1A. PERSONAL HISTORY: HAVE YOU EVER EXPERIENCED CHEST PAIN OR DISCOMFORT WITH EXERCISE?
Chest pain in young athletes is rarely fatal and usually of musculoskeletal origin (2). Once cardiac and other life-threatening causes of chest pain have been effectively eliminated from the differential diagnosis, musculoskeletal etiologies may be investigated. The following questions may aid in the differentiation of these conditions.
Was There Trauma to Your Chest Wall?
Chest wall trauma necessitates evaluation for SC joint pathology, slipping rib syndrome, subluxed ribs, or rib fracture.
Where Is Your Pain?
Determining location of greatest pain followed by careful palpation of the chest wall structures are both useful in narrowing down the differential diagnosis of musculoskeletal chest pain.
Is There History of Repetitive Upper Limb or Trunk Use?
Overuse phenomena in the upper limbs are common in athletes who repetitively perform a stroke or motion. Evaluate for rib stress fractures, intercostal muscle strain, rib articulation pain, tendon injuries, and costochondritis.
Is Your Pain Worse with Exercise?
Pain with specific upper limb movements may occur with a rib stress fracture, rib subluxations, or intercostal strain. On the other hand, conditions that are not exacerbated by exercise include precordial catch syndrome, Tietze syndrome, and cervical etiologies of chest pain.
A differential diagnosis of musculoskeletal chest pain should include the following common and clinically significant etiologies.
Traumatic rib fracture
Traumatic rib fracture is generally caused by blunt trauma to the ribs. Ribs are weakest at the posterior angle; fractures occur most commonly in ribs 4 to 9.
Rib stress fractures
Rib stress fractures should be considered in any athlete with atraumatic chest wall pain associated with repetitive activity. Magnetic resonance imaging is the imaging modality of choice because of its superior specificity (>85%).
Sternoclavicular (SC) joint injuries may occur in collision sports. These injuries may be a source of chronic pain in some athletes. The physical examination will demonstrate pain on palpation directly over the SC joint.
Exercise-related transient abdominal pain ("side stitch")
This is a benign condition that athletes describe as a sharp, crampy, or pleuritic pain in the abdomen or lower chest. It occurs only with exercise and disappears with rest. While the etiology is not completely understood, it is often experienced by less trained individuals during vigorous, prolonged exercise or repetitive torso movement, particularly when performed within an hour of eating or drinking.
Costochondritis presents as a peristernal sharp or pressure-like pain, most commonly at second through fifth sternocostal articulations. Athletes may complain of unilateral symptoms that are worse with deep inspiration and upper limb movements after activities that involve repetitive, strenuous use of the chest musculature such as rowing or weightlifting. Diagnosis is made by reproducing the symptoms with palpation of the affected area and exclusion of other potential causes.
Intercostal muscle injury
Pain between the ribs exacerbated by movement, coughing, or deep inspiration may indicate a sprain of the intercostal or other chest wall musculature. The athlete will often recall a specific a sudden increase in training or a specific incident during activity when the pain began.
Slipping rib syndrome
Intermittent sharp pain in the lower ribcage is typical of slipping rib syndrome. This pain may radiate into the chest or back, and the athlete may describe a “popping” or “slipping” sensation of the ribs. Certain postures, trunk movements, and deep breathing may precipitate these symptoms, and this diagnosis is most common in sports with frequent arm abduction. The “hooking maneuver,” performed by placing fingers beneath the lower costal margin and pulling upward and outward is positive if it reproduces the athlete’s pain or a click due to hypermobility of the lower ribs.
Precordial catch syndrome
Precordial catch syndrome is characterized by sharp, stabbing pain in the left precordial and parasternal region that lasts a few seconds; this syndrome accounts for approximately 15% of noncardiac chest pain cases and is unique because it may occur at rest or with mild activity (2). This benign condition of unknown etiology is often exacerbated by deep inspiration and is associated with slouched position that resolves with progression into an upright posture. Reassurance is the only management necessary.
Cervical disk disease/"cervical angina"
Anterior or posterior chest pain may be caused by disorders of the cervical spine, such as cervical disk disease, ossification of the posterior longitudinal ligament, or a C6 or C7 radiculopathy. The history examination should inquire about alteration of the pain with cervical movements, and physical examination should include cervical range of motion, the Spurling maneuver, and a neurologic assessment of the upper and lower limbs with careful documentation of deficits.
Acute, unilateral, anterior chest pain is the usual presentation of this benign condition, distinguished from costochondritis by the presence of swelling at the sternocostal articulation.
Subluxed rib at the costovertebral (rib head) or costochondral joints/articulations
Joint articulation is “stuck” out of normal position and causes pain with joint movement and reactive muscle spasm. The pain can be located anywhere along the rib distribution. There is usually tenderness at the rib head junction. This can be treated with manual therapy and may self-reduce with time.
Case Report 1: Rib Stress Fracture
A 19-year-old female rower presented with a 2-wk history of insidious onset of left lateral and anterior chest pain. There was no pain with moderate exercise such as walking, elliptical, or light running, but the pain occurred when running at a faster pace and rowing. She reported that during the off-season, she pursued a high-resistance, low-repetition rowing routine. Cardiac examination result was normal. There was focal tenderness over the left eighth rib laterally and no tenderness over the pectoralis, latissimus dorsi, or trapezius. Side-bending and deep inspiration reproduced her pain. Rib-view plain radiographs were negative for osseous abnormality. The patient was treated conservatively for a stress fracture of her eighth rib, including reduction in activity of the upper limbs, cross-training, calcium and vitamin D supplementation, and acetaminophen for pain control. After 1 wk of rest, she was able to progress to upper limb exercises pain-free and returned to full activity within 3 wk with the help of a focused physical therapy program.
Key Point: Insidious onset of chest wall pain in an individual with repetitive upper limb use necessitates the inclusion of a rib stress fracture in the differential diagnosis.
Case Report 2: Precordial Cath Syndrome
A 16-year-old female student athlete on her high school basketball team presented to the sports medicine clinic for left-sided chest pain and trouble breathing. During practice the previous day, she reported these symptoms to her coach. Her coach sent her to the emergency room, and chest x-ray and electrocardiogram results were normal. She described a sharp, stabbing pain in the left parasternal chest that only lasted a few seconds while warming up in practice. When this happened, she had trouble fully inhaling, and after several seconds of shallow breathing, the sharp pain resolved and was followed by a dull ache for about 5 min. She reported a similar episode this morning in class while she was sitting in a slouched position that resolved when she stretched her trunk into a more erect, upright position. A complete musculoskeletal examination of the upper limbs and chest wall yielded negative results, and she was diagnosed with precordial catch syndrome and counseled regarding this common, benign condition that is managed conservatively with postural changes as she performed this morning in class.
Key Point: Precordial catch syndrome is a benign condition characterized by sharp pain of short duration that is often influenced by trunk position or respiration.
Case Report 3: Intercostal Muscle Strain
A 23-year-old left-handed male reported right lateral chest-wall pain since he participated in a “long drive” competition for golfers 5 d ago. He attempted to play again 2 d ago but quit early because of this pain. He denied dyspnea, radiation of his pain, or pain during cardiovascular exercise but noticed that his chest hurt yesterday during a coughing spell. Upon physical examination, there was mild tenderness in the area of the right sixth through eighth ribs laterally that was more pronounced in the intercostal segments than over the ribs themselves. Pain also was reproduced with side-bending to the left. After negative plain radiographs, he was diagnosed with strained intercostal muscles, a common phenomenon after excessive muscular activity of the upper limbs and trunk. He was given a 2-wk course of nonsteroidal anti-inflammatory drugs, counseled to refrain from swinging for at least a week, and prescribed a course of physical therapy. Within 3 wk, he was back to full, pain-free activities.
Key Point: Intercostal muscle strain symptoms are reproduced with forceful contraction, passive stretching, and palpation and improve with rest and conservative care.
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