While there are many causes for chronic chest pain, the most important concern is to rule out any conditions that may be life threatening. Once the pain has been evaluated by a health care provider and determined to be not life threatening (such as pain signaling a heart problem), the patient should be evaluated for conditions that could result in the chronic pain. Chronic pain in the chest may arise from the spine, the chest wall and its nerves, or the internal (visceral) organs.

The bones in the spine may compress and fracture with age causing pain (thoracic vertebral compression fracture). Pain arising from the spine may be related to compression of the nerves that exit the spinal cord (spinal stenosis or disc herniation). When the pain occurs as a result of nerve compression, it may be felt on one or both sides of the chest wall. Pain may also arise the intercostal nerves, the nerves that run under each rib. Intercostal nerve injury after chest surgery is a frequent cause of chronic chest pain (intercostal neuralgia, post thoracotomy pain). Pain can originate from the musculoskeletal system, the ribs and their joints with the spine or sternum (rib fracture, costosternal syndrome, Tietze’s syndrome or costochondritis) or pain may result from infections like Herpes Zoster and its consequence post-herpetic neuralgia. Pain may also arise from the organs within the chest including the organs themselves or their covering such as pleural pain or pericardial pain.

If the chest pain has been evaluated by a cardiologist or pulmonologist and does not present a life threatening or the cause remains unknown, the patient may benefit from an evaluation by a Pain Medicine specialist. Treatment of chronic chest pain differs based on the etiology. The ultimate goal of any therapy is always functional rehabilitation, i.e. going back to doing whatever one was able to do prior to the onset of pain.

Interventions used in the management of chronic chest pain include diagnostic blocks and therapeutic interventions. Examples of diagnostic blocks used in the treatment of chest pain include diagnostic peripheral nerve blocks, differential epidural blockade. Examples of therapeutic interventions in the management of chest pain include peripheral nerve radiofrequency ablation, intercostal nerve cryoablation, epidural steroid injections, facet nerve radiofrequency ablation. Other interventions may include spinal cord stimulation or spinal infusion pumps in selected cases. Physical therapy is often prescribed with therapeutic procedures and medications are prescribed as needed to assist in the rehabilitation process.