Retrosternal Chest Pain (Behind Sternum) Causes

Pain Behind Sternum

Pain behind the sternum (retrosternal pain) is often associated with cardiac conditions, however, the more common causes are related to acid reflux and related gastrointestinal conditions. Rarely, retrosternal pain may be a consequence of referred pain from neighboring structures, especially those in the abdominal cavity as is seen with gastritis, peptic ulcer, gallstones and pancreatitis.

If retrosternal chest pain presents with shortness of breath, dizziness and severe weakness, then cardiovascular conditions needs to be considered. Retrosternal chest pain with coughing, particularly a productive cough, may be attributed to respiratory conditions. Cardiovascular conditions may be life-threatening. The onset of retrosternal chest pain, especially when associated with shortness of breath, sweating, radiation of pain to the left arm, jaw, neck or abdomen, dizziness, fainting, nausea and/or vomiting, needs to be immediately assessed by a medical professional.

Organs Behind the Breastbone

It is important to consider the structures that lie in the central part of the chest cavity, behind the breastbone.

  • Thymus gland (remnants)
  • Heart
  • Great blood vessels (portion originating or ending in the heart)
  • Esophagus
  • Trachea
  • Bronchi (origin)
  • Vertebrae (cervical and thoracic)

However, this may be too simplistic of an overview of the anatomy in this region. Many organs and tissues overlap slightly into the central part of the chest cavity and may partly lie in the area behind the breastbone. This includes the mediastinal lining, pericardium, pleura and lungs. Expansion of the chest cavity with breathing (inspiration) and subsequent contraction (expiration) can also cause slight changes in anatomical position that may also account for retrosternal pain.

Causes of Chest Pain Behind the Breastbone

Pain being the sternum most likely arises from disease of the organs behind the breastbone. However, it is also important to note that sometimes the pain may not originate from this area. Instead it may arise elsewhere and radiate or refer to the region behind breastbone. Therefore evaluating the pain alone in trying to isolate the cause can often be inaccurate. Instead other symptoms and even the patient’s medical history should be taken into account in order to more accurately identify a possible cause. This can then be confirmed with various investigations to reach a final diagnosis.

Gastrointestinal

These are conditions affecting the throat, esophagus (gullet) and upper stomach which may present with chest pain behind sternum. Most often it is diseases, damage and irritation of the esophagus that is responsible for retrosternal chest pain. The most common of these is gastroesophageal reflux disease (GERD) where acid flows backward from the stomach into the esophagus. This causes heartburn.

  • Acid reflux (acute)
  • GERD / Gastroesophageal reflux disease (chronic)
  • Esophagitis
  • Esophageal spasms
  • Esophageal ulcer
  • Esophageal tear
  • Foreign body

Cardiovascular

The heart and great blood vessels are the most important structures in the chest cavity lying behind the breastbone. Therefore pain behind the sternum always raises the concerns of damage or disease of the heart and the root of these large blood vessels. Cardiovascular conditions of this nature can be rapidly life threatening and therefore has to be taken seriously.

  • Angina
  • Myocardial infarction (heart attack)
  • Pericarditis
  • Aortic dissection
  • Pulmonary embolism
  • Atrial fibrillation
  • Mitral valve prolapse

Respiratory

The lungs and lower air passages lie within the thoracic cavity. The trachea runs down the center and then branches out to either side via the bronchi. This divides into smaller airways and carries air to the air sacs of the lungs. Diseases of the trachea, bronchi and medial portions of the lung are therefore more likely to contribute to retrosternal chest pain. Furthermore, the ling around the lungs known as the pleura may also be a source of the pain.

  • Tracheitis
  • Pleuritis
  • Cancer (airway, lung pleura), especially if there is spread to the mediastinal lymph nodes.

Tumors

Tumors, whether benign (non-cancerous) or malignant (cancerous), may also be the cause of pain behind the breastbone. It is not the most common cause but needs to be considered when other causes have been excluded, there are other symptoms indicative of a tumors and there are relevant findings on imaging studies like chest x-rays, CT scans or an MRI.

  • Mediastinal lymphadenopathy, often in lung cancer and mesothelioma
  • Thymoma (thymus gland)

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  2. Breastbone Pain