Pneumothorax in Sports
Issues in Recognition and Follow-Up Care
Sean M. Curtin, MD; Andrew M. Tucker, MD; David R. Gens, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 8 - AUGUST 2021
In Brief: Spontaneous and traumatic pneumothoraces are rare conditions found occasionally in athletes. Although generally not life-threatening, these conditions can be fatal if not appropriately diagnosed and managed. Expedient diagnosis depends on a thorough understanding of possible presenting signs and symptoms such as chest pain, dyspnea, and diminished breath sounds. A chest radiograph may be required for definitive diagnosis. Management depends on the size, stability, and type of pneumothorax and may include serial monitoring, tube thoracostomy, pleurodesis, or apical resection. Return-to-play guidelines after pneumothorax have not been previously published. We present recomendations based on a review of published case reports, our clinical experience, and communication with North American sports medicine providers.
Pneumothorax, a rare but potentially dangerous condition found in athletic activity, can occur spontaneously or result from chest trauma. Although both spontaneous and traumatic pneumothoraces have been reported in association with several sports (1-4), little information is available to guide physicians in the active patient's care, particularly concerning return-to-play guidelines (5,6). We describe two cases of athletes with pneumothoraces and provide information on the differences in the cause, diagnosis, and management of each type. We also present return-to-play recommendations.
Types of Pneumothorax
Spontaneous. Spontaneous pneumothorax in healthy individuals was described in detail by Kjaergaard (7) in the 1930s. The condition occurs primarily in young men 20 to 40 years old (8,9) and has a lower incidence in women (10).
Although the etiologic factors that contribute to spontaneous pneumothorax are not clearly understood, the most generally accepted cause is rupture of subpleural blebs or bullae. The origin of such blebs and cause for their rupture are also currently unknown, but it has been suggested that family history and an asthenic (tall, thin) body build are associated factors (8,9). A history of smoking tobacco and recent substance abuse are also often associated with the condition (9,11,12). The recurrence rate for spontaneous pneumothorax has been reported to vary from 20% to 50%, with an increasing likelihood after each recurrence (7-9,13,14).
Sports-related spontaneous pneumothorax has been described in scuba diving (15), weight lifting (2,16), and jogging (17). It has been postulated that elevated intrathoracic pressure during activity, combined with mechanical factors of the underlying blebs or bullae, may lead to their eventual rupture (2). Most cases of spontaneous pneumothorax, however, are not associated with exertion or activity (9).
Traumatic. Blunt thoracic trauma is a well-known cause of pneumothorax and pneumomediastinum (which often coincides with pneumothorax and is treated in a similar fashion). Frequently, although not always, these conditions result from fractured ribs that are driven inward. Contact sports carry an inherent risk for chest trauma, and several authors (4,18,19) have reported pneumothorax in association with sports-related clavicle and rib fractures. However, traumatic pneumothorax in sports remains rare, particularly when rib or clavicle fractures do not occur (1,3,4). Presumably, in cases not involving a fracture, the acute increase in intrathoracic pressure is responsible for a small rupture in the pleura or bronchial tree. No underlying intraparenchymal pathology has been associated with this type of pneumothorax. To our knowledge, pneumomediastinum resulting from blunt trauma associated with sports has been described only once (4).
Tension. Tension pneumothorax is a rare complication that develops when air progressively collects in the pleural space. The condition is characterized by collapse of the affected lung with mediastinal shift and compression of the trachea and great vessels resulting in hemodynamic collapse. Hypotension and cyanosis are common and foreboding findings. This condition is life-threatening and demands immediate treatment to relieve the trapped air.
Regardless of whether a pneumothorax occurs spontaneously or from trauma, early and accurate diagnosis is essential. The classic presenting complaint of a patient with a pneumothorax is chest pain (table 1), which is present in 80% to 95% of cases (8,14). The pain can be vague but is usually localized to the side of the affected lung and can radiate to the shoulder, neck, and back. Often pain is pleuritic and can be associated with dyspnea on exertion and/or a dry cough. Patients with pneumomediastinum may complain of dysphagia and dysphonia.
Classic physical findings of pneumothorax include tachypnea, tachycardia, hyperresonance to percussion of the affected chest area, diminished breath sounds, and fremitus on the side of the affected lung. A classic finding in pneumomediastinum is subcutaneous emphysema that is palpable over the supraclavicular area and anterior neck. Another finding with a pneumomediastinum (see table 1) is Hamman's sign, which has been described as auscultated precordial crackles or crunching sounds synchronous with the heartbeat (20).
Although both patients reported here (see "A Basketball Player With Spontaneous Pneumothorax," below and "Traumatic Pneumothorax in a Football Player," below) had classic presentations, it is important to note that many clinical presentations of pneumothorax and pneumomediastinum are atypical, consisting of only mild, vague chest pain. As many as 10% of patients with a spontaneous pneumothorax may be asymptomatic at the time of initial evaluation (3). Thus, plain radiographs are required to confirm the diagnosis. Occasionally, computed tomography (CT) is helpful for diagnosing pneumomediastinum.
Any patient suspected by history of having a pneumothorax or pneumomediastinum should have an immediate hemodynamic assessment that includes vital signs. If the patient is hemodynamically unstable in the presence of a suspected tension pneumothorax, an urgent needle thoracostomy should be performed if possible. This can be accomplished by placing an 18-gauge (or larger) needle into the pleural space anteriorly or laterally over a site of absent or decreased breath sounds. Oxygen and intravenous fluids should be used as needed while the patient is immediately transported to a trauma center. If the patient is hemodynamically stable, treatment options depend on the size of the pneumothorax.
With a small pneumothorax, patients can recover successfully with only monitoring of cardiac and pulmonary symptoms and signs and serial chest radiographs (daily in the hospital, weekly after discharge until radiographic resolution), as did the football player in our case study (below).
Larger pneumothoraces (>15% to 20% loss of lung volume) are generally treated with tube thoracostomy. Some authors (8,9) advocate a corrective procedure for spontaneous pneumothorax to reduce the risk for recurrence. Open thoracotomy and apical resection have been shown to provide excellent protection against ipsilateral recurrences of spontaneous pneumothorax (8,14,21). Mechanical or chemical pleurodesis is also commonly used (8,22,23). Although the exact indications for these procedures remain controversial, most authors agree that increasing episodes of recurrent spontaneous pneumothorax require some type of corrective procedure. We recommend thorascopic resection of subpleural blebs and pleurodesis after a patient's third episode of spontaneous pneumothorax or in any patient for whom tube thoracostomy is unsuccessful at relieving the pneumothorax.
Pneumomediastinum generally resolves spontaneously without complications but does require evaluation of the airways and esophagus to rule out an obvious tear. This is usually accomplished with bronchoscopy and esophagoscopy or barium swallow.
The low prevalence of pneumothorax in athletics has hindered the development of accepted clinical return-to-play guidelines for these patients, and we know of no such published guidelines. When considering return-to-play recommendations for a patient who has suffered a pneumothorax or pneumomediastinum, it is important to differentiate between spontaneous and traumatic pneumothorax.
Spontaneous pneumothorax. Some clinicians (5,6) have recommended restricting those who have suffered a primary spontaneous pneumothorax to relatively sedentary leisure competitions such as archery, bowling, golf, recreational swimming, and riflery, unless patients are treated with a corrective procedure. The basis for this recommendation is presumably the increased risk of recurrence in nonoperatively treated patients, estimated to be 50% in patients with spontaneous pneumothorax (24).
Others (25) have suggested that only individuals whose pneumothorax was specifically related to exertion or sporting activity should be so restricted. This opinion takes into account that most cases of spontaneous pneumothorax are not associated with exertion, and therefore athletic activity would present no increased risk for recurrence.
It is generally accepted, however, that such athletes should not be restricted from any activity but should be appropriately counseled regarding the inherent risk of recurrence, regardless of activity.
A careful review of the literature produced no data that specifically addressed this issue to support a consensus on return-to-play recommendations. Through our limited personal experience with three cases and in discussions with six physicians and trainers who have managed a small number of professional and collegiate athletes with pneumothoraces, we know of no cases of recurrent pneumothorax after return to play in athletes treated nonoperatively. The basketball player in our case study (below) who had a spontaneous pneumothorax returned to play in 3 weeks without difficulty. Players usually can return to play 3 to 4 weeks after resolution. However, it is generally recommended that if an athlete develops multiple recurrences spontaneously or during activity, he or she should be strongly advised to undergo a corrective procedure.
Traumatic pneumothorax. To our knowledge, no published guidelines exist for return to play after an episode of traumatic pneumothorax. However, because no published data suggest an increased risk for recurrence of traumatic pneumothorax, it seems reasonable that individuals with the disorder can return to full activity without restrictions once the presenting pneumothorax has resolved. In fact, it stands to reason that the resulting scar tissue formation may decrease the risk of recurrence in individuals who have no underlying lung pathology.
How long a patient should wait after resolution of a pneumothorax before returning to play is unclear, but in the few reported cases, the return time ranged from 4 to 6 weeks (or about 3 to 4 weeks after resolution of symptoms) without complications (1,3,4). Through personal communication (oral communication, Lonnie Albers, MD, director of athletic medicine, University of Nebraska, Lincoln), we know of one football player who developed a recurrent traumatic pneumothorax while competing in a game 1 week after his initial pneumothorax. The football player we described (below) returned to full contact play without complications in 3 weeks. A period of 3 to 4 weeks is probably sufficient to allow the pleura to become well scarred, based on one of our (D.R.G.) impressions.
Air travel. Because many athletes travel great distances to compete, it is important to note some precautions concerning air travel and pneumothorax. There has been much research in the aviation literature that addresses pneumothorax and pilots, particularly in the military. However, there are no clear recommendations for airline passengers and pneumothorax, except that a patient with an acute, unresolved pneumothorax should not travel by air, if at all possible, because of the risk of enlargement of the pneumothorax that could compromise circulatory and ventilatory functions.
The issue as to how soon a pilot should return to flight after resolution of a pneumothorax remains controversial, with recommendations ranging from several months to 9 years (9,26). The authors cited suggest reasons for their recommendations that include the dramatic changes in intrathoracic pressure associated with aggressive military flying and the tremendous responsibility for in-flight safety that a pilot bears. Without these conditions, it seems reasonable that routine commercial airline passengers can return to air travel sooner. Both the athletes we describe (below) returned to air travel within 1 to 2 months without complications. Team physicians and other healthcare providers must be aware of, and appropriately counsel their patients on, the concerns of air travel and pneumothorax.
Traumatic and spontaneous pneumothoraces are rare but potentially dangerous conditions found in athletic activity. Physicians should be familiar with the possible presenting signs and symptoms to establish an early diagnosis and prevent potentially serious complications. Treatment options depend on the size and stability of the pneumothorax. Spontaneous pneumothoraces are known to have a high rate of recurrence, and resection of the subpleural bleb and pleurodesis should be considered after a third episode occurs. No consensus return-to-play guidelines exist, but most athletes can return to full activity 3 to 4 weeks after resolution of the pneumothorax. Special consideration should be given to the potential complications of airline travel—enlargement of a pneumothorax could compromise circulatory and ventilatory function—for patients recovering from pneumothoraces.
A Basketball Player With Spontaneous Pneumothorax
A 22-year-old male college basketball player who had no clinically significant medical history and was in apparently excellent health developed sudden onset of vague left-side chest discomfort approximately 4 hours before an away game. The team had traveled to the game site by a 1.5-hour airplane flight the day before the game. The onset of the discomfort was not associated with any known trauma but may have been temporally related to a bowel movement. He reported that the pain was initially a mild, dull ache over the left apical region, with no other symptoms.
During pregame warm-ups (light running and shooting drills), the pain became more intense and worsened with deep inspiration. He then reported to the training room.
On examination, he appeared comfortable with no apparent respiratory distress at rest. Vital signs were: respiratory rate, 12 breaths per minute; pulse, 60 per minute; and blood pressure, 120/70 mm Hg. No tenderness was reproduced with chest wall palpation or rib compression test. Auscultation revealed slightly decreased breath sounds in the left upper side. There was no evidence of cyanosis or shift of the trachea. Cardiac examination revealed that the patient had a regular rhythm, with no murmur, gallop, rub, or click.
He was taken to the emergency department of a local community hospital where a chest radiograph revealed a large left-side pneumothorax (figure A). No rib fractures were seen on the radiograph, and there was no evidence of tumor or infection. A chest tube was placed in the left side of the chest between the sixth and seventh ribs at the anterior axillary line. A chest radiograph taken 15 minutes later showed the tube in an appropriate position and reexpansion of the lung (figure B).
The patient's subsequent hospital course was uneventful. The chest tube was removed on day 2, and the patient was discharged on day 3. He returned to his school by car because the pneumothorax prohibited travel by plane, and he returned to play in 3 weeks without difficulty.
Traumatic Pneumothorax in a Football Player
A 31-year-old professional football player developed acute onset of substernal chest pain after being tackled and landing on his chest with the football directly between his sternum and the ground. He continued in the game for two or three more plays (about 2 minutes) before coming to the sidelines. He reported persistent substernal chest pain and mild shortness of breath at rest but no radiation of pain, nausea, palpitations, or dizziness. He reported mild difficulty with swallowing.
Sideline exam revealed an alert, oriented man in no apparent distress. Respiratory rate was 18 breaths per minute. Subcutaneous emphysema was noted above his right clavicle, and there was some tenderness to palpation over the sternum. Breath sounds were normal in all lung fields. A chest radiograph taken at the stadium was interpreted by the examining physician as normal. The patient was transported to a local trauma center via ambulance.
Hospital examination confirmed an alert, oriented man in no apparent distress. Vital signs were: respiratory rate, 15 breaths per minute; pulse, 75 per minute; blood pressure, 150/80 mm Hg. Head and neck examination showed a slight hoarseness in his voice that was abnormal for him but no evidence of tracheal shift. No stridor was present, and there was no evidence of cyanosis. His neck showed full, painless range of motion and was nontender without palpable masses. Mild subcutaneous emphysema was present at the base of the right neck. The patient had tenderness to palpation along the right sternal border. His lungs were clear to auscultation bilaterally, with good breath sounds in all lung fields. His abdomen was soft, nontender, and nondistended with normal bowel sounds.
Cardiac examination revealed a regular rate and rhythm with normal S1 and S2, and no displacement of the point of maximal impulse one interspace inferior to the left nipple. No murmurs were present. Hamman's sign (auscultated precordial crackles or crunching sounds synchronous with the heartbeat) was positive. A repeat chest radiograph (figure C1), taken 20 minutes after the initial radiograph at the stadium, showed a small pneumomediastinum. Subsequent CT of the chest (figure C2) confirmed the pneumomediastinum and revealed a 10% right apical pneumothorax.
The patient was hospitalized for observation and serial chest radiographs. Pain was controlled with analgesics as needed. Additional investigations included bronchoscopy and esophageal barium swallow, performed to rule out substantial lesions to the tracheobronchial tree and esophagus, respectively. Subsequent radiographs showed gradual and complete resolution of the pneumomediastinum over the next 2 days, after which the patient was discharged from the hospital.
The apical pneumothorax remained stable and resolved without complications over the next 5 days. Outpatient follow-up radiographs taken later that week showed no recurrence of either condition. The patient was cleared by the team physician and the trauma surgeon consultant to return to full activity in 2 weeks, and he competed without difficulty 3 weeks after the injury.
Dr Curtin is a clinical instructor in the department of medicine at the University of Maryland in College Park. Dr Tucker is the Director of Primary Care in the Sports Medicine Service at the University of Maryland Medical Center in Baltimore, and Dr Gens is an attending trauma surgeon at the R Adams Cowley Shock Trauma Center in Baltimore. Address correspondence to Andrew M. Tucker, MD, c/o Elaine P. Bulson, Editor, Shock Trauma Orthopaedics, 22 S Greene St, Rm T3R64, Baltimore, MD 21201-1595; e-mail to [email protected].