ECG Quiz Answer: Chest Pain in a College Football Player
John D. Cantwell, MD; Drew V. Miller, MDTHE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 8 - AUGUST 96
The resting ECG showed diffuse ST-segment elevation (figure 2a). This could reflect early repolarization, a normal variant, or pericarditis. Features weighing against the latter were the lack of fever or leukocytosis, reproducibility of the pain with pressure on the left anterior chest, absence of a pericardial friction rub, and failure of the pain to improve when sitting up and leaning forward.
Limited echocardiography (1) showed concentric left ventricular hypertrophy with normal systolic function. A repeat ECG was unchanged.
A musculoskeletal source of the pain seemed the most likely cause. The team orthopedist was able to reproduce the patient's discomfort with pressure to the posterior rib cage, just medial to the medial angle of the scapula.
Because of his continued pain, the changing location of the pain, and the pulmonary symptoms, a bone scan was obtained (figure 3); it demonstrated increased uptake at the medial clavicle or first rib. CT (figure 2b) subsequently revealed a nondisplaced stress fracture of the first rib and associated pleural thickening.
Upon further questioning, the athlete recalled that he had had some increasing pain while lifting weights several weeks beforehand, but had not reported to the training room for evaluation. The patient's inframammary discomfort might have been referred pain.
Though most rib fractures occur below the first rib and are associated with blunt trauma, stress fractures of the first rib are not uncommon. Diagnosing rib fractures can be difficult when there is no history of blunt trauma and rib series x-rays are negative. There was no evidence of fracture on this patient's chest x-ray, and a rib series was not obtained.
Stress fractures of the first rib may develop insidiously or may occur with sudden vigorous contraction of opposing muscle groups, especially during heavy lifting with sudden opposing contraction of the scalene and serratus anterior muscles (2,3). The most common location of first-rib stress fractures is at the groove for the subclavian artery (figure 4), located between these opposing muscles. This injury has been associated with many activities, including weight lifting, tennis, basketball, golf, and backpacking (3).
Radiographic evaluation should include appropriate rib films and chest x-rays to rule out pneumothorax. When x-rays are negative, a bone scan may reveal an occult stress fracture. Additional studies such as CT or magnetic resonance imaging may help distinguish between stress fractures of the first rib and of the adjacent medial clavicle, which may be difficult to differentiate on bone scan.
The key to managing rib stress fractures is rest. Modalities such as heat and ice can also be helpful. Patients can progress to aerobic conditioning as tolerated, but should avoid contact sports and other activities such as heavy weight lifting that could displace the fracture and cause associated injuries such as pneumothorax. Clinical and radiographic evidence of fracture healing is usually seen at 3 weeks, and healing should be documented before allowing patients to resume contact sports.
Our patient had an initial rest period from football contact drills, but was able to continue his conditioning exercises. He was advised to decrease weight lifting with his upper extremity to light resistance until his pain resolved. He returned to physical contact after missing 12 practices (2 weeks). A first-string player, he completed the season without further symptoms.
Dr Cantwell is director of preventive medicine and cardiac rehabilitation at Georgia Baptist Medical Center and clinical professor of medicine at Morehouse School of Medicine in Atlanta. He is a member of the editorial board of The Physician and Sportsmedicine and was chief medical officer of the 1996 Summer Olympic Games. Dr Miller is a team orthopedist at the Georgia Institute of Technology in Atlanta and director of orthopedics for the 1996 Olympic Village Polyclinic. Address correspondence to John D. Cantwell, MD, 340 Boulevard NE, Suite 200, Box 413, Atlanta, GA 30312.