Understanding Noncardiac Chest Pain Through the Myofascial Continuum

Chest pain is commonly linked to cardiac issues like myocardial ischemia, but in many cases—up to 70%—it turns out to be noncardiac chest pain (NCCP). NCCP mimics the symptoms of angina but lacks evidence of heart disease upon examination. While gastrointestinal causes like reflux are well-known contributors, musculoskeletal sources—especially those involving the myofascial system—are often overlooked. This article highlights the anatomical and clinical basis for myofascial causes of chest pain and offers insight into better diagnosis and treatment strategies for manual and movement therapists.

Pain from noncardiac causes can mimic heart-related symptoms and often involves trigger points in muscles of the neck, chest, or shoulder. An article published in Clinical Anatomy provided a review the myofascial continuum—a connected network of fascia and muscle across the upper body— for identifying the source of pain and avoiding misdiagnosis or unnecessary medical tests.

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Key Concepts

1. Visceral vs. Musculoskeletal Chest Pain

Chest pain from internal organs often shares spinal pathways with somatic (muscle/joint) pain, making it hard to distinguish between cardiac and musculoskeletal origins. This is why trigger points in the chest or neck can cause pain that feels cardiac in nature.

2. Prevalence and Impact

NCCP affects up to a third of the population and accounts for over half of all chest pain cases in emergency departments. Despite its generally benign nature, it causes high anxiety, disability, and healthcare costs.

3. The Myofascial System

Muscles don’t work in isolation—they are enveloped in a continuous web of connective tissue called fascia. The myofascial system connects the head, neck, chest, and arms, allowing force transmission, postural integration, and, importantly, the spread of pain through fascial chains.

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Myofascial Connections in the Upper Quadrant

The upper quadrant includes the head, neck, chest, shoulder girdle, arms, and hands. Key fascial pathways include:

• Anterior Chain: Connects chest muscles (e.g., pectoralis major/minor) to the arm via the brachial fascia.
• Posterior Chain: Connects neck extensors and scapular stabilizers (e.g., trapezius, levator scapulae) to the thoracolumbar fascia and upper limbs.
• Lateral Chain: Involves fascia from the skull and jaw (e.g., temporalis) linking to the cervical fascia and down into the shoulder and arms.

These myofascial continuities help explain how trigger points in one region (e.g., pectoralis minor or scalenes) can refer pain to the chest, back, arm, or jaw—closely resembling cardiac pain.

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Myofascial Pain Syndrome (MPS) and Chest Pain

MPS is a key contributor to NCCP, particularly when pain originates in muscles like:

• Scalenes – refer pain to chest and scapula
• Pectoralis major/minor – mimic angina
• Subscapularis and trapezius – cause arm or chest wall pain
• Jaw muscles – link postural dysfunction to head and chest pain

These trigger points may be missed in standard cardiac or gastrointestinal evaluations but respond well to manual therapy, dry needling, or stretching.

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Case Studies and Clinical Relevance

• Pain resolved with myofascial release of the pectoralis minor in a patient initially suspected of cardiac disease.
• Trigger points in scalene muscles caused chest and arm pain, misdiagnosed as angina until targeted therapy resolved symptoms.
• Masticatory dysfunction (jaw tension) linked to cervical myofascial imbalance, causing referred pain to the chest.

These cases emphasize the importance of differentiating visceral from myofascial origins using thorough assessment and palpation techniques.