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Chest and Abdominal Conditions

Sports Medicine-Related Breast and Chest Conditions—Update of Current Literature

Obourn, Peter J. DO1; Benoit, Janeeka DO2; Brady, Geena DPT, OCS3; Campbell, Elisabeth DPT, OCS2; Rizzone, Katherine MD, MPH1

Author Information
Current Sports Medicine Reports: March 2021 - Volume 20 - Issue 3 - p 140-149
doi: 10.1249/JSR.0000000000000824
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Abstract

Introduction

There is a paucity of literature that discusses breast and upper chest sports-related injuries. This article reviews the most up to date evidence-based recommendations pertaining to breast and upper chest conditions, specifically for the sports medicine physician.

Breast

Breast Anatomy

The human breast is composed of multiple individual lobes, with a luminal glandular and myoepithelial layer (1). It is bordered superiorly by the superficial fascia between the second and sixth intercostal cartilage and the pectoralis muscle is located inferiorly. In nonpregnant women, the nonpregnant breast weighs approximately 200 g and increases to 400 g to 600 g during pregnancy and to 600 g to 800 g during lactation (2).

The nipple areolar complex is composed of pigmented skin that connects to a system of ducts (3). The nipple is a cone-shaped elevation in the center of the areola and is located at the fourth intercostal space. It contains fibers made of smooth muscle and is abundantly innervated with sensory and pain fibers (2).

Breast-Related Conditions

Nipple Discharge/Nipple Trauma

Epidemiology

In sports, frictional breast injuries, such as jogger's nipple, are most commonly seen in endurance runners. Within endurance event literature, jogger's nipple was reported by 2% to 16.3% of runners (4).

Nipple discharge comprises 7% to 10% of breast symptoms and is often benign (4). Nipple discharge can be a normal finding in pregnant women and postpartum women for up to 2 years (4). Discharge is more common in the overweight patient (5). Reported nipple discharge in sports appears to be uncommon because of the paucity of research in this specific area.

Mechanism of Injury

Nipple trauma most often occurs in runners, particularly women without bras and men who wear coarse fiber T-shirts made of cotton (6). However, nipple trauma has been reported in athletes participating in other sports, as well, including both contact and noncontact sports (7). Jogger's nipple can lead to painful, erythematous, crusted lesions of the nipples and areola. With continued repetitive friction, nipple discharge can present in the form of bleeding from cracked lesions and fissures (6). Nipple discharge secondary to friction should be distinguished from nontraumatic discharge.

Evaluation

The clinical examination and mammography are first-line measures in evaluation of nipple discharge. Mammography is recommended in any person with abnormal discharge, despite its weak positive predictive value (16.7%). Breast ultrasound serves as a complementary diagnostic tool to mammography, because it can visualize lesions within the ducts. It also can be used for fine needle aspiration guidance for cytology collection. Magnetic resonance imaging (MRI) has limited utility in evaluation because of its moderate sensitivity (>75%), low-to-moderate specificity (<65%), and low positive predictive value (<60%). MRI can be used in performing MRI-guided biopsies (4).

Bloody, unilateral, single duct discharge should raise suspicion for associated malignancy, especially in the presence of an associated lump in those older than 50 years (4). These symptoms may warrant referral to an oncological breast specialist.

Treatment

Petroleum jelly and antibiotic ointment, such as erythromycin, can help treat jogger's nipple after it occurs. It can be prevented by applying petroleum jelly or adhesive tape on the nipples prior to runs. Additional prevention in women and men include semi synthetic silk or other soft fiber bras and moisture wicking T-shirts, respectively (6).

Return to Play

In general, an athlete should have open skin conditions covered properly to prevent spread, not have any systemic symptoms for more than 72 h, and not have any active or oozing lesions prior to return to play (8). Otherwise, in the absence of any contagious disease, the athlete should be allowed to participate as tolerated.

Traumatic breast injuries

Epidemiology

Traumatic breast injuries can often lead to fat necrosis, which is a benign, nonsuppurative inflammatory process. Anticoagulation increases the risk for fat necrosis, secondary to breast trauma. There have been reports of fat necrosis associated with motor vehicle accidents as a result of seatbelt trauma; however, there have been limited reports of sports-related breast injuries.

Mechanism of injury

The mechanism of injury for breast trauma includes blunt force to the anterior chest. Collision sports, like hockey, rugby, and golf, as well as martial arts, would be higher risk. Although the specific mechanism of breast injury in collegiate female athletes differs from that of a motor vehicle accident, the physiological sequelae of bruising, contusion, hematoma, edema, and pain are similar (9).

Evaluation

Fat necrosis can appear similar to breast cancer, with clinical features, including skin retraction and associated masses or nodules. In rare cases, it also has been associated with tenderness, bruising, skin tethering, dimpling, and nipple retraction. Therefore, a biopsy is usually recommended (10).

Fat necrosis can be evaluated using a variety of imaging modalities. On mammography, features include coarse calcifications, microcalcifications, and asymmetries. In early stages, fibrosis is minimally extensive and at later stages can be characterized as oil cysts with calcifications on the outer wall. On ultrasound, they appear as solid or cystic masses (Fig.). On MRI, fat necrosis is made up of lipophagic granulomas on T1 weighted images. It is difficult to differentiate lipophagic granulomas from malignancy because biopsy is needed for confirmation. On computer tomography (CT), characteristic features include fibrosis, liquified fat, and inflammation. It is important to encompass histological findings and imaging with clinical findings creating a multimodal approach.

Figure 1
Figure 1:
Early sonographic imaging of a large complex fluid collection within breast tissue, measuring approximately 10.8 × 3.3 × 14.7 cm. The fluid collection appears predominantly anechoic (arrow) on ultrasound with some areas of mixed echogenicity (arrowhead), suggesting early fibrotic changes.
Treatment

Immediate treatment includes ice, analgesics, and antiinflammatories in an effort to minimize hematoma and size of the connective tissue scar (11). A combination of ice and padding or compression over periods of 15 to 20 min with repetitive intervals every 60 min is recommended (12). Cryotherapy and hydrotherapy have been shown to improve soreness when compared with passive recovery (13). Cold water immersion has been shown to have positive effects on muscle soreness and secondary tissue damage (14). Therapeutic ultrasound is widely recommended; however, high-quality evidence to support its effectiveness in treating musculoskeletal injuries is limited (12).

Return to play

Rest is advised in the first 3 d to 7 d to allow the scarring tissue to increase in strength. After the first 7 d of rest, mobilization within pain free ranges of horizontal abduction and extension is encouraged to accelerate capillary ingrowth and promote muscle fiber regeneration (15). Fernandes and colleagues (12) report benefit in contrast therapy accompanied by passive and active stretching. A progression of pain-free isometric training can first be initiated without external load and then addition of resistance as tolerated. Once pain-free isometric training with moderate load has been attained, isotonic training is initiated. Ultimately, efforts should focus on attaining tolerance to isotonic and then isokinetic training for both pressing and pulling movement patterns (12,15).

Postmastectomy/postpartum breast pain

Epidemiology/mechanism of injury

All women undergo significant musculoskeletal stress and trauma during birthing, whether the birth occurs vaginally or by means of cesarean section. There are high levels of force on the muscles and soft tissues of the pelvic and abdominal regions as well as, in some circumstances, significant injury. The birthing process itself is physically and emotionally exhausting and often results in generalized postpartum fatigue. The direct and indirect effects of cancer diagnosis and therapeutic management, which can include mastectomy, can often leave patients in a similar state of physical and mental fatigue. Both of these events are life-altering and both impact breast motion, sometimes necessitating support/alternative sports equipment.

Evaluation

Follow up visits are an essential aspect of postpartum care. However, physical fitness and return to activity may not always be adequately addressed. In the practice of primary care sports medicine, the provider should be equipped to assess postpartum fitness and make recommendations for a return to activity.

Treatment

Women who experience healthy pregnancies are encouraged by the American College of Obstetricians and Gynecologists to engage in regular physical activity for at least 20 to 30 min·d−1 on most or all days of the week during pregnancy and the postpartum period (16). Similarly, breast cancer survivors are encouraged to remain as physically active as they can (17).

Despite the beneficial effects of physical activity in breast cancer survivors, it has been demonstrated that physical activity decreases by 11% after breast cancer diagnosis. There were further decreases in physical activity in women treated with radiation and chemotherapy (50% decrease) compared with women who underwent surgery alone (24% decrease) or surgery plus radiation (23%) (17).

A cohort of 471 women who were followed from the second trimester to 12 months postpartum showed that overall levels of physical activity decreased from 17 to 22 wk gestation to 27 to 30 wk gestation but rebounded at 3 months postpartum and maintained stability at 12 months postpartum. However, physical activity related to caregiving represented the largest proportion of physical activity within the postpartum period (18).

Return to Play
Postpartum

Regular exercise at moderate to high intensity has not been found to alter the quality or quantity of breast milk production. However, anaerobic exercise that is extremely intense may alter the taste of milk due to the buildup of byproduct, that is, lactic acid (19).

A systematic review from the IOC expert committee on exercise and pregnancy found insufficient evidence regarding exercise prescription in the treatment of diastasis recti abdominis. There is limited data to support specific “abdominal binding” exercise intervention strategies (20). These findings are consistent with those for the treatment of lumbopelvic pain, as strong evidence has shown that specific stabilization exercises were not more effective than other forms of active exercise in the long term (21).

Postmastectomy

Clinical practice guidelines recommend initiation of physical therapy the day after surgery, with gentle range of motion exercises progressing to active stretching, followed by strengthening over 6 to 8 wk until full range of motion is achieved (22). A systematic review supports these guidelines, as multimodal interventions inclusive of stretching and active range of motion exercise improved function and minimized pain (23). Treatments to address lymphatic system insufficiency include the use of compression bandages or sleeve-and-glove garments and manual lymph drainage techniques (24).

A randomized controlled trial assessing exercise interventions for women in their first year post-breast cancer surgery found early progressive resistance training to significantly improve social and emotional function (25). Global health status and social functioning improvements were even more pronounced in those individuals whose postoperative symptoms included pain, sleeplessness, and fatigue. These individuals participated in progressive upper body, lower body, and trunk resistance exercises after an initial rest and recovery period of 3 wk (25). Supervised exercise is recommended initially, with exercise selection focused on major muscle groups through the trunk, as well as the upper and lower extremities. Specific prescription of exercise should initially focus on low resistance and moderate-to-high repetitions and then gradually work into moderate working sets of 8 to 10 repetitions as the applied load increases (25). A tailored aerobic and strength training regimen initiated within 4 to 12 wk of breast cancer surgery has been shown in the RESTORE trial to improve physical function and decrease risk of lymphedema (26).

Breast cancer survivors should be encouraged to be physically active, and exercise regimens should be tailored to the breast cancer survivor based on severity of disease (15,17).

Gynecomastia

Epidemiology

It has been reported that up to 70% of all boys experience pubertal gynecomastia; that two-thirds of all adult men have palpable breast tissue on examination, and 50% of all men at autopsy have some level of gynecomastia (27,28). Gynecomastia is the most common benign condition of the male breast and has been reported in 36% to 50% of men on routine examination. Peak occurrence appears in three age groups: infants, pubertal men, and those 50 years or older. There is an association with increased BMI thought to be secondary to excess adipose tissue causing conversion of androgens to estrogen. Prevalence rises to 80% in men with a BMI >25 kg/m2 (29). Pubertal gynecomastia is most often due to an imbalance of estrogen and androgens but also can be secondary to underlying medical conditions, such as hyperthyroidism or Leydig cell tumors. Gynecomastia also can be secondary to prescription medication use (i.e., spironolactone).

Gynecomastia due to exogenous estrogen exposure also has been reported; examples include supplementation in the transgender population and prostate cancer patients, topical application of estrogen creams, such as balding lotions, and occupational exposures. Those at risk of occupational exposure include factory workers producing estrogen-containing products (and their families), barbers, and morticians. Gynecomastia also can occur secondary to use of some illicit drugs (i.e., marijuana, heroin, amphetamines, anabolic steroids) (30,31) or herbal supplements, including panax, ginseng, tea tree oil, topical lavender (soap, shampoo, lotion), and soy (29).

The prevalence of specific causes of gynecomastia have been reported as follows: idiopathic 25%, pubertal 25%, drugs 25%, cirrhosis/malnutrition 10%, primary hypogonadism 8%, testicular tumors 3%, secondary hypogonadism 2%, hyperthyroidism 1%, renal disease 1% (28).

Evaluation

Imaging is of limited use and usually unnecessary in the workup of gynecomastia unless there is significant concern for malignancy, which would warrant further workup with ultrasound and/or mammography. The presence of a testicular mass warrants further imaging workup, including ultrasound. Abdominal CT imaging is recommended if there is concern for adrenal mass.

Perhaps one of the most important aspects of workup is a detailed history, including a detailed review of current medications, supplements, and recreational drugs. The ultimate goal at the time of workup is to differentiate breast versus adipose tissue, rule out malignancy, and determine the underlying cause of gynecomastia (27). Physical examination should include palpation of the concerning tissues to assess for breast versus adipose tissue, as can be seen with lipomastia (pseudogynecomastia), and assess for concerning malignant characteristics. Symptoms that would raise suspicion for malignancy include rapid growth, hard tissue, eccentric pattern, asymmetry, ulceration, retraction, deformity of the nipple, and tissue fixed to the skin. Breast tissue is firmer on palpation and will be localized directly underneath the areola, these characteristics can help differentiate it from adipose tissue. Examination also should include inspection for virilization, secondary sex characteristics, or signs of kidney and/or liver disease. The provider also should perform a thyroid examination, as well as a genital examination to assess the size of the genitalia, the presence of pubic hair, and palpate for possible masses.

Treatment

Most cases are benign and are more of a cosmetic concern for the patient. The incidence of malignancy is very low and has been reported as low as 0.1% (28). Although gynecomastia is often benign, it can represent the expression of a more relevant underlying clinical condition and does warrant thorough workup (27). For this reason, the sports medicine physician should be aware of the appropriate workup and current treatment recommendations for this issue.

Return to play

If examination is consistent with adipose tissue, diagnosis of lipomastia can be made with recommendation for weight loss. Patients with lipomastia who do not respond adequately to weight loss can pursue plastic surgery to address cosmesis and/or discomfort. Pubertal or longstanding adult gynecomastia usually does not require further workup. However, if the patient presents with painful progressive new onset of symptoms, further workup may be warranted. Symptoms of potential malignancy certainly warrant further imaging, but these examination findings are very rare. Workup for nonmalignant examination findings may include morning serum testosterone, luteinizing hormone, follicle stimulating hormone, prolactin, liver and kidney functions, thyroid function, serum estrogen, and hCG. A detailed social history should be performed, and any potentially offending medications, drugs, or supplements should be discontinued immediately. Once the identified cause of gynecomastia is adequately addressed, symptoms should resolve within a few weeks. If symptoms persist, medical therapy can be initiated (i.e., androgens, antiestrogens, or aromatase inhibitors). For those requiring treatment, early initiation is very important. Better response to medical therapy has been reported when medications are started within 12 months of development of gynecomastia. After 12 months, deposition of fibrous tissue occurs and leads to poorer outcomes (30). Refractory cases resistant to chronic medical therapy can be treated with surgery. Patients who undergo surgical treatment for gynecomastia often report high levels of satisfaction with a low rate of complication (30).

Most patients who pursue medical care are seeking reassurance of a benign condition. Palpable gynecomastia of less than 4 cm is likely to resolve spontaneously. Pubertal gynecomastia resolved in 90% of cases. It is important for the team physician to offer psychological support as gynecomastia can potentially lead to embarrassment and bullying, which can significantly affect mental health, specifically in young athletes. Furthermore, gynecomastia can lead to slumping posture, used to decrease breast prominence, subsequently leading to musculoskeletal pain. When addressing the psychosocial aspects of gynecomastia, reassurance of the often-short-term nature of this condition is very important (29).

Chest

Chest Anatomy

The pectoralis major (PM) muscle is made up of two origins, including the more proximal clavicular head and the more distal sternal head, which originate along the clavicle and sternum respectively. The clavicular head sits more superiorly and is made up of a single muscle belly, whereas the sternal head sits inferiorly and is made up of several muscle segments that overlap one another in a fan-like configuration. The sternal and clavicular heads come together at the musculotendinous junction forming a U-shaped common PM tendon before inserting on the proximal humerus at the lateral aspect of the bicipital groove (32). The configuration of these heads has been described as twisting, with the fibers of the clavicular head forming the more distal insertion of the PM tendon and the sternal head forming the more proximal fibers of the PM tendon (33). The mechanics of the PM muscle are such that it contributes to adduction, flexion, and internal rotation of the humerus (4).

The sternum makes up the center piece of the anterior thoracic cage and is made up of three segments, including the manubrium, sternal body, and xiphoid process. The manubrium makes up the widest portion of the sternum and forms a cartilaginous articulation on either side with the medial clavicles. The manubrium and the body of the sternum articulate via a fibrocartilaginous symphysis (34).

The first seven ribs have sternocostal buffering bases. In ribs 6 through 10 there are interchondral synovial joints with an articular capsule between the first three of these, the 9th to 10th rib have a fibrous articulation. These are much weaker buffers in between the lower ribs as compared with those with attachments to the sternum.

Chest-Related Conditions

Sternum stress fracture

Epidemiology

Traumatic sternal fracture is a common injury often associated with high velocity injuries, such as motor vehicle accidents. Sternal stress fractures are much rarer and have been reported in only five recent case studies (34). Of the reported sternal stress fractures, three occurred within the sternal body and two within the manubrium. The manubrial stress fractures were reported in a golfer and a weightlifter, with general sternal stress injuries being reported in wrestlers, weightlifters, golfers, gymnasts, and rugby players (35).

Mechanism of Injury

Sternal stress fractures, more specifically those of the manubrium, have been proposed to be secondary to repetitive torque and muscle forces on the first costal cartilage and manubrium. Other mechanisms described include a hyperflexion mechanism (36), as well as a hunched over position while biking (35). Reduced bone mineral density has been reported as a risk factor (34). Most stress-related injuries of the sternum have occurred in the setting of a recent rapid increase in upper body activity (35). Potential sternal stress injury should be suspected in any athlete with chest pain who performs activity with repetitive upper body stresses.

Evaluation

Initial workup includes X-rays, which are often unremarkable. Other imaging modalities to consider include CT, MRI, ultrasound, and bone scan to assess for occult stress fracture. CT scan is best for assessing traumatic fracture but has limited capability in detecting early edema related to stress injury. Marrow edema suggestive of early stress injury is much better evaluated with MRI. MRI and ultrasound also can show retrosternal hematoma, which is suggestive and often predictive of sternal stress injury (37).

Stress injuries are atraumatic, and athletes will often present with insidious onset of symptoms. Athletes will commonly report a recent increase in athletic activity (34). Examination may include reproducible chest wall pain with cross body arm adduction (34,35) or tenderness to direct palpation of the anterior chest wall. Weightlifters often report no pain during lifting but do complain of postworkout soreness (35).

Treatment

Treatment of sternal stress fractures depends on the severity of the injury, but most sternal stress fractures can be treated conservatively with common modalities, such as rest, ice, pain-free activity, analgesics, and anti-inflammatory medication. Activity should be limited to allow for adequate healing. A prospective observational study concluded that less than 2 mm of micromotion is within safe limits for bone healing and sternal stability, whereas micromotion beyond this is an indicator of compromised sternal healing. They found unweighted upper limb and functional tasks (deep inspiration, cough, unilateral and bilateral upper limb elevation, sit to stand) resulted in less than 2 mm of sternal separation and micromotion (measured by ultrasound).

A systematic review and meta-analysis (38) concluded that aerobic training in combination with resistance training demonstrated greater improvements in physical and functional recovery compared with aerobic training alone in patients undergoing sternal healing. Therapeutic efforts should focus on optimizing thoracic extension mobility, as well as neutral spine lumbopelvic and periscapular neuromuscular control. Biomechanically, this will mitigate compression stress across the thoracic vertebrae and, subsequently, the sternocostal joints and, ultimately, the sternum (36,39).

Other treatments have been reported in recent case studies, including use of a bone stimulator, lidocaine gel, calcium, vitamin D, and a figure-of-eight brace. Efficacy of these modalities has not yet been adequately studied, but they can be considered as potential treatment options for sternal stress fracture (34,35).

Early, accurate diagnosis is important in guiding appropriate management, including activity modification and avoidance of NSAIDs and steroids (35).

Return to Play

Sternal stress fractures have a good prognosis. Treatment includes a slow, guided return to activity once the athlete is completely asymptomatic. In most cases patients reported resolution of symptoms around 8 wk postdiagnosis. A case study of a gymnast reported they were able to return to tumbling with no symptoms at 8 wk and had a full return to unrestricted activity at 16 wk. In another case study an Army cadet returned to pain-free activity at 15 wk (36). In a 2016 case report of a golfer with a sternal stress injury, the athlete was pain free at 1 month and able to return to golf activity with no issues (34). Overall, return to play has been reported in 40% of cases at 6 wk, 75% of cases at 3 months, and 100% of cases at 4 months (35).

PM injury

Epidemiology

PM injuries were historically rare, with the first being described by Patissier in 1882. However, with the increase in activity level of the overall population over the last century, more specifically weightlifting activity, the incidence of PM injuries has risen (40), and it is no longer an uncommon presenting diagnosis for the sports medicine physician. Injury often occurs in younger, more active individuals between the ages of 20 and 40 years. One recent study reported 49% of injuries, secondary to bench-press, and 8% of injuries, secondary to contact sports. Injuries are very common among weightlifters and have been associated with steroid use (40). Another study reported avulsion injuries occurring more commonly in individuals 30 years or younger and more often musculotendinous junction injuries in individuals older than 30 years (41). With the increasing popularity of weightlifting, the incidence of PM injuries is likely to continue to increase (42).

Mechanism of Injury

The unique anatomical design of the PM causes stress on the tendinous fibers of the sternal head, specifically during eccentric load (33) with the arm in abduction, external rotation, and >30° of extension (41). Excessive tension within the maximally contracted PM muscle usually results in indirect trauma to the tendinous portion and subsequent distal tendon injury. More proximal injuries of the musculotendinous junction and the muscle belly are more often related to direct trauma.

Evaluation

MRI and ultrasound are both useful modalities for assessing PM injury. Both modalities prevent exposure to radiation. MRI images show more clear resolution of soft tissues but are more expensive and usually require future scheduling. Ultrasound, although often lower resolution, is adequate to assess soft tissue injury and can often be performed in office the same day as a clinic visit. Ultrasound is much less expensive but is dependent on user capabilities (35). Classic findings on ultrasound include localized edema and disruption of the PM tendon. A recent radiological article by Godoy et al. (43) describes further MR findings suggestive of PM injury, including anterior displacement of the bicep tendon, as well as a peri-bicep tendon hematoma.

Patients will commonly describe a snapping sensation at the time of injury. They will often present with localized pain, ecchymosis, swelling, cosmetic defect of the axilla, and a palpable mass of the anterior chest with muscle contraction and, in some cases, weakness (33,40). Localized ecchymosis over the anterior aspect of the arm more specifically suggests the presence of tendinous avulsion injury versus musculotendinous junction or muscle belly injury (33).

Treatment

The literature on management of this injury highlights the ongoing debate in regards to ideal treatment (33). Specifically, recent studies have addressed the question of surgical versus conservative management. As is the case for most injuries, treatment decisions should be made on a case-by-case basis, taking into consideration, mechanism, severity, location, and timing of the injury.

Treatment is dependent on location and severity of the injury as well as the anticipated future activity level of the patient. An athlete participating in competitive sport may require surgical intervention versus a sedentary individual performing activities of daily living (44). Mid-belly and proximal PM injuries can be treated conservatively with rest, activity modification, anti-inflammatories, and immobilization. The arm should be initially immobilized with a sling in an adducted and internally rotated position (45). Following the 14- to 21-d initial recovery period, passive and active range of motion exercises should be initiated for all planes of glenohumeral movement. Specific attention and focus should be given to frontal and sagittal plane movements, working initially within a tolerable arc of motion. Progressive resistance exercise can begin at 8 wk after the date of injury, although this may be delayed if range of motion goals have not been attained (46). Goals for rehabilitation after the 3-month mark should focus on optimizing strength and function and working toward patient-specific goals for activity and recreation (44,46,47).

Treatment for more distal musculotendinous and tendinous avulsion injuries is more controversial. Several recent reviews have attempted to compare conservative versus surgical management. In an article from Yu et al. (40), they reported 90% return to play with isolated PM tendon repair at 6.1 ± 1.7 months (4 to 8.5 months). However, only 74% of patients returned to their preinjury level of sport. Their study also looked at rated outcomes with 69% excellent, 15% good, 11% fair, and 5% poor outcomes. The primary disadvantage of conservative treatment is loss of adduction and torque strength (44). The majority of literature reports a significant decrease in strength variables and subsequent poorer outcomes; however, patients typically recover full range of motion (44,47). This demonstrates that conservative treatment can serve as a viable option, best reserved for individuals who are unwilling or unable to have surgery.

Gupton et al. (41) performed a literature review to assess surgical techniques for PM tendon repair and reported better outcomes with surgical repair, including improved strength, function, and cosmesis. They found no significant difference in outcomes based on timing of repair and reported no superior technique. They recommended surgical technique based on surgeon preference and comfort.

Postoperative treatment is dependent on the classification of the repair. Muscle-tendon repairs will require a very stringent rehabilitation, secondary to difficulty obtaining firm anchoring during the procedure (44,48). Because of the fragility of the muscle tissue, tendon-tendon and muscle-tendon repairs are recommended to remain immobilized in a sling for a minimum of 4 wk, while bone-tendon repairs are immobilized for 3 wk. Rehabilitation is initiated 2 wk postsurgery, with a focus on passive range of motion for external rotation, flexion, and abduction (47,48). Active range of motion at the shoulder should be avoided in the first 4 wk, although distal active mobility at the elbow, wrist, and hand is appropriate. Full passive and active range of motion goals should be met by 12 to 14 wk postoperation for bone-tendon repairs, whereas tendon-tendon repairs should reach full range of motion goals by 14 to 16 wk. Progressive resistance training can be initiated at the 12-wk mark, provided range of motion goals are steadily being met (48). A series of reviews on athletes and active duty armed services patients demonstrate a typical return to sport and activity by 6 months postoperation, although some reported return to sport as early as 2 months (33,49–51).

Return to Play

In a 2019 article from Liu et al. (42), they report that, during their study period of 51.1 ± 24.1 months, 97.7% return to sport at after PM repair, but only 50% of individuals returned at the same or better level of sport participation. They reported poor outcome with conservative management, including significantly decreased strength. They did suggest that nonoperative management is a viable option and may be more appropriate for the low demand athlete, the elderly patient, and those at significant risk for surgery complications.

Bodendorfer et al. (33) performed a more recent and larger literature review assessing management for PM injuries and also reported stronger evidence for surgical repair over conservative management. They reported increased functional outcome, strength, and cosmesis following surgery. They also concluded that there have been very few studies assessing outcomes of conservative management with only very small sample sizes. They suggest the need for future studies with a larger sample size to assess the true efficacy of conservative management.

In a 2020 study from Sahota et al. (52) assessing PM injuries in national football league players, they reported significantly more time missed from sport with surgery (146.7 ± 55.0 d) versus nonoperative management (77.2 ± 72.9 d). There has been an emerging shift in orthopedic treatment protocols in regards to tendinous injuries in recent years, including pursuing more conservative management of proximal hamstring avulsion injuries and Achilles tendon ruptures (3,33,53,54). Although surgical treatment of such injuries usually results in equal-to-better outcomes, it often also comes with significant inherent postoperative risks. It has been questioned whether these surgical risks outweigh the benefits of surgery when compared with conservative management. For this reason, it is important that conservative management as an option for treatment of PM injuries not be entirely ignored and that more in-depth studies be pursued in the future.

Rib stress fractures

Epidemiology

Prevalence of this issue is difficult to estimate because it is often underdiagnosed or misdiagnosed. The first reported case was in 1869, but it began to be noted more frequently with the advent of radiographs in the 20th century.

Athletes that commonly experience these types of injuries are throwing athletes (baseball players), rowers, and golfers. Some of the most robust epidemiological data on stress fracture in the ribs is from rowers. One review found stress fractures in 8% to 16% of elite rowers, 2% of university rowers, and 1% of junior elite rowers (55). In a study of Australian elite Olympiad rowers, there was a prevalence of 4% to 15% over the 2012 to 2016 Olympics. The incidence was 0.12 to 0.45 per 1000 athlete days, equating to 2 to 8 new cases of stress fracture in the rib over 340 training days. The sixth rib was the most commonly injured rib (56). The highest prevalence was in women, lightweight and sweep rowers. Other groups to consider for this type of injury include adaptive athletes, particularly in sports during which the upper extremities are heavily used (57).

Mechanism of Injury

First rib anatomy differs from the other ribs, as, in addition to the intercostal and serratus anterior musculature, there is the additional upward force of the scalenes. Repetitive contractions of all these muscles occur with a throwing/overhead motion, leading to increased risk of stress injury (58). The first rib has a groove for the subclavian artery creating a weak point in the bone that can be subject to bone stress injury with repetitive trauma. Another theory is that there is limited flexibility in the first rib, and the close articulation of the clavicle creates increased tension on the first rib (59).

The majority of stress fractures of the rib in rowers present in the 4th to 8th ribs in the anterolateral region (55) with the thought being that the imbalance of posterior and anterior movement; the forces during the motions of rowing; and the repetitive motion between the scapular retractors, external obliques, and rectus abdominis lead to the stress injury (55).

Evaluation

Rib stress fractures may have no abnormality noted on X-ray, unless a bony callus is visible. Sensitivity may be as low as 10% (60). Thin slice MRI can be used but also can miss pathology, whereas a bone scan may be the most likely imaging modality to identify the bony fracture. CT can be used for diagnosis and has greater sensitivity, as compared with plain radiographs for fractures. The main point of consideration is the exposure to radiation with this imaging modality. There is no specific grading severity system (60). Ultrasound can be used for diagnosis. There is no radiation exposure, and assessment can be performed bedside on the patient. Sensitivity and specificity were 83.3%, 81.9%, and 75.9%, 66.6%, respectively, for US compared with MRI (60).

First rib stress fracture presents as achy, deep pain in the shoulder or chest. It also can present as pain at the medial or inferior border of the scapula and upper thoracic region (61). Pain can be present at rest but most often occurs with activity. Some athletes will present with a history of a “pop” or “snap” in their chest after activity. Marcussen () found in a case series that nearly all subjects had painful shoulder flexion and abduction, although 8 of 14 subjects had full ROM. It also can present as dyspnea or sharp neck pain. In rowers, pain has been found to be associated with deep breathing, trunk flexion, end-range trunk extension, scapular protraction, scapular retraction and pain with pushing and pulling doors, difficulty rolling over or sitting up from lying position, inability to sleep on the affected side, and positive compression of the thoracic cage (AP and lateral) (55,62).

Treatment

Rest from the inciting activity is the best management of rib stress fractures. Bony healing can occur in 4 to 6 wk, but pain may continue longer as soft tissues may be irritated around the bony area, leading to longer lasting pain. Full return to sport could be anywhere from 6 to 12 months. Rib stress fractures are classified as low risk and are not at high risk for breaking through the cortex (63).

Initial management of rib stress fracture focuses on offloading the ribs by cessation of all aggravating activities; however, cross training is permitted if pain-free (64). Taping or strapping of the painful area can be useful to limit painful expiration or pain with low intensity exercise (65). Soft tissue mobilization and manual therapy can be used to alleviate any symptoms of protective pain mechanisms (66). Although there is little evidence specifically supporting modalities for rib stress fracture, there is recent evidence suggesting therapeutic ultrasound decreased pain and disability and accelerated callous healing in traumatic rib fractures. Pain was significantly lower for the pulsed ultrasound group compared to the control group at 1, 3, and 6 months. Callous consolidation was significantly higher at 1 month and 3 months (67).

The most common complication of first rib fractures is nonunion. Other complications include brachial plexus palsy or thoracic outlet syndrome, sometimes as a result of callus formation around the fracture (58). This may necessitate surgical resection of the rib in order to decompress the area (68).

Return to Play

As the athlete returns to sport, emphasis should be placed on correcting any biomechanical issues in their technique. Thoracic mobility should be assessed and maintained as training load increases. In rowing, thoracic flexion can increase during prolonged rowing and can increase stress on costovertebral, costotransverse, and costochondral joints (55). Attention also should be placed on observing the kinetic chain distal to the ribs. Lack of flexibility in the lumbar spine and hips shortens the stroke and may cause an individual to compensate by increasing scapular protraction. Excessive protraction alters the resultant force between the rhomboids and the combined water resistance on the oar, leading to abnormal posteriorly directed forces on the rib cage (55).

Prior to return to sport, evaluation of the biomechanics of throwing, overhead activity, and core strength should occur, as they are all risk factors for injury. In a systematic review on return to sport in rowers, 10 studies discussed return to sport. Time to return ranged from 1 to 16 wk, and nine recommended 4 to 6 wk. Proposed risk factors include poor rowing technique, female sex, inadequate equipment, and low bone mineral density, although evidence of correlation has not yet been adequately confirmed (69).

Slipped rib syndrome

Epidemiology

Slipping rib syndrome (SRS) usually presents as lower chest, flank, or upper abdominal pain. The lower prevalence of this pathology often leads to delay in diagnosis and/or misdiagnosis all together. The syndrome can be related to a previous trauma in the area or can be secondary to postural or ergonomic issues. However, many patients cannot recall a specific incident leading to their pain. It most often involves the right side but can occur on either side. It is more often observed in women and in active individuals. Pain often gets better with lying down.

This syndrome was first described in 1919 by Cyriax. It is often a missed diagnosis, as the presentation can be nebulous and athletes usually present after months of pain. A large retrospective chart study of 54 athletes showed that the majority were young (mean age 19.1) women (70.4%). Prior to diagnosis, they had had 2.3 specialist consults for their pain, and the mean time from pain onset to formal diagnosis was 15.4 months. The right side was affected in 48.1% of athletes and only 5% were bilateral. The most commonly involved rib was the 10th (44%), with the 8th (31.5%), and 9th (31.5%) being commonly involved as well. Almost a fifth were described as hypermobile. The majority (72.2%) were atraumatic in etiology. The most common sports of those affected were running, rowing, lacrosse, and field hockey (37). One case series also described the less common presentation of pain at the sternocostal junction (70).

Mechanism of Injury

The proposed etiology of this condition is a weakness of the costochondral, sternocostal, or costovertebral ligaments around the ribs leading to hypermobility and subluxation of the ribs, and motion that irritates the intercostal nerves. Many muscles (rectus abdominus, quadratus laborum, transverse abdomonis, and external oblique) attach to the ribs, and imbalance of contractions of these muscles likely contributes to the syndrome. This may be why active individuals are more commonly diagnosed with this syndrome. Contraction of these muscles places pressure on the ribs, moving them into contact with each other. Athletes of sports involving repetitive motions (rowing, swimming) may be more at risk because of this repetitive microtrauma.

Evaluation

Ultrasound studies have shown that there is an overlapping action that is followed by slipping of the lower rib, leading to shearing stress. This movement has been noted to be absent in control volunteers. The observed predominance of right-sided pathology may be explained by the fact that the majority of the population is right-handed and not necessarily that there is an anatomical difference between the right and left chest walls.

SRS can present with visceral symptoms, such as abdominal pain, nausea, or vomiting. The intercostal and visceral nerves overlap in their innervation from the spinal cord at the 8th and 9th ribs, which may be a cause of the referred abdominal symptoms experienced by some individuals. Patients may be diagnosed with rib fracture, intercostal strain, costochondritis, gastroesophageal reflux, gallbladder inflammation, pancreatitis, or gastritis. Pain occurs with twisting, bending, deep breathing, sneezing, or coughing.

The Hook maneuver can be used to assess for SRS. This maneuver involves the examiner manually displacing the rib of interest anteriorly and upward. This recreates the subluxation of the slipping rib. A positive test is one that elicits pain or clicking with the maneuver.

Individuals with this syndrome have often undergone multiple tests for other anatomical systems (i.e., EGD, abdominal and pelvis imaging for appendicitis, biliary issues, gastritis and renal stones). MRI, CT, and plain films are typically without abnormality, as is standard ultrasound. However, dynamic ultrasound may be very helpful for diagnosis (71).

In a study of 46 patients with suspected SRS, dynamic ultrasound was used in diagnosis. The majority of the patients were female athletes (67%) and the average age was 17. Patients were imaged supine, and all ribs were visualized during performance of a number of maneuvers. Maneuvers included Valsalva, abdominal crunch, and rib push maneuver, in which the performing radiologist applied pressure on the rib of interest in an upward motion to show laxity of the rib. Sensitivity was 89% (32/36), and specificity was 100% (10/10). The push maneuver, abnormal morphology visualization, and crunch maneuver sensitivities were 87%, 68%, and 54%, respectively. Valsalva was only 13% sensitive (72). Additional unique findings of this study included often observed fusion of the cartilage of the ribs below the level of interest, potentially being a rigid fix in the chest wall, leading to increased force in the area of pain. They also observed increased intercostal echogenicity in many of the areas of pain. One diagnostic consideration that could be therapeutic is a local anesthetic rib block. Pain may be temporarily or permanently improved.

Treatment

Avoidance of the offending activity is important in reducing pain and promoting healing. More severe cases, or those in athletes who need to continue their sports training, may require nerve blocks or resection of the rib or the cartilage around the rib. Botox injection can be considered for treatment of refractory cases, but evidence is currently limited on this management option (73). If conservative management is not successful, then resection to remove the slipping areas of cartilages can be performed. Case series of postresection results showed improvement in the majority of patients but also noted that pain can reoccur (74–76).

Return to Play

Return to play can be difficult, especially because most athletes have a delayed diagnosis and a variety of symptoms that may change over time, leading to months or years of pain, which does not improve quickly. Another consideration the team physician should be mindful of is the mental health of athletes with this pathology. Mental health can often be negatively impacted by this diagnosis, as it is usually a chronic issue that has detrimentally affected sports participation. Health care providers may overlook or not be familiar with this diagnosis, leading to a diagnosis of somatization, rather than focusing on the etiology of the pain being SRS.

Once diagnosed, conservative treatment should be attempted first, often starting with activity modification. Patient education is extremely important with emphasis on the benign nature of the injury and acknowledgment of pain and disability (37). Ice and over-the-counter analgesics can be recommended for pain control. Manual therapy techniques, including chiropractic and osteopathic manual techniques, have been recommended to reduce a “slipped” rib (37). Soft tissue mobilization, myofascial release, anterior-posterior mobilization from T9 through L2 and anterior-to-posterior mobilization of the affected rib have been studied but not explicitly described (31,37). Wearing a rib belt or taping also can be used for symptom management while returning to sport (77). Postsurgical patients have been restricted from activity for 6 to 12 wk and gradually return to activity (31,70,77).

Conclusions

There is a lack of substantial literature regarding breast- and chest-related injury and pathology, specifically as it pertains to sports medicine. Whether due to a rarity of occurrence or a hesitancy by athletes to seek care for this sensitive area of the body, the pathology discussed here is relatively infrequently encountered by the sports medicine physician, but it is important to understand. For example, a study from Smith et al. (9) reported that breast injuries were less likely to be reported to a health care professional by female collegiate athletes when compared with other injuries.

Because of the unique circumstances of the team physician, they can see a wide breadth of pathology. Athletes may not have primary care physicians and might prefer to present to their team physician for some of the above issues. It is often more comfortable and convenient for athletes to seek treatment in the team setting. Therefore, it is important that the medical professional be aware of not only common pathology but also of that which is rarer.

Any delay in evaluation can result in unnecessary morbidity and lead to complications or extended time lost from sport. Consequently, it also is important to facilitate an atmosphere encouraging early presentation and workup.

The authors wish to acknowledge Dr. Scott R. Schiffman, MD; and Dr. Alison Matich, MD from the Department of Imaging Sciences at the University of Rochester Medical Center, Rochester, NY, for providing sonographic breast imaging.

The authors declare no conflict of interest and do not have any financial disclosures.

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