

 

[oneforfighting]

PT. OMM.

 

[kstarm]

Sometimes this is pec related. You could have her see PT if your exam helps support the pectoralis contributing.

 

[Pain_doc]

Thanks. She has had a complete cardiac workup which was negative. She's been through PT several times and its never helped -- though I don't know what was actually done. That may be worth considering. I put her on turmeric 6 weeks ago. She follows up next week. I'll give her the option of PRP. As long as this has been going on, she may consider it.

 

[lobelsteve]

Happily pass. I have enough difficult cases. Save my time and energy for cervical scs s/p ACDF and laminoplasty.

 

[Ligament]

Try intercostal n. blocks if PLATELET RICH PLASMA does not help.