motility testing after persistent chest pain Intra-abdominal processes such as cholecystitis can present with postprandial pain and pain in the right upper quadrant Musculoskeletal causes of chest pain are common accounting for 15% to 56% of cases and are typically overuse injuries (muscle strain and inflamed tissue) Chest pain often occurs after physical activity and is reproducible by palpation and contraction of the muscle group on physical examination Direct trauma may produce a contusion or rib fracture Costochondritis is an inflammatory condition of the costochondral junctions which may be preceded by a respiratory illness and characteristically has reproducible pain on examination The pain is described as sharp and exaggerated by physical activity or deep inspiration Tietze syndrome is a benign inflammatory condition of unknown cause which results in isolated swelling of a costochondral junction The inflamed area appears as a mass on the chest wall and results in chest pain that typically radiates to the shoulder or arm This syndrome usually occurs in adults but has been reported in children and infants When evaluating a chest wall mass the differential diagnosis should include osteomyelitis and tumors Slipping rib syndrome is a pain syndrome caused by hypermobility of the anterior aspect of the 8th to 10th ribs which not directly attach to the sternum but instead are held together by fibrous tissue It is thought that weakening of the fibrous tissue in the area allows the ribs to rub against the other irritating the intercostal nerve and referring pain to the chest wall and abdomen Patients describe a popping or clicking sensation followed by pain which lasts several minutes Pain is reproduced by hooking the lower ribs with the hand and pulling anteriorly A large group of children with chest pain will have no evidence of organic disease and no history of underlying cardiorespiratory disease or trauma They may have a family history of chest pain and are able to identify a stressful situation that has precipitated the episode Others have chest pain as a manifestation of anxiety or depression Such children have psychogenic chest pain which represent approximately 5% to 17% of pediatric chest pain cases Complaints of chest pain and other somatic aches often are chronic and other symptoms of psychiatric illness or hyperventilation may be present Nonorganic chest pain may appear to cause respiratory distress in the hyperventilating teenager but close examination should distinguish this syndrome from serious problems (see Chapter 126 Behavioral and Psychiatric Emergencies ) Finally, idiopathic chest pain is a very common diagnosis of chest pain in pediatrics representing 23% to 45% of cases The term is used to describe chest