Evaluation and Treatment of Musculoskeletal Chest Pain Amba Ayloo, MD, Teresa Cvengros, MD, CAQSM, Srimannarayana Marella, MD  Primary Care: Clinics in Office Practice  Volume 40, Issue 4, Pages 863-887 (December 2013) DOI: 10.1016/j.pop.2013.08.007 Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 1 Diverse origins and causes of chest pain. (From Cava JR, Sayger PL. Chest pain in children and adolescents. Pediatr Clin North Am 2004;51(6):1553–68. Philadelphia: Elsevier; with permission.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 2 Rib cage with costal cartilages and inflamed cartilages in costochondritis. (A) Labeling of rib cage. (B) Inflammation of coastal cartilages. Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 3 Crowing rooster maneuver. Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 4 Stretching exercises for costochondritis. Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 5 Algorithm for causes of rib pain. Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 6 Algorithm for causes of stress fractures. Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 7 Rib fractures in a child (arrows). (From Rubio EI. How do you read these images? Hone your interpretive skills. Rib fractures in a child. 2008. Available at: http://www.pediatricsconsultantlive.com/display/article/1803329/1405067. Accessed March 30, 2013; with permission.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 8 Hooking maneuver for slipping rib syndrome. (From Waldman S. Atlas of pain management injection techniques. 3rd edition. Philadelphia: Saunders; 2013. p. 274–6, with permission; and Data from Koren W, Shahar A. Xiphodynia masking acute myocardial infarction: a diagnostic cul-de-sac. Am J Emerg Med 1998;16(2):177–8.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 9 Pectoralis muscle structure. (From Cava JR, Sayger PL. Chest pain in children and adolescents. Pediatr Clin North Am 2004;51(6):1553–68. Philadelphia: Elsevier; with permission.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 10 Algorithm for pectoralis muscle injury based on cause of injury. (Data from Hopper MA, Tirman P, Robinson P. Muscle injury of the chest wall and upper extremity. Semin Musculoskelet Radiol 2010;14(2):122–30.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 11 Algorithm for pectoralis muscle injury based on location of injury. (Data from Hopper MA, Tirman P, Robinson P. Muscle injury of the chest wall and upper extremity. Semin Musculoskelet Radiol 2010;14(2):122–30.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 12 Insertion of external and internal oblique muscles. Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 13 Ultrasonographic appearance of normal external oblique (black arrow) and internal oblique (white arrow) muscles. (From Obaid H, Nealon A, Connell D. Sonographic appearance of side strain injury. AJR Am J Roentgenol 2008;191(6):265. Available at: http://www.ajronline.org/doi/full/10.2214/AJR.07.3381. Accessed March 12, 2013; with permission.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 14 Gap in the insertion of internal oblique muscle caused by tear (arrow). (From Obaid H, Nealon A, Connell D. Sonographic appearance of side strain injury. AJR Am J Roentgenol 2008;191(6):265. Available at: http://www.ajronline.org/doi/full/10.2214/AJR.07.3381. Accessed March 12, 2013; with permission.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 15 Tender points in fibromyalgia. (From Shipley M. Chronic widespread pain and fibromyalgia syndrome. Medicine 2010;38(4):202–4; with permission.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 16 Dermatomal distribution of herpes zoster skin rash. (From Swartz MH. Textbook of physical diagnosis: history of examination. Philadelphia: Saunders; 2009. p. 137–95; with permission.) Primary Care: Clinics in Office Practice 2013 40, 863-887DOI: (10.1016/j.pop.2013.08.007) Copyright © 2013 Elsevier Inc. Terms and Conditions