Acute Chest Pain, Worsened by Breathing or Movement

CLINICAL DIAGNOSTIC MANUAL

Acute chest pain that worsens with breathing or movement can have various causes, many of which involve the musculoskeletal, pulmonary, or even neurological systems. Precise identification of the cause requires a detailed evaluation of symptoms, clinical signs, and the performance of complementary tests. This type of pain is often associated with inflammation, infection, or nerve compression in the chest area. An appropriate diagnostic approach allows differentiation between benign origin pathologies and potentially serious conditions such as pulmonary thromboembolism or pericarditis.

Pathology	Symptoms and Clinical Signs	Suspicion Diagnosis	Confirmation Diagnosis
Musculoskeletal injury	Localised pain that increases with chest wall movement, tenderness to touch, swelling in some cases.	History of trauma or physical strain.	Chest radiography to rule out fractures. Physical examination reproducing the pain.
Soft tissue inflammation	Constant pain in the affected area, worsening with deep breathing or palpation. Possible swelling or warmth.	Clinical evaluation based on history of minor trauma or strain.	Physical examination with palpation of painful areas. Ultrasound to assess inflammation or soft tissue oedema.
Tietze’s syndrome	Sharp, localised pain in the costochondral joints, increased pain with deep breathing or movements. Not associated with systemic signs.	Pain in costochondral areas without evidence of heart disease.	Normal chest radiography. Diagnosis based on physical examination (pain reproduction with costochondral palpation).
Pneumonia with pleurisy	Pleuritic pain (sharp and stabbing), fever, productive cough, dyspnoea. Pain worsens with deep inspiration or cough.	Fever, cough, pleuritic chest pain.	Chest radiography showing pulmonary consolidation and signs of pleural effusion. Sputum culture or microbiological analysis to identify the pathogen.
Pulmonary thromboembolism (PE)	Sudden pleuritic pain, difficulty breathing, tachycardia, sometimes haemoptysis. Pain worsens with breathing.	Sudden chest pain with dyspnoea and history of risk factors such as immobility or deep vein thrombosis.	Elevated D-dimer. CT angiography or ventilation-perfusion scan to confirm PE.
Pericarditis	Chest pain that improves when leaning forward and worsens when lying down, fever. Possible signs of pericardial tamponade (hypotension, jugular venous distension, muffled heart sounds).	Pleuritic chest pain, associated with position changes. Recent viral infection history.	ECG showing diffuse ST elevation, echocardiography showing pericardial effusion.
Referred pain from cervical roots	Pain radiating from the cervical spine to the chest, exacerbated by neck movements. Not associated with respiratory or cardiac symptoms.	History of previous cervical pain, pain radiation to the chest.	Cervical radiography or MRI revealing nerve root compression.
Herpes zoster infection	Acute, burning pain, followed by the appearance of vesicles in a specific dermatome. Pain before the skin eruption.	Acute localised pain in a dermatome with or without skin eruption. History of varicella infection.	Clinical diagnosis based on characteristic vesicular lesions. PCR to confirm varicella-zoster virus infection in atypical cases.