Osteopathic Journals and Research by Darren Chandler


Chest pain in osteopathic practice

Posted on



  • The anatomy of chest pain
  • Conditions that can cause chest pain
  • How osteopathic manipulative treatment can help chest pain

The anatomy of chest pain

When patients experience chest pain it is an obvious cause of concern. This is why it should be thoroughly investigated by your doctor to exclude any potential illness before coming for osteopathic treatment.

Frequently patients experiencing chest pain come to our clinic having had all their tests come back as normal but are still experiencing acute and distressing symptoms.

Things are a bit more complex than they initially seem:

  • When a patient places their hand on their chest to indicate where the pain is they are in fact resting their hands on their ribs. Your ribs run all the way around from your spine to your chest. If you were to put your thumb on your spine and run it all the way around your body to your chest you would have followed the course of just one of your ribs.
  • You have twelve ribs on each side. They not only run around your body to your chest but also to the outside of your stomach.
  • Attached to these ribs are muscles that can attach to the back, the side and the front of the ribs and between the ribs. There are also muscles that wrap around the ribs.
  • Different nerves, including those that run between each rib and come down from the neck can give different types of referred pain to the chest.
  • Mechanically the ribs are associated with near enough every movement from breathing to bending, lifting and twisting!

Everyone of these factors come into play when assessing a patient with chest pain and why a thorough diagnosis is essential in weighing up all these factors.

Conditions that can cause chest pain

The following conditions are those that are highlighted as causing chest pain(1).

  • Inflammation of the cartilage that join your ribs to your breastbone (sternum). This can include two conditions Tietze syndrome and costochondritis. The symptoms include sharp chest pain and tenderness aggravated by physical activity or deep breathing as it stretches the inflamed rib cartilages. This type of chest pain or tightness on exertion commonly mimics the symptoms of a heart attack.
  • Chestwall syndrome: this is a generic term for all the conditions mentioned here(2).
  • Muscle pain: often when people get told their chest pain is musculature they think they must’ve done something to tear their muscle. Muscle pain can also include myofascial trigger points. These are special types of knots in muscles caused by overuse. How often are your arms in front of you during day and how often do you slouch? When we’re working at a computer, on a tablet, bent over a desk or worktop or sat slouched on the sofa our muscles in the chest (pectoral muscles) shorten. Over days weeks, months and years this constant shortening causes knots or myofascial trigger points to develop and cause pain. Read our previous blogs on how to prevent round shoulders and measure up your computer workstation.
  • Slipping rib: around the front the ribs attach to each other by fibrous bands. If they get overstretched or pulled they become too loose. This causes the ribs to slip out of place quite readily(3).
  • Cervical angina: the nerves to the neck goes to the chest. So when you trap a nerve in your neck it gives referred pain to your chest. The chest pain is associated with the normal symptoms you would associate with a trapped nerve in the neck such as neck pain/stiffness, headaches, shoulder and arm pain. Interestingly, and they don’t know why, up to 50%-60% of patients also experience difficulty breathing, vertigo, nausea, sweating, pallor, fatigue, double vision, and headaches(4)
  • Segmental dysfunction: just as injuries to the spinal joints in the neck can cause chest pain so can the spinal joints in between the shoulders (thoracic spinal joints)(5,6).  However some studies(7,8) questioned how prevalent thoracic spine problems are in referring pain to the chest.

In reality these conditions rarely exist in isolation and they commonly overlap. For instance tight muscles in the chest can cause inflammation in the rib cartilages and changes in posture that can put strain on the joints in the neck and spine. All these factors by themselves can cause chest pain so if you treat just one of them a patient’s symptoms will continue to persist.

Some studies(2) have raised the concern that although these syndromes are caused by fairly simple and non-life threatening conditions their effects can be quite profound. This study found, for patients, it produced a greater impairment in daily activities, emotional distress and gave higher level of anxiety than heart disease. Furthermore, despite reassurances, a substantial proportion of patients think that they have been misdiagnosed and in fact have heart disease.

How osteopathic manipulative treatment can help chest pain

Any patient with chest pain should be assessed by their doctor before seeking osteopathic manipulative treatment. Once any pathology and illness has been excluded the appropriate treatment can be administered both in terms of manipulative therapy to the pain causing structures and in offering lifestyle advice. We’ve blogged before about how to measure up your computer workstation, how to reduce round shoulders and breathing techniques and this along with specific exercises to address muscle imbalances can help with your symptoms and the anxiety it can produce.


(1) Chest pain in focal musculoskeletal disorders (2010). Stochkendahl MJChristensen HW.

(2) Chest wall syndrome among primary care patients: a cohort study (2007). François VerdonBernard BurnandLilli HerzigMichel JunodAlain PécoudBernard Favrat

(3) The slipping rib syndrome: A case report. (2016). van Delft EAvan Pul KMBloemers FW.

(4) Cervical Angina An Overlooked Source of Noncardiac Chest Pain (2015). Walter I. Sussman, Steven A. Makovitch, Shabbir Hussain I. Merchant, Jayant Phadke

(5) Costovertebral joint dysfunction: another misdiagnosed cause of atypical chest pain. (1992) Arroyo JFJolliet PJunod AF.

(6) Back, chest and abdominal pain - is it spinal referred pain? (2007). Harding GYelland M.

(7) Osteoarthritis of the costovertebral joints . The results of resection arthroplasty (2007). J. R. Sales, R. K. Beals, R. A. Hart

(8) Clinical Effectiveness of Ultrasound-guided Costotransverse Joint Injection in Thoracic Back Pain Patients (2016). Kyung Bong YoonShin Hyung KimSang Jun ParkJi Ae Moon, and Duck Mi Yoon 

Add a comment:

Leave a comment:


Add a comment