Pneumothorax in a Weight Lifter
The Importance of Vigilance
Mario Ciocca, Jr, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 4 - APRIL 2021
In Brief: A 27-year-old weight lifter developed mild chest pain and dyspnea after 'bouncing' a 250-lb barbell off his chest. A plain radiograph revealed a large, right-sided pneumothorax with collapse of the lung. He underwent an emergency tube thoracostomy. One month later, he resumed lifting without recurrence. This case report demonstrates the need to be responsive to dyspnea and chest pain in healthy, young athletes. Pneumothorax in sports is uncommon, but cases of spontaneous and trauma-induced pneumothorax have been reported. Initial symptoms may be minimal, but prompt recognition can help prevent respiratory and cardiovascular compromise. Treatment depends in part on the size of the pneumothorax.
Pneumothorax can occur spontaneously or as a result of blunt trauma. Trauma-induced pneumothorax is frequently caused by a significant force that results in fracture, but it can also occur without fracture. Trauma-induced pneumothorax has been reported in several contact sports; however, all reported cases of pneumothorax in weight lifters have occurred spontaneously. The following case report describes pneumothorax associated with minimal blunt trauma in a weight lifter. It exemplifies the ability of healthy, young athletes to compensate and appear comfortable. Their perception of their symptoms may not reflect the severity of injury.
History. A 27-year-old weight lifter had a 3-day history of right-sided chest pain, dyspnea, and a feeling that he had had "the wind knocked out of him." While bench-pressing 250 lb 3 days earlier, the 6-ft 4-in., 210-lb lifter had "bounced" the barbell off his chest (improperly used his chest to spring the bar off, a common technique). Immediately after this, he experienced mild chest discomfort and dyspnea but was able to continue lifting. His symptoms did not affect his daily activities, and he thought they would dissipate.
When his symptoms persisted after 3 days, he decided to seek medical care. He did not feel "bad" but thought the time course of his symptoms warranted evaluation. He denied holding his breath during concentric contraction while weight lifting. He had no history of pulmonary disease, tobacco abuse, or substance abuse.
Physical examination. Clinical examination revealed no apparent physical discomfort. The patient was slightly tachypneic, with a respiratory rate of 22/min. His blood pressure was 114/74 mm Hg, and his pulse 70 per minute. His trachea was midline. The cardiovascular exam was normal. Auscultation of his lungs revealed a diffuse decrease in breath sounds on the right side with hyperresonance to percussion. No tenderness or pain was apparent with compression of the chest wall.
Diagnosis and treatment. A posteroanterior (PA) chest radiograph demonstrated a large right-sided pneumothorax with collapse of the lung (figure 1). The patient was transported to the emergency room where a tube thoracostomy was performed. The tube was removed after approximately 24 hours with near resolution of the pneumothorax. The patient was restricted from strenuous activity for 1 month. At that time he resumed weight lifting without incident and has not had a recurrence during the following year.
Etiology and Prevalence
Pneumothorax is the loss of air from the lung into the pleural space. It is a common condition, but few cases are related to athletic activity. Tension pneumothorax, which the patient in this case report did not have, develops if there is continued loss of air into the pleural space. The resultant pressure increase creates a shift of the mediastinum away from the pneumothorax, causing respiratory and cardiovascular compromise and requiring immediate decompression (1).
Blunt trauma causing rib fracture, clavicular fracture, or sternoclavicular dislocation can also cause pneumothorax. In the general population, rib fractures are often associated with pulmonary damage, although a sports-related pneumothorax secondary to rib fracture is rare (2). Pneumothorax secondary to blunt trauma without underlying fracture has been reported in hockey (3), soccer (4), and football (2). In addition, blunt trauma not directed at the chest (left lower back) has been linked to pneumothorax in a boxer (5). The force required for blunt trauma to cause a pneumothorax is unknown (3).
Approximately 20,000 new cases of spontaneous pneumothorax occur in the United States per year (6). Less than 10% of these occur during athletic activity (7). Spontaneous pneumothorax can occur in individuals who have no predisposing lung conditions (primary), or in those who have a predisposing lung condition (secondary), such as chronic obstructive pulmonary disease, asthma, cystic fibrosis, sarcoidosis, pulmonary infection or neoplasm, or Marfan syndrome (8).
Typical patients who have primary spontaneous pneumothorax are tall and thin and may have a history of smoking or substance abuse (inhaling drugs using a Valsalva maneuver) (2,7). Primary pneumothorax is thought to occur as a result of rupture of subpleural emphysematous blebs. The mechanism of bleb formation is unknown, but, in taller patients, two theories have been proposed: (1) Such patients have a higher transpulmonary pressure, which may cause overdistension of the alveoli and predispose them to rupture, and (2) taller patients may have relative ischemia due to a low-pressure pulmonary arterial system that is trying to overcome the force of gravity (8).
Spontaneous pneumothorax has been reported in association with chin-ups and in weight lifting (9-11). In these cases, improper breathing is believed to be the cause of pneumothorax. Taking a deep breath and performing a concentric contraction against a closed glottis causes a Valsalva effect. This increase in intrathoracic pressure is combined with the intrathoracic pressure caused by the weight of the specific lift (10). In contrast, the pneumothorax described in this case report appears secondary to trauma from the patient's "bouncing" the barbell off his chest after holding his breath during eccentric contraction.
Making the Diagnosis
Symptoms of pneumothorax include dyspnea and pleuritic chest pain, which is most common and occurs in 80% to 90% of patients (2). Initial symptoms may be minimal, and up to 10% of patients are asymptomatic initially (2). Physical findings may include tachycardia, decreased breath sounds on auscultation, hyperresonance to percussion, and decreased tactile fremitus. Signs and symptoms of tension pneumothorax include tracheal deviation away from the involved side, distended neck veins, hypotension, and respiratory distress.
Pneumothorax can be confirmed by radiograph showing the absence of lung markings peripheral to the visceral pleural line. A PA radiograph will usually show a pneumothorax. However, a smaller pneumothorax—or one that does not show up on PA x-ray but is still clinically suspected—can be viewed with an expiratory film or a lateral decubitus film (8).
On-field diagnosis of pneumothorax can be difficult because of the good underlying pulmonary function of the athlete and because crowd noise can obscure chest percussion and auscultation. If a pneumothorax is suspected, supplemental oxygen should be administered, vital signs monitored, and the athlete transported to an emergency department. Review articles (2,7) provide more detailed information.
Treatment of pneumothorax depends in part on its size. If the patient is not dyspneic and the pneumothorax occupies less than 15% to 25% of the hemithorax, observation is sufficient (6,12). If the pneumothorax is larger or a smaller pneumothorax does not spontaneously resolve, then simple aspiration, aspiration followed by attachment of a one-way valve (such as a Heimlich chest drain valve), or tube thoracostomy should be performed (6).
The above treatments do not prevent recurrences of spontaneous pneumothorax. If the condition recurs, pleurodesis, thoracotomy, videothoracoscopy, or median sternotomy may be considered (6). Supplemental oxygen is also useful for all pneumothoraces because it increases the rate of pleural air absorption (6). For tension pneumothorax, emergency needle aspiration between the second and third rib can be performed, followed by tube thoracostomy.
The recurrence rate of a primary, spontaneous pneumothorax varies and depends on the treatment received. After chest tube drainage, there is a 10% to 21% recurrence rate (13), and simple aspiration carries a 20% to 50% recurrence rate (12). Pneumothorax in the patient in this case report was related to trauma, so the recurrence rate should not differ from the initial incident rate. However, an argument could be made that this patient was more susceptible to pneumothorax because, if subpleural blebs had formed, comparatively little force against a closed glottis could rupture a bleb. Therefore, his chance for recurrence is uncertain.
Return to Activity
Little information in the literature addresses rehabilitation and return to play. One issue to consider is whether treatment other than observation is required. Air is resorbed from the pleural space at the rate of 1.25% every 24 hours (12). At this rate, a pneumothorax occupying 20% of the hemithorax would take approximately 2 weeks to resolve without intervention. After resolution of the pneumothorax, the highest rates of recurrence are within the "first months" (6).
It is unclear whether those with a trauma-induced pneumothorax have an initial risk of recurrence. Volk et al (2) presented a case secondary to blunt trauma in a football player. Tube thoracostomy was performed, and the athlete returned to conditioning at 4 weeks and contact at 10 weeks. In contrast, Levy et al (14) reported three cases of pneumothorax caused by blunt trauma in football players. They were treated with tube thoracostomy and began gradual conditioning 2 days after removal of the tube. They progressed to contact drills when dyspnea was completely resolved and returned to play within 2 weeks of the injury.
Points of Emphasis
This case report and others raise important issues. Clinicians who see weight lifters should emphasize controlled mechanical technique. Bars should not be "bounced" off the chest. Clinicians should also emphasize proper breathing, with inspiration on eccentric contraction and exhalation on concentric contraction. Pneumothorax secondary to blunt trauma can occur without a fracture, and the precipitating trauma can be minimal. In addition, the trauma does not need to occur at the chest wall. Symptoms and clinical examination may be unremarkable, particularly initially or if the pneumothorax is small. Also, healthy, young athletes are capable of compensation that masks the possible severity. Although pneumothorax is rare in sports, physicians should maintain a high index of suspicion, especially when confronted with dyspnea and chest pain.
Dr Ciocca is an internist and sports medicine physician at the University of North Carolina at Chapel Hill. Address correspondence to Mario Ciocca, Jr, MD, The James A. Taylor Student Health Service, Division of Student Affairs, The University of North Carolina at Chapel Hill, CB #7470, Student Health Service Bldg, Chapel Hill, NC 27599-7470.