Chest Wall Pain With Chest Flies

HISTORY: Patient is a 31 year old male weightlifter with a past medical history of hyperlipidemia who presented with 20 months of chest wall pain. Pain is located at the left chest wall that radiates to the back near the shoulder blade. He describes the pain as dull and achy and rates his pain 3/10 but can get up to 5/10. It is worse with pressing on it, rotating his ribcage, or chest fly. It is better with time. He reported intermittent episodic chest pain, lasting 7 to 10 days with longest period without pain of 2 months. PHYSICAL EXAMINATION: On examination, observation revealed anterior head carriage with rounded shoulder posture with scapular protraction. There was decreased motion of the left ribs with inhalation and exhalation. There was focal tenderness at the sternocostal joint at the left 4th and 5th rib. Pain was reproduced with left thoracic rotation, right side bending, and flexion active range of motion testing. Hypomobility of vertebral segments T3 through T6 was also noted. DIFFERENTIAL DIAGNOSIS: 1)Costochondritis2)Slipping rib syndrome3)Sternocostal joint dysfunction4)Tietze’s syndrome5)Pericarditis TEST AND RESULTS: Focused ultrasound of the left chest wall was completed at bedside. There were no cortical irregularities of the sternal border or ribs 3 to 6. Hypoechoic swelling was visualized at the 5th sternocostal joint likely represents inflammation. Normal appearing sternocostal joints at ribs 1, 2, 3, 4, and 6 as well as the sternoclavicular joint. FINAL/WORKING DIAGNOSIS: 5th Sternocostal joint mechanical dysfunction TREATMENT AND OUTCOMES: The patient was referred for physical therapy. Treatment included mobilization of the rib cage and thoracic spine, diaphragmatic excursions, postural retraining followed by a scapular stabilization program. He was also advised to use diclofenac gel as needed. At return visit 14 weeks later, he reported 90% improvement in his symptoms after 4 therapy visits. Symptoms were managed with self mobilizations. On examination, pain was no longer reproducible with thoracic active range of motion and there was a decrease in severity of tenderness to palpation at the 5th sternocostal joint. Repeat POCUS showed improvement in the effusion at the left 5th sternocostal joint. He returned to sport without pain.