Chest Pain - How Massage Can Help
Chest pain can be mysterious and deceiving. Regardless of the sensation, it will get your attention. And so it should. It could be a matter of life and death.
Massage therapy’s scope of practice is primarily limited to musculoskeletal dysfunctions, so we will focus on common conditions massage therapists treat, and explore some practical methods we can use to resolve chest pain. Included is a review of the red flags associated with heart attacks and angina and review how we screen for these conditions in clinical practice.
Heart Attack - Signs & Symptoms
The first thing we must always consider if you are experiencing chest pain, is whether or not you are having a heart attack. So before we start reviewing musculoskeletal conditions that we can address, let us first quickly go over some of the Red Flags of a heart attack. If you are experiencing any of the following symptoms (or a combination of these symptoms) phone 911 IMMEDIATELY for help.
Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw, or back.
Shortness of breath (dyspnea).
Extreme or unusual fatigue.
FUNCTIONAL ANATOMICAL CONSIDERATIONS
The chest and back (thorax) is the central structure between the abdomen and neck. Visualize a 3-dimensional barrel-like structure that functions as one unit. As we breath in and out, the diaphragm moves up and down, expanding and contracting the thorax.
Every physical stress we place on the thorax has a physical consequence. Physical stresses cause musculoskeletal remodelling that can be related to numerous dysfunctions.
This process is described by two specific laws. Wolff’s and Davis’s laws which state that tissue (bone and soft tissue) in the body remodel in accordance to imposed demands (repetitive motions, trauma, posture, lifestyle, exercise, etc). Therefore both soft tissue and bone (joints) must be considered when treating any type of chest dysfunction.
Our joints need to move in an unrestricted fashion, our nerves need to freely carry their signals (and glide with motion), our muscles need to respond efficiently, and our connective tissue must stabilize our movement effectively to enable the chest to move in synchronicity with the rest of the body.
Otherwise, when the body fails to meet the demands we place upon it, pain will manifest itself. Hence chest pain, and accompanying dysfunctions!
MUSCULOSKELETAL CHEST PAIN
Chest pain represents roughly a third of the cases that are seen in general practice and in hospital settings. Fortunately, pain of musculoskeletal origin is the most common problem (and are conditions which we can address as MSK practitioners). Let's consider five causes of chest pain that we often encounter in our clinical practice.
Strain - Sprains
A strain is damage to muscles, tendon, and connective tissue with contractile properties such as fascia. A sprain is almost exclusively used to describe ligament damage. Acute symptoms can include decreased strength/flexibility/mobility, inflammation and pain.
Solution: Strain and sprains are some of the most common chest injuries that we address. Whether the injury is sports related or, from an accident, massage therapy with the correct exercise program is often the shortest path a resolving these injuries. (11)
This condition is characterized by tenderness local to articulations of the ribs, rib cartilage, and where the ribs meet the sternum with no associated swelling. Pain may present superficially to deep and can even refer into the abdomen. (1,3)
This condition involves compression or irritation of the nerves of the rib musculature. Nerve pain and altered sensation is experienced locally and radiates throughout the rib area. This condition typically arises following blunt force trauma, disease (viral infections), muscle tension or after resting in a compromising position for a prolonged time such as sleeping awkwardly. (1,3)
One virus in particular that causes intercostal neuralgia is virecella-zoster. Commonly known as the shingles virus in adults. This infection causes a rash. In severe cases this virus can attack the intercostal nerves, thus resulting in the nerve pain described above.
Solution: Massage therapy can greatly reduce pain in cases of intercostal neuralgia that are mechanical in origin. It can also increase circulation function, and decrease muscle spasticity. Massage can also increase thoracic rib mobility which helps to reduce neural irritation.
This syndrome is characterized by tenderness present in the sternalis muscle and it's fascial connections to surrounding structures. The sternalis muscle is an anatomical variation (only 7.8% of the population) that lies in front of the sternal end of the pectoralis major muscle parallel to the margin of the sternum. (10)
This muscle is rare and not commonly found in all people, however is still important to be considered as a differential cause. (9)
Like most muscle strains, it will have tender points that show a positive jump sign (muscle twitch) when palpated. Pain is felt deeply in the middle of the chest and can radiate in either direction into the chest muscles and arms but is not aggravated by upper body movement. (8)
Solution: A severe enough acute presentation of this condition can easily give the impression of a heart attack. (1) Fortunately this syndrome usually responds very well to massage therapy and exercise, we just need to rule out that you're NOT having a heart attack.
This condition is distinguished by abnormal movement of the joints where the ribs articulate with the spine (costovertebral joints). Contributing factors include, poor posture, trauma and abnormal changes to the joint itself. Range-of-motion is affected, pain is local and often radiates across the middle of the back occasionally towards the chest (similar to intercostal neuralgia). (1)
Solution: Massage therapy can help relieve pain and restore movement. This is achieved by mobilizing the thoracic vertebrae and ribs, and by releasing soft tissue structures in the surrounding region. In these cases it is very common to work with a chiropractor to release restrictions in the costovertebral joints to speed the healing process.
A PRACTICAL APPROACH TO CHEST PAIN
Keep in mind that this framework is NOT intended to suggest a perfect method to treat each condition. It is a general treatment framework that we use when patients come to us seeking treatment for chest pain. Within this framework adjustments are made case by case to tailor the treatment to the individual. No one treatment is the same.
1. First, upon arrival, it is critical to rule out the possibility of heart disease. This is determined by evaluating history, visual evaluation, and by asking questions during the standard interview process. Blood pressure may be taken. Imaging and clearance by your physician may be requested before proceeding with treatment. (3)
- Observations of posture, gait and breathing (especially of laboured breathing patterns).
- Testing to evaluate pain patterns, (rule in/out specific conditions). (3)
3. Following examination, treatment will begin. Breath considerations should be made.
4. Hydrotherapy such as heat may be recommended at this stage. Relaxation techniques are effective means to reduce pain intensity and reduce overall muscle tension at the beginning of every session. (4)
5. Advanced techniques are then used to treat deeper and reduce trigger points. At this stage, pain associated with nerve compression, joint restrictions, and muscle tension can be relieved. (2,4,5)
6. Zeroing in on pattern-related pain by considering how pain is manifested by specific movements or structural relationships is the next step. You will be guided through precise procedures to address your specific presentation. This is often the final and most critical step in breaking cycles of dysfunction and resolving chronic pain. (2,4)
7. Finally, we provide to you a home care protocol to help encourage the progress made during that session. A strong protocol should reflect the progress and changes that occur during each session. This can include strengthening, stretching, self release exercises, hydrotherapy and activity level considerations.
The best intervention for body optimization relies on evidence-based multi-disciplinary strategies. (6) This means working together with all health care practitioners to create a stronger community to serve the public.
But not only that! We must constantly stay informed with the best quality research while utilizing a diverse repertoire of techniques and treatment methodologies. This is how you can rest assured that you are receiving the best care possible.
If you are experiencing chest pain (and you suspect it is musculoskeletal in nature), don’t wait, come see our team at Kinetic Health. We will do our best to help you resolve your problem!
Tania Winzenberg, Graeme Jones, Michele Callisaya. August 2015. Musculoskeletal chest wall pain. Australian Family Physician 44;8:540-544
Jeanne Massingiil, Cora Jorgenson, Jaqueline Dolata, Ashwini R. Sehgal. August 2018. Myofascial massage for chronic pain and decreased upper extremity mobility after breast cancer surgery. Int J Ther Massage Bodywork 11;3:4-9
Anne M. Proulx, Teresa W. Zryd. September 2009. Costochondritis: Diagnosis and Treatment. 80;6:617-620
Laura A Frey Law, Kathleen Sluka. August 2008. Massage reduces pain perception and hyperalgesia in experimental exercise pain: a randomized, controlled study. The Journal of Pain 8;9:714-721
Susanne M. Cutshall, Laura J. Wentworth, Deborah Engen, Thoralf M. Sundt, Ryan F. Kelly, Brent A Bauer. Effects of massage therapy on pain, anxiety and tension in cardiac surgical patients: A pilot study
Liza Dion, Nancy Rodgers, Susanne M. Cutshall, Mary Ellen Cordes, Brent Bauer, Stephen D. Cassivi, Stephen Cha. June 2011. Effects of massage on pain management for thoracic surgery patients. Int J Ther Massage Bodywork 4;2:2-6
John A. Ambrose, George Dangas. May 1999. Unstable angina current concepts of pathophysiology and treatment. Arch Intern Med 160;1:25-37
Steven D. Waldman. (2003). Atlas of Uncommon Pain Syndromes. Retrieved from http://www.pocayo.com
Snosek, Michael; Tubbs, R. Shane; Loukas, Marios (2014-09-01). "Sternalis muscle, what every anatomist and clinician should know".Clinical Anatomy.27(6): 866–884.
Tero AH Järvinen, Markku Järvinen, Hannu Kalimo. February 2014. Regeneration of injured skeletal muscle after the injury. Muscles Ligaments Tendons J 3;4:337-345
Simon-Daniel Jolicoeur-Forrester, RMT
Simon is a young man hailing from Disraeli, Quebec who has been calling Calgary his home since the day he could walk. Passionate for holistic medical approaches, he is looking to make his mark in the health and wellness industry. He is a graduate of the Mount Royal University massage therapy program and currently a member in good standing with the Natural Health Practitioners of Canada (NHPC).
Simon has extensive experience as an athlete himself and brings a unique perspective to his treatment in that respect. Believing strongly that the best results come from a cooperative team effort that includes both the practitioner and the patient.
In his spare time he enjoys catching up with friends, music, staying involved with the YYC drum troupe, providing massage at charity events to participants and pushing himself to learn something new everyday.