BrJ'Sports Med 1996;30:359-360 359 Pneumomediastinum in a surf lifesaver Br J Sports Med: first published as 10.1136/bjsm.30.4.359 on 1 December 1996. Downloaded from K E Fallon, K Foster Abstract Three days following the initial consultation he Pneumomediastinum is an uncommon complained of left sided chest pain on very complication ofsporting activity. The case deep inspiration and the surgical emphysema of a young asthmatic surf lifesaver is had clinically resolved. Chest x ray two weeks reported in which several factors are later was normal. thought to have been involved in the aetiology of his condition. Treatment was expectant and a full recovery was made Discussion over a short period. This is the first Pneumomediastinum is a relatively rare condi- reported case of pneumomediastinum tion which has been associated with mechani- occurring following training for a surfbelt cal ventilation, childbirth, marked vomiting race. and coughing,' marijuana smoking,2 asthma, (BrJ7 Sports Med 1996;30:359-360) closed tracheal injury, and anorexia nervosa. In relation to athletic activity it has been de- Key terms: pneumomediastinum; surf lifesaving; scribed following swimming,"7 tennis,' weight asthma lifting,"4 football,57 mountain climbing,6 rugby training,8 fast bowling in cricket,9 scuba Case report diving,112 and kendo." A 20 year old professional lifeguard and In a general population study the mean age competitive surf club swimmer presented with ofpatients with spontaneous pneumomediasti- a four hour history of sore throat which he had num was 18.8 years and 84% were male. The noticed upon wakening. He had a long history most common symptoms on initial presenta- of mild asthma which was predominantly exer- tion are chest pain (88%), dyspnoea (60%), cise induced and effectively blocked by taking and neck pain (48%), the most frequent physi- inhaled salbutamol before exertion. On the cal sign being subcutaneous emphysema preceding evening he had suffered a mild noc- (60%) most commonly found in the neck turnal attack of asthma which settled rapidly (40%).' Auscultation may reveal a crunching without medication. sound during systole-Hamman sign-which The previous day he had trained for a surf was reported in 52% of cases in one series.'4 belt race which he had found more difficult Should sufficient air accumulate in the medi- than usual. He did not use prophylactic astinum the pleura can rupture, resulting in an medication before this episode of exercise. The associated pneumothorax. Particularly in cases http://bjsm.bmj.com/ surf belt race is an event in which a swimmer of traumatic aetiology, oesophageal rupture has a wide belt placed firmly around his abdo- (Boerhaave syndrome) should be excluded. men. This is attached to a rope fed from a large Treatment of non-traumatic cases is expectant reel through the hands of four lifesavers and does not usually require hospital admis- stationed on the beach. The swimmer races sion. Resolution occurs rapidly and complica- through the surf to a potential drowning victim tions such as pneumothorax and airway and brings him back to the shore. The patient compromise are rare.415 complained that during this event he had to Cases described in the athletic population on October 2, 2021 by guest. Protected copyright. strain against the belt and rope as his team occurred in young males,4 5 7-9 most presenting mates were not feeding him sufficient line. with anterior chest pain, and were associ- Such an occurrence tends to cause the ated with straining which may have involved a to Australian Institute of swimmer swim for longer periods underwa- Valsalva manoeuvre489 or a direct blow to the Sport, Canberra, ACT, ter than is usual. chest. 5 In no case so far reported has asthma Australia On examination the patient was not dysp- been a potential aetiological factor. K E Fallon, senior noeic and the throat was normal. The lung The patient in this case is again a young male lecturer in sports fields were normal to auscultation, as were the who presented with a sore throat, a presenta- medicine heart sounds. Subcutaneous emphysema was tion previously reported.8 His history indicates Gosford District found in both sides of the neck and across the that the onset of pneumopericardium was Hospital, Gosford, upper chest. The remainder of the physical related to severe exertion possibly associated NSW, Australia examination was unremarkable. Spirometry with Valsalva manoeuvres, breath holding, K Foster, revealed a forced expiratory volume in one sec- underwater swimming, and abdominal com- consultant physician ond (FEV1) of 3.97 litres (100% of predicted), pression by the surf belt. Chronic but appar- a forced vital capacity (FVC) of 5.10 litres ently well controlled asthma may well have Correspondence to: Dr Kieran Fallon, Australian (108% of predicted), and an FEV,/FVC ratio been a factor since, while the patient was Institute of Sport, PO Box of 77.8%. A chest x ray was reported as show- asymptomatic at the time ofhis swim, subclini- 176, Belconnen ACT 2616, ing pneumomediastinum and subcutaneous cal airways obstruction and associated alveolar Australia. emphysema. distension may well have been present. The Accepted for publication The patient was treated expectantly and the patient's usual asthma prophylactic medication 5 June 1996 management of his asthma was reviewed. was not used before exertion. 360 BrJ Sports Med 1996;30:360-362 It is conceivable that the onset of pneumo- 3 Abolnik I, Lossos IS, Breuer R. Spontaneous pneumomediastinum: a report of 25 cases. Chest 1991;100: mediastinum occurred during the episode of 93-5. asthma on the night before presentation; how- 4 Casamassima AC, Sternberg T, Weiss F. Spontaneous Br J Sports Med: first published as 10.1136/bjsm.30.4.359 on 1 December 1996. Downloaded from pneumopericardium: a link with weight lifting? Phys Sports ever, the mild nature of this attack suggests Med 1991;19:107-10. otherwise. This attack was probably a factor in 5 Morgan EJ, Henderson DA. Pneumomediastinum as a complication of athletic competition. Thorax 1981;36:155- increasing the amount of mediastinal air 6. following the initial leak initiated by the 6 Vesk A, Houston CS. Mediastinal emphysema in mountain climbers. Heart Lungs 1977;6:799-800. patients unusual exertion. 7 Doyle M, Given F. Pneumomediastinum as a complication This case represents the first report of pneu- of athletic activity. IrJ Med Sci 1987;156:272-3. 8 Haynes RJ, Evans RJ. Pneumomediastinum after rugby momediastinum occurring as a result of surf training. BrJ Sports Med 1993;27:37- 8. lifesaving. Of importance is the associated his- 9 Cements MR, Hamilton DV. Pneumomediastinum as a complication of fast bowling in cricket. Postgrad Med J tory of mild chronic asthma and this case also 1982;58:435. represents the first description of this compli- 10 Edmonds C, Lowry C, Pennefather J. Diving and subaquatic medicine. Oxford: Butterworth Heinemann, 1992:97-9. cation of asthma in an asthmatic athlete. The 11 Raymond LW. Pulmonary barotrauma and related events in importance of impeccable control of asthma in divers. Chest 1995;107:1648-52. 12 Harker CP, Neuman TS, Olson LK, Jacoby I, Santos A. The the athlete-and in particular the monitoring roentgenographic findings associated with air embolism in of lung function before activities involving strain- sport scuba divers. J Emerg Med 1993;11:443-9. 13 Komatsu H, Enzan K, Mitsuhata H, Hasegawa J, Mat- ing and the Valsalva manoeuvre-and the correct sumoto S, Suzuki M, et al. A case of pneumomediastinum use ofprophylactic medication is highlighted. caused by closed tracheal injury during the game of Kendo (Japanese fencing) [in Japanese]. Masui -Jpn J Anaesthesiol 1992;41 :673-6. 1 Munsell WP. Pneumomediastinum: a report of 20 cases and 14 Panacek EA, Singer AJ, Sherman BW, Prescott A, review of the literature. JAMA 1967;202:689-93. Rutherford WF. Spontaneous pneumomediastinum: clini- 2 Miller E, Spiekerman RE, Hepper NG. Pneumomediasti- cal and natural history. Ann Emerg Med 1992;21: 1222-7. num resulting from performing Valsalva manoeuvers 15 Bratton SL, O'Rourke PP. Spontaneous pneumomediasti- during marijuana smoking. Chest 1972;62:223-4. num. J EmergMed 1993;11:525-9. Exercise induced leg pain chronic compartment syndrome. Is the increase in intra-compartment pressure exercise specific? Nat Padhiar, John B King Abstract problem encountered by young athletes after Intra-compartment pressure studies re- an increase in activity or at the start of the sea- main the main investigative method in son.' The terms shin splints2 or freshers leg' are http://bjsm.bmj.com/ diagnosing chronic compartment syn- often used to describe the condition. These drome (CCS). Standard exercise proto- terms are non-specific and are falling out of cols have been used to cause the raise in favour. The pivotal symptom is pain, which pressure measured in the laboratories. occurs on exercise and is relieved by a variable This case suggests that CCS cannot be period of rest. The cause of pain will usually excluded without the specific sports activ- fall into one of the following four categories: ity being used to raise the intracompart- (1) Pain of bony origin, for example focal mental pressure. stress fracture or diffuse micro-stress on October 2, 2021 by guest. Protected copyright. (BrJ Sports Med 1996;30:360-362) fractures."6 (2) Pain of osteofascial origin, for example Key terms: chronic compartment syndrome; intra- periostitis and medial tibial stress syn- compartmental pressure; exercise drome.78 Exercise induced leg pain is a common 40 Anterior compartment RA Department of Sports Medicine, The London Lateral 30 Hospital Medical compartment Tibia RDP College, London El 4DG, United Kingdom 40 _8\ \ N Padhiar, honorary IJ, Deep posterior LA consultant podiatrist Fibula compartment J B King, consultant 30 orthopaedic surgeon Fa*cia / I Fascia \ |Superficialitposterior LDP _ Correspondence to: - - - ~.