A CrossFitter with Chest Pain: A Case Report
AOASM Conference 2020 Amanda Wise, DO UW Physical Medicine & Rehabilitation
Erek Latzka, MD, RMSK UW Sports Medicine Disclosures
None HISTORY
32 year-old F, otherwise healthy CrossFitter with a 6-month history of chest pain: > “Sudden pop” while doing dips
> Improved with 2 months rest
> Pain returned when doing 65 lb. power cleans, intermittent
> 2 months later pain now more constant after lifting a ladder overhead
> Seen by her PCP, CXR was unremarkable
https://www.crossfit.com/wp-content/uploads/2019/11/13142737/Bar-Dips-Foucher-1024x576.png History
> Location: Initially bilateral, now left mid-sternal border
> Description: 3/10 dull ache, intermittently sharp
> Alleviating/Aggravating factors:
– Better with rest
– Worse with palpation, deep breathing, overhead movements
> Other: Denied any direct trauma
> Treatments tried: HEP, Physical Therapy, NSAIDs PHYSICAL EXAM:
> NAD
> Significant for tenderness at the left sternocostal border between ribs 4-6
> Non–tender in the pectoralis
> No pain with AROM
> Pain was reproduced with a resisted pushup and overhead press DIFFERENTIAL DIAGNOSIS:
> Tietze Syndrome
> Pectoralis tear
> Rib fracture
> Thoracic radiculitis
> Xiphoidalgia
> SC joint dislocation/subluxation
https://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/article_thumbnails/video/wibbitz/wbz-costochondritis.jpg INITIAL TREATMENT:
Presumed Costochondritis
> Treatment:
– Activity Modification
– Physical Therapy
– Steroid taper for 1 week then 1 week of naproxen: >pain returned quickly when transitioning to NSAIDs
> Follow-Up Visit:
– Planned Ultrasound-Guided Steroid Injection
– Same area of persisting pain ULTRASOUND:
NORMAL STERNOCHONDRAL JOINT
https://mrimaster.com/anatomy/chest/axial/mri%20cross%20sectional%20anatomy%20chest%20(thorax)%20axial%20image%2020.jpg ULTRASOUND:
PATIENT’S STERNOCHONDRAL JOINT ULTRASOUND:
STERNUM ULTRASOUND:
Acoustic Shadowing
> Occurs when sound waves encounter a dense structure
Gallstone > Sound reflects back to the probe leaving a shadow behind the object
https://www.med-ed.virginia.edu/courses/rad/edus/text%20jpegs1/4b-gallstone.jpg WORKING DIAGNOSIS & OUTCOME
Sternal fracture secondary to left 6th rib dislocation or subluxation
> No injection
> XR Sternum: “subtle periostitis or cortical thickening is suspected in the lower sternum…etiology is indeterminate”
> Referred to General Surgery, rib fracture specialist
> Activity Modification, PT, NSAIDs LITERATURE REVIEW
> Sternal ultrasound:
– Nickson, 2011 – median assessment time is ~ 46 seconds
> Return to sport:
– Few similar case reports:
> return to activity once asymptomatic, ranging from 8-16 weeks > Treated with analgesics or anti-inflammatories
– Alent et al in 2018 – “largely depend[s] on the severity of the injury, resolution of symptoms, radio-graphic healing, and resolution of associated injuries” DISCUSSION
> Ultrasound can be a useful diagnostic tool to evaluate for occult fracture
> Athletes can sustain sternal fractures without direct trauma
> Return to sport:
– Limited guidelines for pain persisting beyond 12 weeks
> Reminder: Fracture is a contraindication to OMT
> Osteopathic Considerations:
– Could indirect OMT be helpful ? POLL QUESTION!
What is my dog’s breed? POLL QUESTION!
What is my dog’s breed?
BERNEDOODLE Thank you! RESOURCES
> Alent, J., Narducci, D.M., Moran, B. et al. Sternal Injuries in Sport: A Review of the Literature. Sports Med 48, 2715–2724 (2018). https://doi.org/10.1007/s40279-018-0990-5 > Nickson C, Rippey J. Ultrasonography of sternal fractures. Australas J Ultrasound Med. 2011;14(4):6–11. doi:10.1002/j.2205-0140.2011.tb00131.x > McCurdie I, Etherington J, Buchanan N. Sternal fracture in a female army officer cadet. British Journal of Sports Medicine 1997;31:164. > Proulx A M, Zryd T W. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009; 80 617-620 > Khadavi, Michael, Fredericson, Michael, MD, FACSM. Chest Pain in Athletes from Personal History Section (Musculoskeletal Causes). Curr Sports Med Rep. 2015;14(3):252-254. doi:10.1097/01.CSMR.0000465135.63122.bc. > Emergency Ultrasound, University of Virginia Health Sciences Center, Department of Radiology https://www.med-ed.virginia.edu/courses/rad/edus/index.html