Marc Childress, MD Self –Renowned Sports Medicine Expert

Chest and Abdomen Problems in Athletes

Marc Childress, MDSelf –Renowned Sports Medicine Expert

Rules to live by in Sports Medicine

. A person hears only what they understand

Johann Wolfgang von Goethe

Look wise, say nothing, and grunt. Speech was given to conceal thought.

William Osler

Background

Chest and Abdomen problems frequent primary care complaintsYounger (<35) patients, cardiac causes of chest pain uncommonCauses of trauma increase with athletic participation

Preview

Chest TroublesNo SpineNo Heart

Abdomen TroublesNo PregnancyNo GI specific complaints

Everything else, Fair Game

Runner's Nipples

Noted on 2-16% of marathonersRepetitive friction between shirt and nipple, resulting in painful, erythematous, and crusted nipplesPrevent with petroleum jelly, skin lube or bandage/tape layerTreat with petroleum jelly or bandage/tape layerMay need topical abx

Muscle Strain (Intercostal)

Macro/micro trauma due to unaccustomed or excessive activityUpper body activitiesCoughMinor traumaDiagnosis

Pain BETWEEN ribs, worse with movement or deep inspiration, pain AT area of pressure

Treatment w/ NSAIDS, rest

Rib Fractures

Lucencies fall into one of three groups1) Acute Fracture

Severe Direct TraumaIndirect Trauma – rapid contraction of neck muscles (MVA, lifting, cough, etc.)

2) Stress FractureDifferent patterns seen in first rib vs remainderFirst rib stress fx usually result of ant scalene force (overhead activities – baseball, basketball, tennis, weight lifting, )Others usually result of serratus anterior force (downward stabilizing force – rowing, golf)

3) Congenital Defect – unique to first rib

Acute Fracture - Ribs

Treatment includes pain reliefBEWARE of complications

PneumothoraxSplenic ruptureFlail chest…

Stress Fracture – First Rib

Pain can present in the shoulder, anterior neck, or clavicular regionPain may refer to lateral upper armPain with deep inspirationTenderness possible at:

Superior angle of scapulaSupraclavicular triangleDeep in the axilla

Plain films often (-), consider bone scan, MRI, CT

Stress Fracture -- Ribs

Insidious onset of vague discomfort leading to sharper painPosterior thorax commonRadiation along associated intercostal nerveDeep inspiration, direct palpation, provocative overuse motions painful

Stress Fracture -- Ribs

ManagementPain free rest 4-6 weeksGradual reintroductionMost improved by 8-10 weeks

Rowers usually improved in 4 weeksGolfers 8 weeks

Require scrutiny of technique, underlying bone health concerns (endo, metabolic dz, female athlete triad, steroid use, etc.)

Slipping Rib

Also known as:Rib tip syndromeClicking ribSlipping rib cartilage syndromePainful rib syndromeNerve NippingDisplaced ribsTwelfth rib syndrome

Defined by:Pain in lower chest/abdTender spot on the lower costal marginReproduction of pain with palpation

Slipping Rib (cont'd)

Typical Hx includes intermittent sharp stabbing pain followed by prolonged sorenessNo imaging modalities to ascertain dx, excludes other DxsConsider rest, manipulation, nerve block, local steroid injection, resection of rib end

Mixed literature on prognosis

Prolonged courseOne study with conservative measures showed 70% patients with pain at 8 yearsRemainder became pain free after approx 16 mos.

In series of excision patients (n=17), 82% pain free at 7 days, 100% at 6 weeks

Thoracic Wall Joint Conditions

CostochondritisChest wall pain and tenderness at the costochondral or costosternal jointsLikely inflammatory (positive gallium scan)Unlikely degenerative or traumatic

Tietze’s SyndromeDistinct from above by swelling at tender area

Fracture-dislocation of the Sternocostal Synchondrosis

Precordial Catch

Sharp, stabbing pain in precordial/left parasternal region without radiationOnly last secondsCan be at rest or with mild or moderate exerciseRare above age 35Thought to be have pleural originMay respond to repositioning/stretching

Effort Thrombosis

Thrombosis of the subclavian or axillary veinMost common with repetitive overhead motion- pitchersSxs typically include pain and swelling into the arm, possible numbnessSigns include edema, venous prominenceDx with US or venography

Tx with rest, elevationHeparin followed by coumadin

Pneumothorax

Traumatic vs SpontaneousSpontaneous bleb rupture, sudden compressive force, displaced rib fractureBoth associated with tachypnea, dyspnea, and sudden chest pain

Simple vs TensionShift of mediastinal structures (with both)Tension sees additional tachycardia, neck vein distention, and hypotension.

Pneumothorax (cont'd)

Dx made by quick hx and assessment of signs/sxs

PE may demonstrate decreased breath sounds / hyperresonance on affected sideX-rays can be confirmatory, but suggested tension pneumo should NOT WAIT for films

Tx based on degree and stabilityRapid assistance with needle decompressionTension and signif simple require tube thoracostomy Small (<20%) simple pneumothorax may be treated with close observation

Pulmonary Contusion

Blunt force to lung tissue resulting in edema, hemorrhageChildren more prone given elasticity of chest wall (concurrent decreased risk in rib fx)

Cough, hemoptysis, SOB, and dyspneaDiminished breath sound, ralesFluffy infiltrate on x-raysLimit fluid intake, rest, may need add’l vent support

Cardiac Contusion

Rapid deceleration, compression against sternumCycling, skiing, parachuting, rock climbing, race car driving

Signif cardiac events are rare, most happen within 24 hours

Monitoring to include tele, vitals, and exam to include auscultation and neck vein distention

Initial EKG best predictorPoor prognostic capability with additional testing (CPK, echo, gated pool scans)

Commotio Cordis

Abdominal Wall Injury

Muscular contusion – rest, ice, return once pain freeRectus sheath hematoma – rupture of the epigastric vein or artery

May need surgical evacuation and ligationRecovery and return determined once pain resolved, typically 1 to 2 weeksForces required can easily induce intra-abdominal injuryConsider CT, DPL

Splenic Injury

Can be result of:1) Direct force to abdomen 2) Sudden deceleration tearing the hilum 3) Displacement of left lower rib fracture

Increased risk with increased sizeMononucleosisHematologic dz

Dx made on PE and clinical suspicion, rapid imaging with CTOptions for Operative vs conservative tx based on patient stability, reassuring CBC, and lack of associated injuriesRecovery within 1-2 weeks, avoid contact 3-4 months

Hepatic Injuries

Can be result of:1) Direct blow to abdomen 2) Sudden deceleration 3) Displacement of right lower rib fracture

Increased risk with increased sizeHepatitis

Dx made on PE and clinical suspicion, rapid imaging with CTOptions for Operative vs conservative tx based on patient stability, reassuring CBC, and lack of associated injuriesRecovery within months, avoid contact at least 3-4 months, completely pain free and CT normal

Renal Trauma/In jury

Mechanism, focal pain, and hematuria are most suggestive signs/sxs, but imprecise

Hematuria NOT present in 25% of renal, 40% renal pedicle injuries Flank mass or ecchymosis may be present but often absent

In trauma, high risk suspicion (gross hematuria, micro hematuria w/hypotension or flank mass) should result in CT, possibly IVP

Renal Trauma / Injury (cont'd)

Only injuries with clinical worsening or instability require surgeryMost injuries, even severe, will heal within 6 to 8 weeksMicro hematuria can persist 2 to 4 weeks after injuryDo not confuse / overlook urethral injuries

Sports Hernia

“Athletic pubalgia”“Sportsmen’s hernia”“Osteitis Pubis”“Gilmore’s groin”“Hockey groin syndrome”“Ashby’s inguinal ligament enthesopathy”

Sports Hernia

Dull, diffuse groin painOften radiating to the perineum and inner thigh Typically more intense with athleticUsually chronic in nature

Variable numbers

sports hernia review.pdf

Sports Hernia1992, Malycha and Lovell“. . . .bulge in the posterior wall consistentwith an incipient direct inguinal hernia”.

1995, Simonet et al“Partial or complete tears on the floor of the inguinal ring, at the internal oblique muscle. “The posterior wall and external oblique aponeurosis were intact.

2000, Meyers“loose inguinal floor, a small defect in the external oblique aponeurosis, and thinning or tearing of the rectus abdominis insertion.”

2001, Irshad et al.“isolated tears of the external oblique aponeurosis”

Sports Hernia

2002, Kumar et al.Majority had >1 lesion.

56% - External oblique tear50% - Bulge in the posterior wall 12% - Conjoined tendon disruptions32% had both a tear of the external oblique aponeurosis and a deficiency of the posterior wall, but an intact conjoined tendon. The ilioinguinal and genitofemoral nerves were normal

Sports Hernia

Consider ultrasound and herniography to evaluate for an attenuated abdominal wallMRI to evaluate pubic bone edema, attenuated musculature, and edema within pathologic tissueRule out confounders to the best of your abilityFind a believing consultantsports hernia review.pdf

Summary

Musculoskeletal injuries common in truncal areaKnowledge of pertinent anatomy is criticalMedical common sense rules the dayMaintain vigilance for rare but potential life-threatening situationsRemember my uncle