found this dont know if it will help anything but thought id post for you anyway, Chest pain: Not always a cardiac problem. J Musculoskel Med, 10(3):37-49, 1993. 6 References Dept of Medicine, University of California School of Medicine, San Francisco, CA (Dr BR Kaye) DT.05A 270.1 9/93 (C) 1991 Chest pain is a cause of great anxiety for all because of the fear of a serious cardiac event. Differentiation of cardiac from noncardiac chest pain on the basis of clinical characteristics and physical exam is usually possible. This article discusses the various causes of chest pain and how specific clinical features direct the differential work-up. Four important characteristics of pain include: (1) location, (2) pattern, (3) character, and (4) duration. Pain may be substernal and radiating, indicating cardiac origin, or nonradiating, as in musculoskeletal (Tietze's, costochondritis), or esophageal (spasm or heat burn) disorders. Xiphoid pain is usually musculoskeletal (xiphoid syndrome, Tietze's syndrome). Anterior chest pain with thoracic backache suggests musculoskeletal disease (osteoarthritis, ankylosing spondylitis) or possibly thoracic aneurism. Referred pain to the chest wall can be from cervical or thoracic disease, thoracic outlet syndrome, pancreatitis, gall bladder disease, or subphrenic abscess. Other uncommon causes are metastatic/malignant disease or rib fractures. Lateral chest wall pain may be from myalgias, or infections (epidemic myalgia) or trauma. Widespread or very localized pain leads to musculoskeletal or psychogenic origin. If located along a dermatome it suggests herpes zoster. Dull, aching pressure or tightness usually describes cardiac origin whereas burning or aching can be from esophageal or abdominal disorders (reflex, ulcers, cholecystitis). Sharp or stabbing pain frequently indicates pericarditis, psychoneurosis, pleuritis, or musculoskeletal disorders. Dull and aching pain may be associated with condensing osteitis, or arthritis. Thoracic aneurysm may induce a ripping sensation. Psychogenic pain is usually described in dramatic terms like "severe tearing", "stabbing", "knife-like", or "burning like fire". Cardiac chest pain is usually a crescendo pain lasting from 3-15 mins. If it persists for hrs, it usually results in frank myocardial infarction (MI). Aortic aneurysm or pneumothorax is greatest at the start and decrescendos. It may last hrs to days. Pain from pericarditis, pleuritis, or dissecting aortic aneurysm can begin suddenly or gradually and last for hrs. Musculoskeletal disorders may be associated with intermittent pain (costochondritis, Tietze's syndrome) and may have an insidious onset (slipping rib syndrome) or sudden onset (epidemic myalgia). Sternalis syndrome, traumatic muscle pain, and fibromyalgia, however, are sources of chronic continuous pain. Cardiac pain is aggravated by exertion, emotional stress, cold, or sexual activity, and is relieved with rest and nitroglycerin (although not specific for cardiac). Swallowing or oral intake pain is associated with esophageal, stomach, or gallbladder disease. Position may exacerbate or relieve pain, thereby giving clues as to the source. Breathing, coughing, or movement may exacerbate pain, especially those involving the musculoskeletal system. Fibromyalgia tends to be intensified with cold, damp weather and relieved with warm, dry weather and moderate exercise. Heavy lifting can aggravate condensing arthritis or be an indicator of specific muscle strains. Diaphoresis, nausea, and vomiting are classically associated with MI but also indicate gallbladder disease. Heartburn strongly points to esophageal disorders. Fibromyalgia may be indicated if headaches, irritable bowel syndrome, fatigue, stiffness, and Raynaud's are seen. Psychogenic pain is often associated with hostility, apprehension, depression, anxiety, and hyperventilation. Signs of rubbing, murmurs, clicks, arrhythmias or heart failure may be present with cardiac disease, however, the exam may also be normal. Chest wall tenderness in one location typifies Tietze's syndrome, whereas diffuse tenderness is usually more common with costochondritis. Point tenderness may signify trauma. Swelling over a rib may also signify trauma or infection but possibly may be a neoplasm. Swelling, crepitus, and tenderness over the sternoclavicular joint suggests trauma, arthritis, or infection. Muscular pain from strains or trauma is usually localized. Fibromyalgia is characterized by pain in the second costachondral junction, upper trapezius, and supraspinatus muscles. Psychogenic pain is usually nonspecific and inconsistent. Diagnostic studies are required for only a minority of patients with chest pain. ECGs are required when cardiac origin is suspected. Echocardiography is best for pericarditis or vascular disease. Endoscopy is helpful for esophageal or gastrointestinal disease. An abdominal x-ray can show whether gas in the hepatic or splenic flexure is causing chest pain. X-rays can also help in diagnosing many musculoskeletal diseases as well as pulmonary pathology. Computed tomography and magnetic resonance imaging are currently used in evaluating thoracic disc disease.