Precordial catch syndrome

Precordial catch syndrome, also known as Texidor's twinge, is a benign and self-limited cause of sharp, stabbing chest pain that is felt maximally at the left precordium and occurs mainly in otherwise healthy children and adolescents

Individual episodes usually last between 30 seconds and 3 minutes, are provoked by inspiration, and ease when the patient deliberately breathes shallowly

It is coded R07.2 (precordial pain) in ICD-10 and MD30.1 (other chest pain) in ICD-11, and is widely regarded as the commonest benign cause of recurrent chest pain in school-aged children once trauma and musculoskeletal strain have been excluded

Terminology and classification

• In ICD-10 the syndrome sits within block R07, pain in throat and chest, and is assigned the specific code R07.2 for precordial pain
• ICD-11 places the condition in block MD30, pain in throat or chest, under the residual category MD30.1 for other chest pain, because no dedicated code exists for precordial catch
• The eponym Texidor's twinge commemorates the co-author of the 1955 description, and the descriptive term precordial catch refers to the sensation of the chest being caught or pinched during a deep breath
• The United States National Library of Medicine added Precordial Catch Syndrome as a narrower concept under Chest Pain in MeSH in 2017, with the concept identifier M000616115
• Wikidata maps the entity to Q3408834, and the syndrome is classified functionally as a benign, non-cardiac chest pain disorder that requires no structural explanation
• It must not be conflated with effort syndrome, also called Da Costa syndrome, which described exertional breathlessness and fatigue in soldiers, nor with Bornholm disease or epidemic pleurodynia caused by enteroviruses

History

• Miller and Texidor described the entity in 1955 in the Journal of the American Medical Association, reporting young, otherwise healthy patients with recurrent brief precordial pain who had no evidence of heart disease
• A 1978 survey by Sparrow and Bird in healthy young adults confirmed that the characteristic pain could be reproduced and was far more common than contemporary clinical records suggested
• In 1981 Pickering reported 17 children aged 8 to 16 years in Oxford whose episodes matched the original description and who remained free of cardiac disease on follow-up
• During the 1980s and 1990s the syndrome became a standard item in paediatric cardiology differential lists, and unnecessary echocardiography and Holter monitoring were increasingly recognised as avoidable
• Reviews published after 2010 re-emphasised that the diagnosis is clinical, that parental anxiety drives most referrals, and that imaging should be reserved for atypical features or red flags
• Despite more than six decades of literature, the condition remains under-recognised in primary care and emergency departments, and many children still undergo extensive cardiac investigation before the benign explanation is offered

Epidemiology

• Precordial catch syndrome is most often encountered between 6 and 12 years of age, although the reported age at onset ranges from about 4 to 10 years in paediatric series
• Community surveys of adolescents have found that up to one in five healthy teenagers recalls at least one characteristic episode, a figure far higher than the number who seek medical attention
• Most series find no meaningful sex difference, although referral patterns sometimes favour girls because of greater parental concern about chest symptoms
• Adults can be affected, but new onset in middle age or old age should prompt a search for coronary, pericardial, pleural, and oesophageal disease rather than acceptance of a benign diagnosis
• Because the condition is diagnosed clinically and is rarely recorded in registries, population prevalence cannot be measured directly and all estimates derive from questionnaire surveys and clinic audits
• The syndrome is reported across continents and socioeconomic groups, and no ethnic, geographic, or seasonal pattern has been established
• Recurrence is common over months to a few years, but the frequency and intensity of episodes usually decline as the child grows, and persistence into adulthood is uncommon
• In paediatric chest pain clinics, precordial catch is consistently among the three most frequent final diagnoses, together with costochondritis and anxiety-related chest pain

Pathophysiology

• The mechanism remains unknown, and no autopsy, biopsy, or imaging study has identified a structural lesion responsible for the pain
• The most widely cited hypothesis is mechanical irritation of the parietal pleura or chest wall at the moment of maximal inspiratory expansion, producing a sudden focal catch
• An alternative explanation invokes transient compression of an intercostal nerve or a small intercostal vessel between adjacent ribs during deep inspiration
• Rapid growth of the thoracic cage during the pubertal growth spurt may increase susceptibility by altering chest wall compliance and muscle coordination
• The pain is not ischaemic, inflammatory, or pleuritic in the pathological sense, and there is no evidence of myocardial injury, pericardial inflammation, or pneumothorax
• The absence of structural disease at imaging and the spontaneous, self-limited course over years strongly support a benign functional mechanism rather than an occult organic process

Clinical features

• The hallmark is a sudden, sharp, stabbing pain in a small area of the left precordium, often described by children as a catch, a pinch, or a knife-like stab
• Episodes last seconds to a few minutes, rarely longer than 30 minutes, and reach maximal intensity almost immediately rather than building up gradually as angina does
• Deep inspiration, coughing, sneezing, or sudden trunk movement reliably aggravates the pain, while deliberate shallow breathing, holding the breath, or leaning forward may abort an episode
• Between episodes the child is entirely well, with normal growth, normal exercise tolerance, and no constitutional symptoms such as fever, weight loss, or night sweats
• Physical examination, including cardiac auscultation, chest wall palpation, and assessment of costo-chondral junctions, is normal, and reproducing the pain by palpation is unusual
• The unpredictable, recurrent pain can generate substantial anxiety in children and parents, leading to school avoidance, restriction of sport, and repeated emergency visits even when the condition is benign

Diagnosis

• Diagnosis is clinical and is made when the typical history is obtained in a healthy child or adolescent after cardiac and pulmonary causes have been reasonably excluded
• A 12-lead electrocardiogram is usually normal and is performed chiefly to identify red flags such as conduction disease, hypertrophy, or repolarisation abnormalities
• Chest radiography is reserved for patients with fever, cough, breathlessness, asymmetry on auscultation, or a history suggesting pneumothorax or pleurisy
• Echocardiography should be considered when the pain is exertional, associated with syncope or palpitations, or when a family history of sudden cardiac death or cardiomyopathy is present
• The differential diagnosis includes costochondritis, Tietze syndrome, slipping rib syndrome, pleurisy, pericarditis, pneumothorax, oesophageal spasm, angina, and anxiety-related chest pain
• No laboratory test is diagnostic, and routine measurement of troponin, D-dimer, or inflammatory markers is discouraged in the typical presentation because it promotes false-positive cascades
• The 2021 American Heart Association and American College of Cardiology chest pain guideline and NICE CG95 both emphasise structured risk assessment so that low-risk, non-cardiac pain is not over-investigated

Management

• Management consists of confident reassurance, a clear explanation of the benign mechanism, and an explicit statement that the pain does not damage the heart or lungs
• Parents should be told that episodes are self-limited, that the child may continue normal activity and sport, and that no restriction or school absence is warranted
• A simple breathing technique, in which the child takes a slow shallow breath and then resumes normal breathing, can shorten an episode and reduce panic
• Correcting habitual slumped posture and encouraging gentle chest wall stretching may reduce the frequency of mechanically provoked episodes in some adolescents
• Simple analgesics such as ibuprofen, paracetamol, or topical diclofenac are sometimes tried by families, but no controlled trial supports their use and they are not recommended as routine treatment
• Opioids, beta-blockers, calcium channel blockers, and anti-anxiety drugs have no established role and should not be prescribed for this benign condition
• Follow-up is unnecessary when the history is typical and examination is normal, but review is appropriate if pain becomes exertional, wakes the child from sleep, changes character, or is accompanied by syncope or fever
• The prognosis is excellent, with most children experiencing progressively fewer episodes and complete resolution by late adolescence, and no long-term cardiac, pulmonary, or psychological sequelae

Research and controversies

• The pathophysiological mechanism has never been conclusively demonstrated, and the mechanical, neural, and growth-related hypotheses remain untested in controlled studies
• Prevalence estimates differ by an order of magnitude because survey methodology, recall periods, and case definitions vary between studies
• Whether precordial catch overlaps with other functional chest pain syndromes, including panic-associated chest pain and chest wall syndrome, is still debated
• No randomised trial has compared reassurance alone with reassurance plus breathing retraining, physiotherapy, or psychological intervention
• Better undergraduate and postgraduate teaching, together with brief point-of-care decision aids, could reduce the diagnostic odyssey and the cost of unnecessary cardiac testing in affected children