INTRODUCTION — Isolated musculoskeletal chest pain has been attributed to a number of conditions (table 1). Their management usually involves a range of general measures, topical agents, analgesics, and antiinflammatories, which individually or together may be helpful for most patients with isolated musculoskeletal chest pain. Most musculoskeletal chest pain improves over the course of a few weeks or months. However, some patients require specialist referral for persistent symptoms.
There are few data that specifically address the efficacy and safety of therapeutic interventions for patients with isolated musculoskeletal chest pain. In general, the use of these interventions in treating musculoskeletal chest pain is based upon analogy with their usefulness in treating pain of similar origin elsewhere in the body (eg, neck and low back pain).
Musculoskeletal chest pain must be differentiated from chest pain due to potentially life-threatening disorders, such as myocardial ischemia or infarction, pulmonary embolism, aortic dissection, or pneumothorax, and from that due to systemic illnesses for which it may be one of multiple manifestations [1].
The management of isolated musculoskeletal chest pain will be discussed here. Causes of chest pain and the evaluation of chest pain in adults and children are discussed separately:
●(See "Major causes of musculoskeletal chest pain in adults".)
●(See "Outpatient evaluation of the adult with chest pain".)
●(See "Causes of nontraumatic chest pain in children and adolescents".)
●(See "Nontraumatic chest pain in children and adolescents: Approach and initial management".)
TYPES OF ISOLATED MUSCULOSKELETAL CHEST PAIN — There are several types of isolated musculoskeletal chest pain, a subset of the many local and systemic diseases and disorders that cause musculoskeletal chest pain (table 1 and table 2). However, localization of pain, in particular, is not helpful in differentiating musculoskeletal chest pain from chest pain due to other causes [2]. The range of conditions that cause musculoskeletal chest pain, including isolated musculoskeletal chest pain, are discussed in more detail separately. (See "Major causes of musculoskeletal chest pain in adults".)
Briefly, the conditions for which treatment is described here that cause isolated musculoskeletal chest pain include:
●Muscle strains, particularly of the intercostal muscles, which may cause musculoskeletal chest pain. Tenderness over the affected muscle is present and increases with stretching the involved muscle (eg, taking a deep breath).
●Costochondritis and costochondral junction syndrome (also termed Tietze syndrome or chondropathia tuberosa), which are both associated with tenderness of one or more of the costochondral joints. Although there is some controversy over whether these two disorders are truly distinct, in this discussion the term costochondral junction syndrome is used for the combination of pain, tenderness, and swelling, while costochondritis is used when swelling is absent.
●Posterior chest wall syndromes, which include costovertebral joint dysfunction and thoracic disc herniations and present as tenderness over the affected area or band-like chest pain with a dermatomal distribution.
●Lower rib pain syndromes, for which many different names have been used, including slipping or clicking rib syndrome, rib-tip syndrome, or twelfth rib. Pain can be diffuse or localized. Palpation of the costal margin characteristically reproduces the pain.
●Osteoarthritis of the sternoclavicular joint, which is uncommon but can cause focal pain of the sternoclavicular joint.
●Xiphoidalgia or xiphodynia, which is an uncommon syndrome with localized pain and tenderness over the xiphoid process.
●Spontaneous sternoclavicular subluxation, a condition that typically occurs in young to middle-aged women. It usually occurs on the dominant side and is associated with moderate to heavy repetitive tasks.
●Sternalis syndrome, which is a rare disorder characterized by localized tenderness over the body of the sternum; palpation of the tender area often causes radiation of pain bilaterally.
INITIAL MANAGEMENT — Initial management for most patients includes general nonpharmacologic interventions (see 'General measures for most patients' below) and the use of short-term analgesic medications (see 'Analgesia' below). Most isolated musculoskeletal pain improves over the course of a few weeks or months. Patients with symptoms lasting more than three months may also have a chronic widespread pain syndrome.
It is important to first confirm the suspicion of a musculoskeletal cause of the patient's chest pain, which must be differentiated from chest pain due to potentially life-threatening disorders, such as myocardial ischemia or infarction, pulmonary embolism, aortic dissection, or pneumothorax, and from chest pain due to systemic illnesses for which it may be one of multiple manifestations. The evaluation of chest pain is described in detail separately. (See "Outpatient evaluation of the adult with chest pain".)
General measures for most patients — A few general measures may be helpful for most patients with isolated musculoskeletal chest pain, including education, activity restriction or modification, and local application of heat and/or cold to the affected area. Although the efficacy and safety of these measures have not been specifically evaluated in patients with isolated musculoskeletal chest pain, they have been beneficial in treating musculoskeletal back and neck pain. (See 'Education' below and 'Activity restriction' below and 'Application of cold and heat' below.)
Education — All patients should receive education regarding the nature of their condition and the general management strategy. Several issues may be particularly helpful to review for patients with musculoskeletal chest pain. A common patient concern, stated or unstated, is that the pain is due to heart disease, and this concern must be addressed. Demonstration of the ability to reproduce or exacerbate the chest pain by palpation or with various maneuvers helps the patient understand the noncardiac nature of the problem. A careful explanation of the diagnosis and reassurance may be therapeutic for some patients. For them, watchful waiting without any other specific intervention may be appropriate.
A scheduled follow-up visit can also be reassuring and may be appropriately scheduled four to six weeks after the first clinical encounter [3]. A follow-up appointment with a primary care provider allows an opportunity for further discussion and may identify patients with persistent symptoms who require further evaluation or additional treatment.
Activity restriction — Any activity that causes or reliably exacerbates the pain should be reduced and/or stopped, at least temporarily, if possible. As examples, overload and overuse, as during weight training, lifting, or pushing heavy objects, may cause musculoskeletal chest pain. Activity modification is particularly important for patients with spontaneous sternoclavicular subluxation (see 'Spontaneous sternoclavicular joint subluxation' below). Anecdotal reports of benefit from activity restriction are widespread, although not assessed in the scientific literature.
Application of cold and heat — For isolated musculoskeletal chest pain, the application of cold or heat may be helpful. We usually prefer heat in patients with more muscle spasm and cold for patients experiencing localized swelling, and we advise trying the alternate modality if the first is not beneficial. This approach is based upon clinical experience and common practice, but this approach has not been established in randomized trials.
●Cold therapy – Cold may reduce swelling and discomfort [4]. Crushed ice (covered, not directly applied) can be compressed against the injured area for up to 20 minutes followed by an exposure to room temperature for one to two hours; this treatment may be repeated every 2 to 2.5 hours and continued for 48 hours.
●Heat therapy – Heat therapy increases blood flow and is thought to promote relaxation of tightened muscles. The usual recommendation is to avoid application of heat during the first 48 hours after an injury because of the potential to increase inflammation, although little formal evidence exists to support this approach. Heat is applied with either a heating pad, hot compress, or chemical heat pack for 20 minutes, several times daily. Single-use, disposable heating pads or patches that can provide a source of heat for up to eight hours are available without a prescription; they can be applied to any part of the body. Thus, if local heat (eg, a heating pad) helps for 20 minutes at home, such pads or patches may provide benefit in other settings, such as at work, for a number of hours as well. Care should be taken to avoid thermal injury from excessive temperature or prolonged exposure time.
Analgesia — In addition to the general nonpharmacologic measures, initial management usually includes analgesics. Although the efficacy and safely of the agents discussed below have not been specifically evaluated in patients with isolated musculoskeletal chest pain, they have been beneficial in treating musculoskeletal back and neck pain.
Mild pain — For patients with mild isolated musculoskeletal chest pain, defined as pain that does not interfere with light activity, we typically suggest acetaminophen or a nonsteroidal antiinflammatory drug (NSAID) in a low to moderate dose, rather than nonpharmacologic or topical measures alone. In addition, patients may also add a topical pain therapy.
Comorbidities, patient preferences, and response to therapy influence the choice of agent. Although use of an oral analgesic has the advantage of ease of use, some patients may have relative or absolute contraindications to such agents (eg, renal, gastrointestinal, or cardiovascular disease). In others, the combination of a systemic and local analgesic therapy together may be more effective.
●Acetaminophen – In patients with mild pain, we initially try acetaminophen, given its safety; the magnitude of the patient's response is evident within a few doses. Acetaminophen (up to 3 g daily in divided doses for adults) may provide adequate pain relief and is preferred for those who have a relative or absolute contraindication to the use of NSAIDs.
●Nonsteroidal antiinflammatory drugs – In patients without an adequate response to acetaminophen, we suggest an NSAID. We prefer naproxen (eg, naproxen sodium 220 mg, one to two pills twice daily), and if naproxen is inadequate, we use ibuprofen (eg, 200 mg, two to three tablets up to three to four times daily). These medications have the advantages of both being available without a prescription and that they may be more effective than acetaminophen, especially for patients with costochondral junction syndrome (Tietze syndrome), because of their antiinflammatory effect. We use the lowest dose for the shortest duration required.
●Topicals – Topical analgesic and antiinflammatory agents, applied as creams, gels, or patches, can be used for a trial period of up to two weeks to determine efficacy of a given agent, which should then be discontinued if it does not provide adequate relief of symptoms. The medication can be continued on an as-needed basis subsequently if it improves symptoms. Choice between agents is based upon patient preference and treatment response. These include:
•Capsaicin cream or salicylate-containing creams or gels, which may be employed, with application three to four times daily [5-7]. These agents are widely available without a prescription.
•Topical NSAID preparations (eg, 1% topical diclofenac gel or diclofenac patch), or ethyl chloride spray, which may also provide some relief and can be used up to several times daily.
•A lidocaine patch or topical lidocaine gel, to which local pain may also respond.
Moderate pain — For patients with moderate isolated musculoskeletal chest pain, defined as pain that interferes with light to moderate activity, we typically suggest prescription-strength oral NSAIDs. We use the same strategy as noted for mild pain but initiate treatment with higher doses of naproxen (375 to 500 mg twice daily) or ibuprofen (400 to 800 mg three to four times daily). If these are inadequate, we add acetaminophen (500 mg; one to two every three to four hours to a maximum, if needed, of up to 3000 mg daily). If a maximum acceptable dose of a particular NSAID does not relieve symptoms or efficacy wanes, anecdotal reports suggest that switching classes of NSAIDs may prove helpful (from an acetic acid to a propionic acid, for example) (table 3) [8].
NSAIDs should be avoided or used with particular caution in patients with increased risk of adverse effects due to comorbid renal, cardiovascular, or gastrointestinal disease (see "Nonselective NSAIDs: Overview of adverse effects" and "Overview of COX-2 selective NSAIDs", section on 'Toxicities and possible toxicities'). Patients should be cautioned about the potential gastrointestinal adverse effects of NSAIDs, including gastritis, peptic ulcer disease, and gastrointestinal bleeding. Those at high risk of NSAID-induced gastroduodenal damage may benefit from ulcer prophylaxis with a proton pump inhibitor or misoprostol. Risk factors and prevention strategies are discussed separately. Use of a selective cyclooxygenase 2 (COX-2) inhibitor may be an alternative for patients at high risk of gastrointestinal toxicity. (See "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity".)
Interference by some NSAIDs with the beneficial antiplatelet effects of aspirin may be a concern for those taking low doses of aspirin for prophylaxis or treatment of cardiovascular disease. (See "NSAIDs: Adverse cardiovascular effects".)
Severe pain — We define musculoskeletal chest pain as severe if it interferes with activities of daily living. Severe musculoskeletal chest pain usually occurs in the setting of trauma (eg, rib fracture). The evaluation and management of patients with chest wall trauma is discussed separately. (See "Initial evaluation and management of chest wall trauma in adults" and "Initial evaluation and management of rib fractures".)
Adjunctive exercise — Several particular conditions may benefit from specific interventions in addition to the measures described for initial management of most patients. (See 'Costochondritis' below and 'Spontaneous sternoclavicular joint subluxation' below.)
Costochondritis — Patients with musculoskeletal chest pain from costochondritis may improve with stretching exercises (table 4) in addition to activity restriction, ice or heat, and analgesics [9,10]. (See 'General measures for most patients' above and 'Analgesia' above.)
Spontaneous sternoclavicular joint subluxation — Patients with spontaneous subluxation of the sternoclavicular joint can be referred to physical therapy for shoulder/scapular strengthening exercises if symptoms persist after initial management with activity restriction, ice or heat, and analgesics. (See 'General measures for most patients' above and 'Analgesia' above.)
FOLLOW-UP — Patients should be seen by the treating clinician four to six weeks after the onset of pain to address patient concerns, assess effectiveness of initial therapy, and identify patients with persistent symptoms who may require treatment modification, further evaluation, or additional treatment.
MANAGEMENT OF PERSISTENT PAIN — In patients in whom isolated musculoskeletal chest pain persists beyond four to six weeks, or if symptoms are not adequately controlled with initial treatment measures, additional interventions or specialty referral may be warranted depending upon the cause of pain or expertise required for effective management. These interventions are typically provided by a pain management specialist, orthopedist, physical medicine and rehabilitation specialist (physiatrist), rheumatologist, or interventional radiologist, depending upon the specific intervention, local referral and practice patterns, and the expertise and interest of the potential consultant. In some cases, referral to other specialists with an interest in these conditions, including primary care clinicians, pulmonologists, and cardiologists, may be appropriate. (See 'Individualized interventions' below and 'Other therapies' below.)
Individualized interventions — For patients who do not respond to initial therapies or who have certain conditions, local injections or other interventional techniques may be necessary. (See 'Posterior chest wall syndromes' below and 'Sternoclavicular osteoarthritis' below and 'Costochondritis or costochondral junction (Tietze) syndrome' below and 'Xiphoidalgia' below.)
Posterior chest wall syndromes — Patients with pain from posterior chest wall syndromes may require referral to a pain specialist for intercostal nerve block or glucocorticoid injections of the costovertebral facet joints.
●Intercostal nerve blocks may be useful in patients with thoracic disc herniations who do not respond to initial management. In one series of patients with thoracic disc herniation, surgical decompression was required in only 27 percent of patients, as a majority of those treated with conservative measures returned to normal activities [11]. (See "Thoracic nerve block techniques", section on 'Intercostal nerve block'.)
●Glucocorticoid injections of the costovertebral facet joints have been used to treat pain in patients with degenerative changes in these joints. However, the efficacy of such injections has not been studied. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)
●Botulinum toxin injections have been used to treat posterior chest pain due to slipping rib syndrome (sometimes called rib tip syndrome or painful rib syndrome) if palpable rib subluxation or hypermobility is present and conservative interventions have failed [12,13].
Sternoclavicular osteoarthritis — Injection of the sternoclavicular joint with an anesthetic-glucocorticoid combination may be helpful to patients with pain localized to the sternoclavicular joint due to osteoarthritis. Local injection of the sternoclavicular joint must be performed with caution in order to reduce the risk of pneumothorax or injury to blood vessels. The approach to injection of the sternoclavicular joint is similar to aspiration and injection of other joints. (See "Joint aspiration or injection in adults: Technique and indications".)
Costochondritis or costochondral junction (Tietze) syndrome — Infiltration of the region of the costochondral junctions with an anesthetic-glucocorticoid combination may be beneficial for the patient with one or two tender areas due to costochondritis or costochondral junction syndrome. Local injection of the costochondral junctions must be performed with caution in order to reduce the risk of pneumothorax or laceration of blood vessels in the chest wall or mediastinum.
Costochondral junction injection was evaluated in an observational study in which ultrasonography was used to confirm the diagnosis of Tietze syndrome in nine patients [14]. The point of maximal tenderness and/or ultrasonographically enlarged costochondral joint was injected with a mixture of triamcinolone and lidocaine. Complete resolution of swelling and tenderness was noted after one week in eight patients and "substantial" improvement was noted in the one remaining patient.
Xiphoidalgia — Persistent chest pain localized to the xiphoid process can be treated with local infiltration with an anesthetic-glucocorticoid combination [15]. Local injection of the xiphoid must be performed with caution in order to reduce the risk of pneumothorax or laceration of blood vessels in the chest wall or mediastinum. Options for referral for these procedures, which should be done with imaging visualization for safe localization of needle placement, include interventional radiology, interventional pain centers, and physical medicine and rehabilitation specialists with training in these techniques.
Other therapies — In patients with persistent symptoms unresponsive to initial management measures and other adjunctive or individualized interventions (see 'General measures for most patients' above and 'Analgesia' above and 'Adjunctive exercise' above and 'Individualized interventions' above), other pharmacologic measures may be of benefit, including those used for centralized pain, such as interventions used for fibromyalgia, and muscle relaxants (see 'Medications for chronic centralized pain' below and 'Muscle relaxants' below). We generally avoid the use of opioids in these patients. (See 'Opioids' below.)
Medications for chronic centralized pain — In patients with persistent isolated musculoskeletal chest pain that significantly affects a patient's quality of life despite standard measures, it may be helpful to prescribe medications that are used for treatment of chronic widespread (centralized) pain, such as fibromyalgia syndrome. These include selected antidepressants (eg, tricyclic antidepressants, selective serotonin and norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors) and selected anticonvulsants (eg, gabapentin and pregabalin). These medications have been used with benefit in patients with nonspecific chest pain [16,17]. The agents and dosing are similar to the approach in fibromyalgia or myofascial pain syndrome and are described in detail separately. (See "Overview of soft tissue musculoskeletal disorders", section on 'Myofascial pain syndrome' and "Initial treatment of fibromyalgia in adults".)
Opioids — Use of opioids should be avoided in patients with chest pain of musculoskeletal etiology. For patients with continued symptoms interfering with performance of activities of daily living and who have not experienced an adequate response to other therapies, including treatment with topical agents, physical measures, nonsteroidal antiinflammatory drugs (NSAIDs), and local injection (where appropriate), a trial of tramadol at a dose of up to 200 mg daily in divided doses may be used, although the lowest dose necessary should be employed. We typically limit the use of such agents to short-term (up to three days) treatment for acute symptom flares.
Opioid analgesics with mixed agonist and antagonist properties, such as tramadol, do not completely avoid the risk of development of dependence or addiction, so the decision to use this agent chronically should be made with the same care as for other opioids. The decision to use this approach is best made in consultation with a pain management specialist. The use of opioids in the management of chronic pain is discussed in detail separately. (See "Use of opioids in the management of chronic non-cancer pain".)
Muscle relaxants — In patients in whom other interventions are ineffective, cyclobenzaprine or methocarbamol may be beneficial for treating musculoskeletal chest pain, particularly if there is associated muscle spasm. However, muscle relaxants are not recommended for older (typically defined as ≥65 years of age) adult patients or those patients prone to misuse of the drugs, and we avoid the use of benzodiazepines for these symptoms. Long-term therapy for musculoskeletal chest pain with muscle relaxants should generally be avoided. Drugs with anticholinergic or sedative properties are associated with an increased risk of adverse events in older adults. (See "Drug prescribing for older adults", section on 'Inappropriate medications'.)
●Cyclobenzaprine – Cyclobenzaprine is typically started at a dose of 10 mg orally once at bedtime. Doses during the day can be added up to three times daily, but this may cause excess sedation. In patients with excessive sedation, it can be given only at bedtime. We typically do not exceed a total dose of 30 mg daily. Patients should be warned about drowsiness with this agent and cautioned to avoid hazardous activities while taking it, especially driving an automobile.
Cyclobenzaprine may be more efficacious than other muscle relaxants due to biochemical similarities with tricyclic antidepressants, and the exact mechanism of action for chronic musculoskeletal pain is unknown but likely multifactorial. Cyclobenzaprine at doses of 5 to 10 mg three times daily has been more efficacious than placebo in the treatment of neck and low back pain [18]. There are no data that specifically address the efficacy of this agent in chest wall pain, but we have sometimes found it to be beneficial in our clinical experience.
●Methocarbamol – In patients with acute exacerbations of pain unresponsive to usual measures, we use methocarbamol (750 to 1500 mg three times daily). As with other muscle relaxants, patients should be warned about sedative effects. Data are lacking to assess the efficacy of methocarbamol for musculoskeletal chest pain; however, we have found it is sometimes effective in this setting in our clinical experience.
●Benzodiazepines – We generally avoid the use of benzodiazepines for patients with isolated musculoskeletal chest pain. Clinicians should refer patients to chronic pain specialists and/or an expert in mental health care if comorbid psychiatric affective disorders are present. Patients should be cautioned about possible sedation and the potential for dependence or addiction if they are receiving these medications.
INDICATIONS FOR REFERRAL — Indications for referral to a specialist such as a rheumatologist, physiatrist (physical medicine and rehabilitations specialist), or a pain management specialist, depending upon the specific condition or expertise required, include:
●Persistent pain from posterior chest wall syndrome requiring intercostal nerve block or facet joint injection
●Persistent pain from other isolated musculoskeletal conditions requiring local glucocorticoid injection
●Uncertainty about the diagnosis
●Lack of improvement after one to three months of treatment with several interventions, depending upon the severity of symptoms, local referral practices, and availability of specialists
If concomitant psychiatric problems such as anxiety, depression, panic attacks, or abnormal health beliefs exist, psychiatric referral should be considered. Evidence from randomized trials has shown benefit with cognitive behavioral therapy [19-21] and antidepressant drugs in selected populations [17].
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Costochondritis (The Basics)")
SUMMARY AND RECOMMENDATIONS
●The first step in the management of suspected musculoskeletal chest pain is to confirm that the patient is not experiencing chest pain due to a potentially life-threatening disorder, such as myocardial ischemia or infarction, pulmonary embolism, aortic dissection, or pneumothorax, and that the patient does not have pain due to a systemic illness. The diagnostic evaluation of chest pain is described in detail separately. (See 'Initial management' above and "Outpatient evaluation of the adult with chest pain".)
●For most patients, the initial management of musculoskeletal chest pain includes general nonpharmacologic interventions and the use of short-term analgesic medications. Most isolated musculoskeletal pain improves over the course of a few weeks or months. In general, the choice of these interventions in treating musculoskeletal chest pain is based upon analogy with their usefulness in treating pain of similar origin elsewhere in the body (eg, neck and low back pain). (See 'Introduction' above and 'General measures for most patients' above and 'Analgesia' above.)
●In most patients, general nonpharmacologic measures for the management of isolated musculoskeletal chest pain include reassurance that the pain is not life-threatening, avoidance of activities that cause or aggravate the pain, and local application of heat or cold. (See 'General measures for most patients' above.)
●In addition to the nonpharmacologic general measures, initial management includes oral and topical analgesics, depending upon symptom severity:
•For most patients with mild pain (ie, pain that does not limit activity), we suggest acetaminophen or a nonsteroidal antiinflammatory drug (NSAID) in low doses on an as-needed basis, rather than daily high-dose NSAIDs. The total maximum daily acetaminophen dose should not exceed 3000 mg. We usually use naproxen (220 mg two or three times daily) or ibuprofen (200 mg, one to two pills two to three times daily). These may be administered with or without topical therapy (eg, capsaicin or topical NSAIDs), which are an alternative to oral NSAIDs as well. (See 'Mild pain' above.)
•In patients with moderate pain (ie, pain that interferes with activity), we suggest oral NSAIDs in moderate to high doses, rather than low doses. We usually use naproxen (375 to 500 mg twice daily) or ibuprofen (600 mg to 800 mg three times daily) in such patients. (See 'Moderate pain' above.)
•Severe musculoskeletal chest pain usually occurs in the setting of trauma (eg, rib fracture) and thus requires referral to an appropriate specialist for evaluation and management. (See "Initial evaluation and management of chest wall trauma in adults".)
●Patients with costochondritis may improve with the addition of stretching exercises (table 4), and patients with spontaneous subluxation of the sternoclavicular joint can be referred to physical therapy for shoulder/scapular strengthening exercises. (See 'Adjunctive exercise' above.)
●Patients with isolated musculoskeletal chest pain due to posterior chest wall syndromes, sternoclavicular osteoarthritis, costochondritis, costochondral junction (Tietze) syndrome, or xiphoidalgia that persists beyond four to six weeks or those with symptoms from one of these conditions that are not adequately controlled with initial treatment measures may benefit from local nerve blocks or glucocorticoid injections. (See 'Individualized interventions' above.)
●In patients with isolated musculoskeletal chest pain that is persistent and significantly adversely affecting the patient's quality of life, it may be helpful to prescribe a treatment program used for chronic widespread (centralized) pain, such as fibromyalgia, which may include selected antidepressants (eg, tricyclic antidepressants, selective serotonin and norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors) and/or selected anticonvulsants (eg, gabapentin and pregabalin). The agents employed and dosing are similar to the approach in fibromyalgia or myofascial pain syndrome, described in detail separately. (See 'Medications for chronic centralized pain' above and "Overview of soft tissue musculoskeletal disorders", section on 'Myofascial pain syndrome' and "Initial treatment of fibromyalgia in adults".)
●The use of opioids should be avoided in patients with chest pain of musculoskeletal etiology. (See 'Opioids' above.)
●Indications for referral include persistent pain from posterior chest wall syndrome requiring intercostal nerve block or facet joint injection, persistent pain from other isolated musculoskeletal conditions requiring local glucocorticoid injection, uncertainty about the diagnosis, and lack of improvement after one to three months of interventions are tried. (See 'Indications for referral' above.)
