By Bernard M. Abrams, M.D.
Clinical Professor of Neurology, University of Missouri at Kansas City, School of Medicine; Director, Midwest Neurological Institute Menorah Medical Center, Kansas City, Missouri
In the evaluation and treatment of common pain syndromes of the chest wall, flank, abdomen and groin it must be remembered that pain may arise from the skin, subcutaneous tissues, muscles, musculoskeletal attachments, bones, viscera, nerve roots, nerves and other structures. It is tempting to say that most chest wall pain is of primarily musculoskeletal origin, and dismiss the fact that by far the most common cause of chest pain is pain referred from the ischemic myocardium, from esophageal and stomach mucosal disorders, from the biliary tree and pancreas, and from the lung. The history should disclose whether or not chest pain is caused by visceral organs with its interrelationship with exertion, food intake, shock, respiratory problems, digestive problems or on a background of malignancy or trauma.
The differential diagnosis is well delineated (1,2) and runs the entire gamut of human misery. Some causes such as post mastectomy or post thoracotomy pain syndrome are obvious because of their setting. Others such as epidural spinal cord compression are suggested by physical findings or history of metastatic disease. Their treatment obviously rests with the primary specialist.
Pains of neuropathic origin include thoracic myelopathy, lesions of the roots or rootlets at the thoracic spinal level, lesions of the intercostal nerves, and the entity of intercostal neuralgia and notalgia paresthetica should be noted. Obviously diabetic thoraco- abdominal neuropathy is always a consideration. Post herpetic neuralgia needs to be treated by early and aggressive sympathetic blockade.
Pains of primarily musculoskeletal origin include lesions of bone, myofascial pain syndromes, and other rarer and more difficult to pin down syndromes.
Amongst these are rib trauma without fracture, the slipping rib syndrome, Tietze’s syndrome, a nonspecific benign self-limiting nonsuppurative painful swelling of the costal cartilages most often in the second and occasionally the third. This is often confused with costochondritis; another clinical syndrome associated with pain and tenderness of the costochondral junctions that occur much more frequently than Tietze’s. Tumors of the costal cartilages, costochondral dislocations, trauma and arthritis of the sternoclavicular joint as well as manubriosternal arthritis, trauma to the sternum should be considered. There is a syndrome characterized by spontaneous pain in the anterior chest associated with distinct discomfort of the xiphoid process known as xiphoidalgia.
Myofascial pain syndromes with trigger points are common in the anterior and posterior chest wall. In the anterior chest the pectoralis major, pectoralis minor, scalenus muscles, sternal head of the sternocleidomastoid and subclavius are frequently involved. In the upper thoracic back the levator scapula syndrome sometimes, as the scapulocostal syndrome is a common entity.
In the mid thoracic back syndromes of the latissimus dorsi, rhomboids, serratus posterior and trapezius and serratus anterior are seen. In the low thoracic back serratus posterior inferior and the iliocostal muscles are sometimes noted. Some of the entities noted are over lapping.
Rarer entities include the precordial catch syndrome and the debatable precordial migraine.
It should not be forgotten that disorders of the diaphragm cause pain referred to the shoulder blades.
Chest pain may be caused by extrathoracic diseases, including diseases of the cervical spine and shoulder, by abdominal diseases including gas entrapment syndromes, disorders of the GI tract, disease of the biliary tract and pancreas, and other abdominal visceral disease. Amongst the diseases of the diaphragm, acute primary diaphragmatis, subphrenic abscess or diaphragmatic flutter may occur.
Chest pain primarily of psychogenic origin since it is the “seat of the heart” is not uncommon. These include abnormal emotional reactions to visceral disease, anxiety syndrome, depression, conversion reaction, hypochondriasis, and panic disorder.
Diseases of the abdomen obviously run the entire gamut of intra- abdominal catastrophes. These include in the right hypochondrium biliary colic, acute cholecystitis, pancreatitis, and appendicitis as well as pain related to disorders of the liver. Also costochondritis of the lower right anterior chest and costal margin (2) or pleuroabdominal pain due to pneumonia or pulmonary infarction. Disorders of the right kidney including acute pyelonephritis or abscess may also be referred there. There are also cases of herpes zoster.
Reference 2 gives an indication of the common and uncommon illnesses related to the abdomen. Acute epigastric pain may be caused by perforation of the peptic ulcer or duodenal ulcer as well as benign or malignant liver tumors, acute pancreatitis, gallbladder disease, acute appendicitis, acute myocardial infarction and intestinal obstruction. Pain in the left hypochondrium includes disorders of the spleen, peptic ulcer disease, acute gastric dilatation, acute pancreatitis, subphrenic abscess or disorders of the colon. In addition, pleuritis secondary to left lower lobe pneumonia, and costochondritis are major contributors.
Rarer causes of abdominal pain include diabetic thoracoabdominal neuropathy, abdominal cutaneous entrapment neuropathy, including “intercostal neuralgia” or “notalgia paresthetical. Porphyria or lead colic should always be considered. In addition especially in patients on anticoagulants trauma with hemorrhage in the anterior abdominal wall or to the psoas should be considered. Major causes of abdominal pain are well laid out in Reference 1.
It should be remembered that abdominal pain primarily of psychologic origin includes the irritable bowel syndrome, anxiety states, depression and hypochondriasis. Complete physical examination must be carried out.
Abdominal migraine is a rare cause of abdominal pain, as is sickle cell anemia, acute or chronic hemolytic crisis and anemia and acute intermittent porphyria. Extra-abdominal diseases may be referred to the abdominal viscera from the thoracic and pelvic viscera including acute myocardial infarction, acute pericarditis, pulmonary embolism, pneumonia, upper respiratory infections, esophageal diseases, and gynecological disorders.
Pain of neuropathic origin has been covered under the chest in that most thoracic processes of the thoracic porion of the spinal cord and of the thoracic spinal nerve roots or peripheral nerves produce similar pain syndromes in the chest and abdomen.
The groin is an area particularly rich in overlapping sensory nerve supply giving one a better opportunity to delineate syndromes of the nerves. This includes the ilioinguinal entrapment neuropathy, the iliohypogastric and genitofemoral entrapment neuropathies and the lateral femoral cutaneous nerve of the thigh entrapment neuropathies. obviously these areas do not escape herpes zoster or diabetic thoracoabdominal neuropathy. Pelvic pain (1) may result from gynecological disease or dysfunction, acutely recurrent pelvic pain may also be a result of gynecological problems. Disorders of the vulva and vagina, pelvic and perineal pain of urologic disorder including diseases of the urinary bladder, urethra, prostate and seminal vesicles and acute epididymitis should be considered.
Musculoskeletal disorders of the pelvis include trauma including sprains and fractures, coccydynia and infectious disorders including osteomyelitis of septic arthritis.
Neoplastic bone disease including metastatic disease should be considered.
Myofascial syndromes include muscle spasm, spasms of the internal rectal sphincter, post traumatic syndrome, post episiotomy pain and post laminectomy muscle spasm.
Amongst the myofascial pain syndromes are the rectus abdominis syndrome, the lower abdominal muscle syndrome and trigger points in the glutei and piriformis.
Pains of neuropathic origin include lesions of the conus medullaris (disc or tumor), multiple sclerosis, and extramedullary intrathecal lesions including primary or metastatic neoplasm, abscess or hemorrhage and compression of the conus medullaris. Following surgery arachnoiditis of the lower cauda equina may result.
Rare entities include phantom pelvic visceral pains such as following cystectomy or spinal cord injury, phantom anus pain syndrome following abdominal perineal resection and proctalgia fugax.
Referred pelvic pain may come from abdominal diseases including appendicitis, pyelitis, spasm of the lower bowel, or passage of a stone through the lower urethra. Referred perineal pain may come from diseases of the rectosigmoid. Diseases of the prostate and seminal vesicles or urinary bladder as well as the uterus and adnexa may also present pain.
Pelvic and perineal pain may arise from psychologic origin and may present as gynecologic, pelvic, rectal or perineal pain or orchiodynia.
In summary, chest wall, abdominal flank and groin pain encompass nearly every etiological category in medicine, every site of tissue pain production known to produce pain in other portions of the body, plus the presence of abdominal viscera and a propensity for referred pain from other body areas. The treatment depends upon the diagnosis and the diagnosis depends upon a meticulous history, physical examination and ancillary studies limited only by the setting of the patient and the astuteness and scholarship of the examiner.
1. Bonica, John J. The Management of Pain. Second edition La &
Fibiger. Philadelphia, London, 1990.
2. Wiener, Stanley L. Differential diagnosis of acute pain by
body region. McGraw-Hill. New York, N.Y., 1993