Thoracic Pain In A College Basketball Player

HISTORY: A 22-year-old male division I college basketball player presented for right-sided thoracic pain. The pain was sharp and localized to the anterior aspect of rib 6, inferior to the nipple, at the midclavicular line. Symptoms began two weeks prior, without any precipitating injury or trauma, although he had recently started weightlifting four times weekly and practicing basketball in anticipation of the upcoming season. Upper body lifting, deep breathing, and direct pressure exacerbated the symptoms. The pain did not prevent him from shooting a basketball or performing activities of daily living. Acetaminophen had provided minimal benefit. He denied numbness, tingling, loss of strength or sensation of the lower extremities. PHYSICAL EXAMINATION: No erythema or edema of the right anterior chest wall. There was tenderness to palpation of the anterior aspect of the right 6th rib at the midclavicular line and costochondral junction. No step-off was present. The patient had minimal pain with right side-bending, rotation, and flexion/extension of the thoracic spine. Light touch sensation of the chest wall was grossly intact. Differential Diagnosis: 1. Rib stress fracture 2. Costochondritis 3. Intercostal muscular strain 4. Rib subluxation 5. Mid-thoracic radiculopathy TEST AND RESULTS: X-ray Right Ribs/Chest: - Negative for rib fracture - No pleural effusion or pneumothorax Limited Diagnostic MSK Ultrasound of Rib 6: - Mature amorphous hyperechoic calcification with significant posterior acoustic shadowing over the junction of the anterior aspect of the rib and costal cartilage - No significant displacement of the chondral portion of rib FINAL WORKING DIAGNOSIS: Right 6th rib costochondral stress fracture TREATMENT AND OUTCOMES: 1. Recommended avoiding upper extremity weightlifting and contact practice/drills, with allowance of cardiovascular endurance training and shooting if pain free. 2. Three week follow up with improvement of pain by 80-90%. 3. Repeat diagnostic ultrasound demonstrated further callus formation and minimal tenderness to sonographic palpation. 4. Patient was limited from heavy lifting for an additional two weeks and instructed to avoid full-contact drills until no longer experiencing tenderness to palpation. 5. Encouraged to wear a padded rib protector upon return to play.