Management of Acute Musculoskeletal Chest Pain

Diagnostic Confirmation

The American College of Physicians and American Academy of Family Physicians recommend confirming the musculoskeletal origin of chest pain through the absence of cardiac red flags, which include no radiation to arm/jaw, no diaphoresis, no dyspnea at rest, and normal ECG and cardiac biomarkers if these were obtained 2, 3

The American College of Physicians and American Academy of Family Physicians strongly recommend topical NSAIDs (with or without menthol gel) as first-line therapy for acute musculoskeletal chest pain, with moderate-certainty evidence, as this provides the strongest evidence for pain relief, improved physical function, and patient satisfaction while avoiding systemic side effects 1
Topical formulations reduce systemic absorption and minimize gastrointestinal and cardiovascular risks compared to oral NSAIDs 1
Apply topical NSAIDs to the affected area 3-4 times daily 3

The American College of Physicians and American Academy of Family Physicians conditionally recommend oral NSAIDs, such as ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily, for patients who do not respond to topical NSAIDs, with moderate-certainty evidence 1, 4
Oral NSAIDs are more effective than acetaminophen for improving physical function 1
The American College of Physicians and American Academy of Family Physicians conditionally recommend oral acetaminophen, 650-1000 mg every 6 hours as needed, for patients who cannot tolerate NSAIDs, with moderate-certainty evidence 1, 4
Acetaminophen reduces pain but has less evidence for improving physical function compared to NSAIDs 1

The American College of Physicians and American Academy of Family Physicians conditionally recommend specific acupressure, with low-certainty evidence, as an adjunct to pharmacologic therapy for patients who prefer non-pharmacologic approaches or have contraindications to NSAIDs 1, 4
Transcutaneous electrical nerve stimulation (TENS) may reduce pain intensity, with low-certainty evidence 1, 4

The American College of Physicians and American Academy of Family Physicians explicitly recommend against using opioids, including tramadol, for acute musculoskeletal chest pain, with low-certainty evidence, due to the risk of opioid use disorder outweighing benefits for this self-limited condition 1, 4
Approximately 2 million persons in the US have opioid use disorder from prescription opioids 1

Do not use nitroglycerin response as a diagnostic test, as relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain, with guidance from Praxis Medical Insights 3
Do not assume mild pain equals benign cause, as intensity of symptoms does not correlate with disease severity, with guidance from Praxis Medical Insights 3

Acute musculoskeletal chest pain typically lasts less than 4 weeks, with guidance from the American College of Physicians and American Academy of Family Physicians 1