Expert: Dr. J. Shawn Leatherman - 1/16/2008

Question
I write on behalf of my 76 year old Gran. She has been experiencing pain in her chest since Oct 07. She has had a few visits to her g.p as a result who initially sent her away telling her it was just muscular.Eventually with family intervention she returned to her G.P 2 weeks ago as the pain was getting more severe. Her g.p suggested it could be costochondritis but didn't seem to elaborate or pursue this suggestion. Instead he asked her to make an appointment at a private hospital to see a heart consultant. Last night she attended this appointment. She had an ecg which was fine, she has a heart murmmer which she has had since birth.The consultant gave her a thourgh upper body examination. She was crying with the pain when he touched her chest. He gave her a letter to take to her G.P re blood tests he wants done. My gran has said since the start that she feels the pain is in her bones. The consultant did mention last night that it could be related to cartilage. Yesterday she said whilst lying back in the bath she felt as if all her bones in her chest had exploded. She said the pain was excruciating. Whilst we await the results of her blood tests, which wont be back until mid or end of next week, is there not some kind of scan that could be done to determine whether the pain is due to cartilage. I would be gratefully for your opinion.

Answer
Dear Claire,

Well, a simple x-ray can visualize the bones of the anterior chest while also looking for any related pathology, but the cartilage is not really seen with this type of imaging unless it has calcified.  

A bone scan will be able to detect if there is an ongoing metabolic process of the cartilage and bone in the area, but it is not specific for a diagnosis. A CT would actually be more diagnostic, but again cartilage is not visualized that well.  

However, an MRI is sensitive enough to actually visualize cartilage and damage if it has occurred.  An MRI would also be helpful to visualize the surrounding tissue to see if inflammation/swelling is present, and you can actually see bone on an MRI as well.  It would probably be the best overall test in this case, followed by the CT.

Realize that an MRI or CT scan is an expensive test to order, and the doctors will probably try to get information from a physical examination and bloodwork first.  If there are abnormal markers in the blood to indicate some type of bone or cartilage issue (infection/cancer/etc...), like high white blood cells, or  alkaline phosphatase, they will order the scans immediately.  On the other hand, if the blood work comes out fine, and they still do not have a diagnosis, you might get them ordered for a closer look.  

Bottom line, you need to make sure that the doctors are explaining what their thought processes are and their rationale for the tests ordered and the results.  If they can't give you answers to the problem...ask for further imaging to be performed.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net