The patient was a 61-year-old female who was complaining of severe left-sided chest pain that radiated to her nipple, into her left shoulder, and down the anterior and medial aspect of her left arm. She described the pain as gripping in nature; it was usually most severe at night, at times even waking her up from sleep. She reported no exacerbation due to exertion, and no shortness of breath. She was extremely distressed because of the intensity of the pain and because of concern that it could be coming from her heart. She reported no nausea or vomiting. Palpation of her radial pulse and auscultation of her heart revealed no apparent abnormality. There were no signs of sweating or pallor. Motion palpation revealed joint dysfunction of the costotransverse joint of rib four on the left. Palpation of the left pectoralis major muscle revealed trigger points (TPs) in the costal and abdominal fibers which reproduced the patient's breast pain, and in the midsternal fibers which reproduced her gripping chest pain and part of her arm pain. Palpation of the left subclavius muscle revealed TPs which reproduced the patient's arm pain. Referral was made to a cardiologist to rule out the possibility of a viscerosomatic reflex causing the TPs. Echocardiogram and stress tests were negative. The patient was placed on a schedule of chiropractic adjustments along with ischemic compression and postsometric relaxation to the pectoralis major and subclavius muscles, and was pain free upon re-examination two weeks later.
This is a fairly typical example of a myofascial disorder causing pain that can easily be mistaken as cardiovascular disease by a physician who is not trained in the diagnosis of dysfunction in the locomotor system. The close interaction of the locomotor and visceral systems is such that not only can a disturbance in one have an effect on the other,13,14 but the symptoms of a disturbance in one system can appear very similar to the symptoms of a disturbance in the other. This clearly points to the important role the chiropractic physician can play in the differential diagnosis of various visceral diseases. In order to competently fill this role, we must be able to examine the locomotor apparatus as a whole and be aware of the various types of dysfunctions that are capable of producing both symptomatic and asymptomatic reflex abnormalities in the body.
References
- Grieve, G.P. Thoracic joint problems and simulated visceral disease. In: Grieve, G.P. ed. Modern Manual Therapy of the Vertebral Column. 1986 Churchill Livingstone, New York.
- Travell, J.; Rinzler, S.H. "Pain syndromes of the chest muscles: resemblance to effort angina and myocardial infarction and relief by local block." Can Med Assoc J 1948; 59:333-338.
- Mendlowitz M. "Strain of the pectoralis minor, an important cause of precordial pain in soldiers." Am Heart J 1945; 30:123-125.
- Wiles M. "Pseudoangina pectoris of cervical origin: a case report." JCCA 1980; 24(2):74-75.
- Booth, R.E.; Rothman, R.H. "Cervical Angina." Spine 1976; 1(1):8-32.
- Hamberg J., Lindahl, O. Angina pectoris symptoms caused by thoracic spine disorders: Clinical Examination and Treatment. Acta Medica Scand Suppl 1981; 644:84-86.
- Bechaard P. Segmental Thoracic Pain in Patients Admitted to a Medical Department and a Coronary Unit. Acta Medica Scand Suppl 1981; 644:87-89.
- Levine, P.R.; Mascetta A.M. "Musculoskeletal chest pain in patients with angina, a prospective study." S Med J 1989; 82(5):580-591.
- Good, M.G. Pseudoappendicitis. Acta Med Scand 1950; 138:348-353.
- Patton, I.J.; Williamson, J.A. "Fibrositis as a factor in the differential diagnosis of visceral pain." Can Med Assoc J 1948; 58:162-166.
- Harman, J.B.; Young, R.H. "Muscle lesions simulating visceral disease." Lancet 1940; 1:1111-1113.
- Travell, J.G. "Referred pain from skeletal muscle: the pectoralis major syndrome of breast pain and soreness and the sternomastoid syndrome of headache and dizziness." NY State J Med 1955; 55:331-339.
- Sato, A.; Schaible, H.; Schmidt, R. "Types of afferents from the knee joint evoking sympathetic reflexes in cat inferior cardiac nerves." Neurosci Letters 1983; 39:71-75.
- DeBoer, K.F.; Schultz, M.; McKnight, M.E. "Acute effects of spinal manipulation on gastrointestinal myoelectric activity in rabbits." Man Med 1988; 3:85-94.
Donald R. Murphy, D.C.
Westerly, Rhode Island
Editor's Note: Dr. Murphy will be conducting his next Myofascial Pain seminar in St. Louis, Missouri, May 18-19. You may register by dialing 1-800-327-2289.
Correction: In our April 12, 1991 issue we welcomed Dr. Murphy as a new columnist and MPI faculty member. We mistakenly referred to Dr. Murphy as a diplomate of the American Chiropractic Academy of Neurology. Dr. Murphy corrected us on this point. He is not a diplomate of the American Chiropractic Academy of Neurology, but is currently enrolled in that program.
Dr. Donald R. Murphy graduated from New York Chiropractic College in 1988 and thereafter obtained three years of postgraduate education in neurology. He is the clinical director of the Rhode Island Spine Center in Pawtucket, R.I., as well as clinical assistant professor at the Alpert Medical School of Brown University. He maintains a busy primary spine care practice and lectures worldwide on various topics related to spinal disorders. Dr. Murphy also serves as president of the West Hartford Group.