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Chest Conditions: Section Articles

Atypical Chest Pain in Athletes

Sik, Emma C; Batt, Mark E; Heslop, Laurence M

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Current Sports Medicine Reports: March 2009 - Volume 8 - Issue 2 - p 52-58
doi: 10.1249/JSR.0b013e31819c7d01
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Abstract

INTRODUCTION

Chest pain is a common problem in the general population, accounting for approximately 20%-30% of hospital admissions (29). Typically, the initial concern is whether the patient has pain from ischemic heart disease, but once excluded, the diagnosis is not always straightforward. Some causes of chest pain may affect athletes more frequently than the general population due to their sport and training patterns, or less frequently due to their unique anatomy and physiology. This article concentrates on the different causes of atypical chest pain in athletes.

DEFINITION/METHODS

A generally accepted definition for "atypical chest pain" is chest pain that is not typical for anginal/ischemic pain. This definition is not always helpful, given that ischemic heart disease can present in an "atypical" manner. To simplify matters, we have defined atypical chest pain as chest pain not caused by myocardial ischemia. Myocardial ischemia results from an imbalance between myocardial oxygen demand and coronary blood flow, and there are several conditions that can cause this including atherosclerotic disease, coronary emboli, coronary vasospasm, anomalous coronary arteries, arteritis, aortic stenosis, mitral valve prolapse (pain is thought to result from papillary muscle ischemia) (29), hypertrophic cardiomyopathy, severe anemia, and thyrotoxicosis. We will not mention these conditions further and also have excluded causes of chest pain due to acute, direct trauma. For traumatic causes of chest pain in athletes, we suggest reading the review by Perron (25).

This review was compiled following a search of Medline and Embase for relevant articles that were related to sport/exercise/athletes and were published after 2000. If no (or limited) articles were found for a specific condition, we widened our search to include earlier articles or those involving the general population, or performed a Google search for online articles.

DIFFERENTIAL DIAGNOSIS/INCIDENCE

There is a paucity of studies measuring the incidence of conditions causing chest pain in an athletic population. A cohort study looked at causes of atypical chest pain in patients admitted to an English hospital over a 5-wk period and followed up with them after 1 yr (31). They separated the diagnoses into five categories: musculoskeletal (23% of initial diagnoses, 27% at 1 yr), cardiac (19%/25%), gastrointestinal (11%/14%), respiratory (9%/12%) and no diagnosis (37%/22%). The individual conditions included in each category were not mentioned. An earlier study on a larger inpatient group found a similar percentage of people diagnosed with chest wall conditions (28%) but a higher percentage of gastroesophageal disease (42%) (13).

It is impossible to rank causes of atypical chest pain in athletes by incidence because of lack of data and differing patterns of conditions in different sports. The table lists the differential diagnoses by anatomical region.

TABLE
TABLE:
Causes of atypical chest pain in athletes.

MUSCULOSKELETAL/CHEST WALL CONDITIONS

Several conditions that arise from the chest wall can cause chest pain. They can arise from the bones, joints, thoracic spine, and muscles.

Bone/Cartilage

Rib stress fractures

Repetitive movements in certain sports can lead to stress fractures of the ribs. The most common rib to sustain a stress fracture is probably the first rib during sports involving repetitive overhead movements such as tennis, basketball, javelin, weightlifting, and baseball (6,14,18). The first rib has a point of relative weakness where there is a deep groove for the subclavian artery. The bone undergoes stress at this point due to opposing forces from the scalene muscles and the serratus anterior (6,18).

A stress fracture of the first rib normally presents with dull, aching pain in the region of the shoulder, neck, clavicle, or scapula that may radiate towards the sternum (18). There subsequently may be an acute increase in pain associated with a "pop" (6). Upon examination, there may be tenderness over the first rib with associated muscle spasm. Plain radiographs are often negative initially and may show an incidental congenital defect or fibrous non-union (14). Therefore, if clinically suspected, the early investigation of choice is a triple phase bone scan, with computed tomography (CT) or magnetic resonance imaging (MRI) being useful later if further information is needed (6,18).

Treatment involves initial rest until asymptomatic, followed by gradual return to overhead activity, with biomechanical and technical correction if needed. Return to full activity is cited as anything between 1 and 12 months (6,14). Delayed union and non-union are not uncommon but can often be asymptomatic. Other rare late complications include brachial plexus palsy, Horner's syndrome, and thoracic outlet syndrome due to extensive callus formation (6).

Other rib stress fractures can occur, primarily of ribs 4 to 8, with reports in athletes involved in rowing, golf, swimming, and canoeing (18). One study found stress fractures in 9% of Italian Olympic rowers (8); other studies have suggested a frequency up to 12% in rowers (14). Contributing factors include gender (more common in women) (18), technique, training volume, and equipment (8). Fractures are thought to occur more commonly at posterolateral (14) or anterolateral (8,18) sites, but the exact mechanism leading to a fracture is unclear.

Athletes typically present with vague chest wall pain that is difficult to localize and worsens upon deep breathing and movement. The pain may then increase to prevent sporting activity as it becomes more localized with point tenderness over the affected rib (14,18). Plain radiographs and ultrasound may demonstrate the fracture line or callus formation, but some fractures may be missed, particularly in the early stages, so bone scan or MRI are the investigations of choice (8,14,18). Treatment involves rest and analgesia with gradual return to the provocative activity at 4-6 wk and normally full training/competition by 8-10 wk (14).

Slipping rib syndrome

This syndrome may be under-reported and has been given several different names, including rib-tip syndrome, clicking rib, and twelfth rib syndrome (14). It can be caused by repetitive trunk motion in sports such as running and swimming (18). It is thought to occur due to hypermobility of the false/floating ribs (8 to 12) allowing the affected rib to slip under the adjacent superior rib (14,18). This slippage can cause intercostal nerve irritation, strain of the intercostal muscle, or sprain of the costal cartilage (35).

Typical presentation is of sharp, stabbing pain followed by an ache that can last for several days (14). The pain can be felt under the rib cage, or in the upper abdomen/lower chest or back (14,18,35). Pain can be reproduced by pressure over the lower costal margin and the hooking maneuver causes pain and clicking. This maneuver, which can be performed before and after a nerve block, involves the clinician hooking his or her fingers under the lower costal cartilage and pulling anteriorly (35). Imaging does not aid the diagnosis, although CT scanning may be considered to look for a costal cartilage fracture (which may only respond to surgery) (14). Treatment options include reassurance, avoidance of exacerbating movements, taping, manipulation, and nerve blocks. In severe cases, excision of the anterior rib end and costal cartilage may be required (14,35).

Sternal stress fractures

Stress fractures of the manubriosternum are thought to represent only 0.5% of all sternal fractures (14). They are caused by repetitive contraction of muscles attaching to different areas of the sternum and have been reported in wrestlers and a golfer (14). Two cases of manubriosternum stress fractures were reported in female military recruits after performing triceps dips for the first time (16).

Athletes present with gradual onset of anterior chest pain or sudden, severe pain after a click in the sternum (16). The pain is worse upon inspiration/movement, and there is sternal tenderness, often with associated swelling. Plain radiographs will often confirm the diagnosis; if not, a bone scan or MRI can be performed. CT will exclude other causes of bony pain such as a neoplasm (14). Treatment consists of analgesia and rest followed by a gradual return to sport. The time taken for symptoms to resolve can vary; the first female military recruit was symptom free at 6 wk, whereas the second was still symptomatic at 2 yr and was discharged from the Armed Forces (16).

Joint

Costochondritis

Costochondritis is a poorly understood but common diagnosis for atypical chest pain. In one study, 30% of patients presenting to a hospital with chest pain were diagnosed with costochondritis, more of them women (14). Most reports are in the general population, but some have related the condition to specific movements in sports such as volleyball and rowing (2). It is thought that inflammation in the costochondral region could be caused by increased muscular pull at the rib or a dysfunction at the costotransverse joint of the rib (2).

Costochondritis is suspected if the athlete has anterior chest pain and localized tenderness over the costochondral junction without swelling, heat, or erythema. The second to fifth costal cartilages most commonly are involved (14). Examination also may reveal restriction of corresponding costovertebral and costotransverse joints (2). Results of investigations have been inconsistent, with some studies reporting raised erythrocyte sedimentation rate (ESR) on blood tests and changes on plain radiographs, CT, and bone scan but others reporting normal imaging/blood tests (2). Treatment normally involves analgesia and reassurance, but other treatments used include acupuncture, steroid/local anesthetic injections, sulfasalazine, taping, and mobilization/manipulation (2). Symptoms normally resolve within 1 yr (14).

Tietze's syndrome

Tietze's syndrome also affects the costochondral junctions, but unlike costochondritis, it is associated with swelling at the area of pain. There should be no warmth or erythema over the swelling - this finding raises suspicion of a septic or inflammatory arthritis. It normally presents in young people, most commonly affects the second and third costochondral junctions, and is more frequently unilateral (14). It is generally a diagnosis of exclusion, with two papers highlighting the importance of CT scanning to rule out other causes, especially if symptoms are prolonged. The first reports the case of a woman who was found to have squamous cell carcinoma of the mediastinum after CT and biopsy, having initially been diagnosed with Tietze's (33). The second reports four cases of young patients initially diagnosed with Tietze's who were subsequently found to have lymphoma (11).

Sternoclavicular, sternocostal, and costovertebral joint subluxation

There have been several reports of sternoclavicular and sternocostal joint subluxation in athletes. One report was of a female swimmer with bilateral, atraumatic, subluxing sternoclavicular joints (9). She experienced pain and clicking associated with overhead movement and was found to have congenital multijoint hypermobility causing the subluxation. She was treated conservatively but had to give up swimming. Such anterior subluxations are not rare; however, surgery for this condition has variable results and normally is reserved for posterior dislocations or severe symptoms (9). Another report was of a wrestler who twisted during a fight and sustained a fracture-subluxation of the second sternocostal synchondrosis, resulting in a painful swelling over the anterior chest wall (14). CT confirms diagnosis (plain radiographs are normal), and if symptoms do not settle with conservative management, surgical debridement may be needed (14).

Costovertebral subluxation is more common and has been reported in rowers, butterfly swimmers, gymnasts, and dancers (29). The pain is often posterior but can be referred to the anterior chest wall and is normally at the level of the sixth and seventh ribs (14). Pain is exacerbated by movements and deep breathing/coughing, and there is tenderness in the region of the affected joint. Treatment is manipulation of the affected rib back into place (18).

Other sternoclavicular joint conditions

The sternoclavicular joint can be affected by conditions that affect other joints, such as osteoarthritis, inflammatory arthritis (e.g., rheumatoid, psoriatic, ankylosing spondylitis), septic arthritis, and crystal arthropathies. However, there are some conditions that are relatively specific to the sternoclavicular joint (26). SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome or sternoclavicular hyperostosis is a spectrum of skin and osteoarticular conditions that may present with pain, swelling, and restriction of sternoclavicular joints. Up to 60% of patients have associated pustular skin lesions, and the osteoarticular symptoms may move to other sites, including costochondral/sternocostal junctions and the manubriosternal joint (26).

Condensing osteitis is a condition of unknown etiology involving aseptic enlargement and osteosclerosis of the medial clavicle, causing pain and swelling of the sternoclavicular joint (26). It occurs almost exclusively in women aged between 20 and 60 yr and is usually self-limiting. Friedrich's disease is osteonecrosis of the medial clavicle (without predisposing causes) and is another self-limiting condition. MRI can be used to aid diagnosis in both conditions; treatment involves non-steroidal anti-inflammatory medication and restriction of activity (26).

Xiphodynia

Xiphodynia or painful xiphoid syndrome is a self-limiting cause of chest pain but rarely is reported in the literature. The pain is thought to be caused by inflammation at the xiphisternal joint, and palpation over the xiphisternum should reproduce symptoms (14). It must be noted that xiphodynia is a diagnosis of exclusion and that patients with chest wall tenderness may have serious underlying conditions. This is demonstrated in a report of a patient diagnosed with xiphodynia who went on to develop echocardiogram (ECG) changes consistent with impending myocardial infarction within 24 h of pain onset (19).

Thoracic Spine

Pain from structures in the thoracic spine may radiate to the lateral or anterior chest. Thoracic disc prolapse can occur but is rare because of the relative immobility of the thoracic vertebrae (18). Other conditions that need to be considered are discitis and spinal cord or vertebral body lesions (e.g., metastases, myeloma, and other tumors). The first line investigation of choice for thoracic spine problems is typically MRI.

Myofascial

Intercostal muscle strain

Intercostal muscle strains can occur acutely or may be of gradual onset and are related to unaccustomed or excessive muscular activity (14). They are more frequent in sports with intense upper body activity, such as rowing, and may occur upon returning to training after a period of rest. The athlete complains of pain between the ribs that is worse upon movement, deep inspiration, and coughing. Treatment consists of analgesia and rest from exacerbating activities (14). Some authors have suggested that intercostal muscle strains are actually rib stress reactions that develop into stress fractures if the athlete continues training (18).

Serratus anterior injury

Serratus anterior also can be injured by overuse in sports such as rowing (18). Athletes typically complain of pain at the medial scapula border that radiates to the anterior chest wall. Resisted scapular protraction reproduces the pain (18). Symptoms improve with rest from exacerbating activities, but this may take several weeks. A case of acute serratus anterior avulsion has been reported in an athlete after weight-lifting and using a rowing ergometer (18). The athlete had chest wall pain and a lateral mass, the diagnosis was confirmed with MRI, and the athlete responded to conservative treatment.

Myofascial trigger points

Myofascial trigger points are hyperirritable tender spots in palpable bands of muscle that can refer pain or motor dysfunction to another location (10). They are common and can occur in any muscle as a result of muscle overload, causing poorly localized, aching pain, and sometimes parasthesia (10). Myofascial trigger points in regions such as the neck and shoulder can refer pain to the chest, and pectoralis major trigger points may also cause chest pain (10). It is important to realize that visceral pain (e.g., from myocardial infarction) can cause trigger points, so serious underlying conditions must be excluded. Treatment of trigger points includes recognition of the cause that activated the trigger point, muscle stretch/relaxation techniques, massage, heat, ultrasound, and needling/injection of the trigger point (10).

GASTROINTESTINAL CONDITIONS

Several conditions arising from structures in the gastrointestinal tract can cause chest pain. Many are equally or more frequent in the general compared with the athletic population, such as biliary colic/cholecystitis and hiatus hernia. The conditions mentioned below may occur more frequently during exercise or may be associated with athletes.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is one of the most common conditions causing chest pain (13), with over 50% of surveyed athletes reporting symptoms (5,17). Weightlifting, running, rowing, and cycling may lead to more GERD symptoms; however, some studies have shown no difference in symptoms during rest and during exercise (5,17). One large population study showed an inverse relationship between frequent physical exercise and risk of reflux (17). This has led to the belief that reflux is provoked by higher intensity exercise, with several studies supporting this hypothesis (17). Several mechanisms are thought to contribute to exercise-induced GERD including decrease of gastrointestinal blood flow, reduced contraction pressure of the esophagus, delayed gastric emptying, and an increase in intra-abdominal pressure (5,17). Food intake immediately prior to exercise also appears to increase GERD symptoms (5).

Athletes often present with burning retrosternal pain and may have a dry cough, sore throat/hoarseness, and asthma-like symptoms (29). If the diagnosis is unclear or symptoms are not settling with treatment, then gastroscopy is warranted. Treatment may include reduction in high intensity activity, avoidance of eating immediately before exercise, and a proton-pump inhibitor, which may need to be continued long term (17).

GERD may lead to complications such as stricture, ulcers, and esophagitis (17), with non-steroidal anti-inflammatory medication increasing the risk of these complications. Eating disorders that involve purging also increase the risk of esophagitis and should be considered in athletes who are under pressure to maintain/achieve a particular body shape/weight (29).

Pancreatitis

Acute pancreatitis causes severe epigastrium/lower chest pain and can be life-threatening. There is no evidence that exercise increases the risk of pancreatitis, but there is one case study of an athlete who developed suspected arginine-induced acute pancreatitis (27). L-arginine is an amino acid that is taken as a supplement by many world-class athletes. The athlete had been taking it for 5 months when he developed severe epigastric pain and vomiting and was diagnosed with pancreatitis based on raised serum and urinary amylase. There have been several reports of arginine causing pancreatitis in rats (27), and thus it was suspected that arginine was a causative agent of pancreatitis in this case.

Boerhaave's Syndrome

Boerhaave's syndrome is spontaneous esophageal rupture secondary to a sudden rise in intraluminal pressure (30). One cause of this pressure rise could be heavy lifting, suggesting that weight-lifters could be at risk. It is a rare condition but mortality rate is reported to be as high as 46% if diagnosed late (30). Symptoms include painful swallowing and pleuritic chest pain, and surgical treatment is required. There has been a case report of Boerhaave's syndrome secondary to chiropractic manipulation for back pain (30).

RESPIRATORY CONDITIONS

Respiratory conditions that may cause chest pain include exercise-induced asthma, lower respiratory infection, pneumothorax, and pulmonary embolism. The first two conditions are by far the most common and occur frequently in athletes.

Exercise-Induced Asthma/Bronchoconstriction

Exercise-induced asthma (EIA) and bronchoconstriction (EIB) are similar conditions, with EIA inferring symptoms provoked directly by exercise whereas EIB represents reduced lung function during or after exercise even in the absence of a previous asthma diagnosis (36). Surveys have suggested a prevalence of at least 10%-20% among athletes (1). Symptoms include chest tightness/pain, dyspnea, wheeze, cough, and fatigue.

If EIA/EIB are suspected, a physical examination must be carried out to assess severity and exclude other diagnoses such as heart failure. A diary of peak expiratory flow readings may demonstrate a drop associated with exercise. Treatment is outside the scope of this article but often involves inhaled beta-2 agonists, requiring a therapeutic use exemption in athletes undergoing drug testing. Beginning January 2009, the World Anti-Doping Agency will only accept a diagnosis of asthma if spirometry reveals evidence of reversible airway obstruction, or if a bronchial provocation test shows the presence of airway hyperresponsiveness.

EIA/EIB can be a serious condition with one report identifying 61 deaths in competitive athletes between 1993 and 2000 (1). Therefore, it is important to remove an athlete with ongoing symptoms of EIA/EIB from play and monitor him or her closely until symptoms have resolved.

Lower Respiratory Infections

Lower respiratory tract infections, including bronchitis, influenza, and pneumonia, can cause chest pain secondary to inflammation of the pleura or overuse of the chest wall muscles during coughing. Athletes may be susceptible to developing respiratory infection due to increased physical stress (from intense training and sleep deprivation) or increased pathogen exposure (from person to person contact and shared use of equipment) (21). It has been suggested that an athlete with influenza should be isolated for 5 d after symptom onset to prevent spread of disease (20).

Return to intense exercise too quickly following infection can lead to complications such as activation of latent airway disease, myocarditis, and musculoskeletal injury (21). The "neck check" has been suggested which states that if the athlete's symptoms are above the neck only they can return to play (21). Athletes should also be afebrile before returning to training (20). Finally, it has been recommended that following atypical pneumonia most athletes can begin light training 7 d after resolution of signs/symptoms, gradually increasing intensity over the next 7 d (1).

Spontaneous Pneumothorax

There exist reports of spontaneous pneumothorax occurring in weight-lifting, jogging, scuba-diving, and basketball (7). This condition is uncommon, with 10% of spontaneous pneumathoraces occurring during physical activity (20). It has been suggested that elevated intrathoracic pressure is the precipitating factor for pneumothorax during exercise (7). Athletes at increased risk include young men, smokers, and those who have had a previous spontaneous pneumothorax. Chest pain is present in 80%-95% of cases (7), is often pleuritic, and can be associated with breathlessness and a dry cough. Examination reveals reduced chest expansion, reduced air entry, and hyperresonance over the affected side.

Diagnosis is by chest x-ray, although suspicion of a tension pneumothorax warrants immediate needle thoracocentesis. Small pneumothoraces do not need treatment other than monitoring, and athletes can normally return to training immediately after resolution, with a gradual increase in activity (20). The definition of a "small pneumothorax" varies in the literature, ranging from <10% to <30%. Larger pneumothoraces require a chest drain, and athletes can generally return to sport after 2-4 wk (20). The risk of recurrence is approximately 30%, and if this occurs, athletes should probably refrain from higher intensity activity unless they undergo a corrective procedure (20).

Pulmonary Embolus

Pulmonary embolism (PE) is a potentially life-threatening condition. It generally is associated with sedentary behavior and so is less common in the athletic population unless involved in long-haul travel. However, there have been reports of PE occurring in a soccer player, a wrestler, and long-distance runners (12,23). PE in athletes may be secondary to an underlying coagulopathy; when this is not the case, a possible contributing factor is dehydration (23). Treatment of PE is normally anticoagulation with warfarin, and athletes should be advised not to partake in contact/collision sports while on warfarin.

CARDIAC CONDITIONS

There are a few cardiac conditions that cause chest pain without myocardial ischemia. The most common are pericarditis and myocarditis, with aortic dissection another potential cause.

Pericarditis

Pericarditis is inflammation of the pericardium and has many causes, the most common being infection. Other causes include sarcoidosis, systemic lupus erythematosus (SLE), rheumatoid arthritis, and idiopathic (28). It is diagnosed in approximately 5% of patients presenting to hospital with atypical chest pain and is more common in young adults (28). Chest pain (normally pleuritic) is the major clinical symptom and is often worsened by lying down or relieved by sitting forward (24). Pericarditis typically presents with a friction rub on examination and characteristic ECG changes including upwards concave ST-segment elevation in all leads (28). A potential complication is pericardial effusion, seen on echocardiography, which can rarely lead to life-threatening pericardial tamponade.

Treatment is generally supportive, depending on the underlying cause. Symptoms normally resolve within 2 wk but can recur in 15%-30% of idiopathic cases (28). Athletes can return to play once there is no evidence of active disease (no fever, no pericardial effusion and normal serum inflammatory markers) (28).

Myocarditis

Myocarditis is an inflammatory disease of the heart muscle caused by infectious agents (most commonly viruses) and non-infectious agents such as drugs (e.g., lithium and cocaine) (3). It is the most common acquired cardiac disease in the young, with 52% of cases occurring in people aged 20-39 yr (4). Infective myocarditis may occur more frequently in athletes due to overtraining having a depressant effect upon the immune system (3). Physical activity also may increase the inflammation and necrosis seen in myocarditis (3), leading to increased risk of complications such as dilated cardiomyopathy, heart failure, arrhythmias, and death (21). Myocarditis has been reported as causing between 5.2% and 42% of sudden death (3).

Athletes may present with a variety of symptoms including chest pain, fatigue, dyspnoea and/or palpitations and often have a recent history of flu-like symptoms (4). The physical examination is often normal. Diagnosis can be aided by ECG, echocardiography, and cardiac MRI but these may be normal or show non-specific changes, so the "gold standard" investigation is endomyocardial biopsy (4). Treatment is generally supportive. The general consensus is that athletes should refrain from sporting activity for at least 6 months after onset of symptoms and until echocardiogram and ECG (resting and exercise) are normal (21).

CHILDREN/ADOLESCENTS

A condition that can cause chest pain exclusively in adolescents is breast budding during puberty. This can cause discomfort in females and males (29). Other conditions causing atypical chest pain that occur most frequently in children or adolescents are mentioned below.

Psychogenic Causes

Psychogenic chest pain from, for example, anxiety and hyperventilation can be relatively common, occurring most frequently in adolescents (29). One study suggested that hyperventilation was the cause of chest pain in 20% of adolescent patients (29). Careful history can point toward psychogenic causes, such as recent family or school stress and a family history of chest pain (29).

Precordial Catch Syndrome

Precordial catch syndrome was first described in 1955 and is characterized by sudden onset sharp, stabbing, well-localized pain (15). It is thought to be a common cause of chest pain in children, frequently presenting between the ages of 6 and 12 yr (15). Episodes last between 30 s and 3 min and rarely are associated with other symptoms. The etiology is unknown and the only treatment required is reassurance.

MISCELLANOUS CONDITIONS

Finally, there are some miscellaneous conditions that can cause atypical chest pain that are all relatively rare in the young athletic population:

Malignancy has been mentioned above and is an important diagnosis to consider even in younger athletes. Other malignancies that can cause chest pain include lung, breast, and gastric cancer.

Drugs including steroids and stimulants have been reported to cause chest pain (29). One study reports the case of a wrestler who developed atypical chest pain during exercise following ingestion of ma huang (a derivative of ephedrine) (24). He was trying to lose weight and was dehydrated. The cause of the pain was not found; ECGs (resting and exercise), echocardiogram, and Holter cardiac monitoring were all normal.

Herpes zoster was found to be a cause of chest pain in 1 out of 802 patients admitted to hospital with chest pain (13). Pain normally appears before the characteristic blistering skin rash, and so diagnosis can initially be difficult.

Epidemic myalgia (also known as pleurodynia or Bornholm disease) is an acute viral illness that can cause sharp lower chest pains due to involvement of the intercostal muscles and pleura. It is caused mainly by Coxsackie B virus and is transmitted via a shared water source (14). The incubation period is 3-5 d; symptoms normally resolve after a few days but may recur (14).

Spontaneous pneumomediastinum has been reported as a result of sporting activity (scuba diving, basketball, soccer, volleyball, marathon running, swimming, and rugby) (22,34). The athletes presented mainly with retrosternal chest pain and subcutaneous emphysema (22). They all made a full recovery within 2 wk, without intervention (other than administration of oxygen and analgesia).

Mondor disease is a superficial phlebitis of the chest wall that can cause chest pain. Clinical examination reveals palpable, superficial, cordlike structures over the chest wall (32). One of the predisposing factors to this disease is physical strain, and it has been reported after walking with a heavy backpack and after upper-body gym work (32). It often resolves without treatment.

CONCLUSION

There are multiple causes of atypical chest pain, including those arising from the musculoskeletal, gastrointestinal, respiratory, or cardiac systems. Some conditions, including rib stress fractures, intercostal muscle strain, myofascial trigger points, gastroesophageal reflux disease, and exercise-induced asthma, occur more frequently in the athletic population. Careful history and examination, with consideration of the athlete's sport and age, will often point to a specific diagnosis without the need for further investigations. However, serious, potentially life-threatening conditions such as myocardial infarction, pancreatitis, pulmonary embolism, and malignancy always must be considered and excluded.

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