Chest and Abdomen Problems in Athletes

1. Chest and Abdomen Problems in Athletes Marc Childress, MD Self –Renowned Sports Medicine Expert

2. 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

3. Background • Chest and Abdomen problems frequent primary care complaints • Younger (<35) patients, cardiac causes of chest pain uncommon • Causes of trauma increase with athletic participation

4. Preview • Chest Troubles • No Spine • No Heart • Abdomen Troubles • No Pregnancy • No GI specific complaints • Everything else, Fair Game

5. Runner's Nipples • Noted on 2-16% of marathoners • Repetitive friction between shirt and nipple, resulting in painful, erythematous, and crusted nipples • Prevent with petroleum jelly, skin lube or bandage/tape layer • Treat with petroleum jelly or bandage/tape layer • May need topical abx

6. Muscle Strain (Intercostal) • Macro/micro trauma due to unaccustomed or excessive activity • Upper body activities • Cough • Minor trauma • Diagnosis • Pain BETWEEN ribs, worse with movement or deep inspiration, pain AT area of pressure • Treatment w/ NSAIDS, rest

7. Rib Fractures • Lucencies fall into one of three groups • 1) Acute Fracture • Severe Direct Trauma • Indirect Trauma – rapid contraction of neck muscles (MVA, lifting, cough, etc.) • 2) Stress Fracture • Different patterns seen in first rib vs remainder • First 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

8. Acute Fracture - Ribs • Treatment includes pain relief • BEWARE of complications • Pneumothorax • Splenic rupture • Flail chest…

9. Stress Fracture – First Rib • Pain can present in the shoulder, anterior neck, or clavicular region • Pain may refer to lateral upper arm • Pain with deep inspiration • Tenderness possible at: • Superior angle of scapula • Supraclavicular triangle • Deep in the axilla • Plain films often (-), consider bone scan, MRI, CT

10. Stress Fracture -- Ribs • Insidious onset of vague discomfort leading to sharper pain • Posterior thorax common • Radiation along associated intercostal nerve • Deep inspiration, direct palpation, provocative overuse motions painful

11. Stress Fracture -- Ribs • Management • Pain free rest 4-6 weeks • Gradual reintroduction • Most improved by 8-10 weeks • Rowers usually improved in 4 weeks • Golfers 8 weeks • Require scrutiny of technique, underlying bone health concerns (endo, metabolic dz, female athlete triad, steroid use, etc.)

12. Slipping Rib • Also known as: • Rib tip syndrome • Clicking rib • Slipping rib cartilage syndrome • Painful rib syndrome • Nerve Nipping • Displaced ribs • Twelfth rib syndrome • Defined by: • Pain in lower chest/abd • Tender spot on the lower costal margin • Reproduction of pain with palpation

13. Slipping Rib (cont'd) • Typical Hx includes intermittent sharp stabbing pain followed by prolonged soreness • No imaging modalities to ascertain dx, excludes other Dxs • Consider rest, manipulation, nerve block, local steroid injection, resection of rib end • Mixed literature on prognosis • Prolonged course • One study with conservative measures showed 70% patients with pain at 8 years • Remainder became pain free after approx 16 mos. • In series of excision patients (n=17), 82% pain free at 7 days, 100% at 6 weeks

14. Thoracic Wall Joint Conditions • Costochondritis • Chest wall pain and tenderness at the costochondral or costosternal joints • Likely inflammatory (positive gallium scan) • Unlikely degenerative or traumatic • Tietze’s Syndrome • Distinct from above by swelling at tender area • Fracture-dislocation of the SternocostalSynchondrosis

15. Precordial Catch • Sharp, stabbing pain in precordial/left parasternal region without radiation • Only last seconds • Can be at rest or with mild or moderate exercise • Rare above age 35 • Thought to be have pleural origin • May respond to repositioning/stretching

16. Effort Thrombosis • Thrombosis of the subclavian or axillary vein • Most common with repetitive overhead motion- pitchers • Sxs typically include pain and swelling into the arm, possible numbness • Signs include edema, venous prominence • Dx with US or venography • Tx with rest, elevation • Heparin followed by coumadin

17. Pneumothorax • Traumatic vs Spontaneous • Spontaneous bleb rupture, sudden compressive force, displaced rib fracture • Both associated with tachypnea, dyspnea, and sudden chest pain • Simple vs Tension • Shift of mediastinal structures (with both) • Tension sees additional tachycardia, neck vein distention, and hypotension.

18. Pneumothorax (cont'd) • Dx made by quick hx and assessment of signs/sxs • PE may demonstrate decreased breath sounds / hyperresonance on affected side • X-rays can be confirmatory, but suggested tension pneumo should NOT WAIT for films • Tx based on degree and stability • Rapid assistance with needle decompression • Tension and signif simple require tube thoracostomy • Small (<20%) simple pneumothorax may be treated with close observation

19. Pulmonary Contusion • Blunt force to lung tissue resulting in edema, hemorrhage • Children more prone given elasticity of chest wall (concurrent decreased risk in rib fx) • Cough, hemoptysis, SOB, and dyspnea • Diminished breath sound, rales • Fluffy infiltrate on x-rays • Limit fluid intake, rest, may need add’l vent support

20. Cardiac Contusion • Rapid deceleration, compression against sternum • Cycling, 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 predictor • Poor prognostic capability with additional testing (CPK, echo, gated pool scans) • CommotioCordis

21. Abdominal Wall Injury • Muscular contusion – rest, ice, return once pain free • Rectus sheath hematoma – rupture of the epigastric vein or artery • May need surgical evacuation and ligation • Recovery and return determined once pain resolved, typically 1 to 2 weeks • Forces required can easily induce intra-abdominal injury • Consider CT, DPL

22. 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 size • Mononucleosis • Hematologic dz • Dx made on PE and clinical suspicion, rapid imaging with CT • Options for Operative vs conservative tx based on patient stability, reassuring CBC, and lack of associated injuries • Recovery within 1-2 weeks, avoid contact 3-4 months

23. 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 size • Hepatitis • Dx made on PE and clinical suspicion, rapid imaging with CT • Options for Operative vs conservative tx based on patient stability, reassuring CBC, and lack of associated injuries • Recovery within months, avoid contact at least 3-4 months, completely pain free and CT normal

24. 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

25. Renal Trauma / Injury (cont'd) • Only injuries with clinical worsening or instability require surgery • Most injuries, even severe, will heal within 6 to 8 weeks • Micro hematuria can persist 2 to 4 weeks after injury • Do not confuse / overlook urethral injuries

26. Sports Hernia • “Athletic pubalgia” • “Sportsmen’s hernia” • “Osteitis Pubis” • “Gilmore’s groin” • “Hockey groin syndrome” • “Ashby’s inguinal ligament enthesopathy”

27. Sports Hernia • Dull, diffuse groin pain • Often radiating to the perineum and inner thigh • Typically more intense with athletic • Usually chronic in nature • Variable numbers • sports hernia review.pdf

28. Sports Hernia • 1992, Malycha and Lovell • “. . . .bulge in the posterior wall consistentwithan 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”

29. Sports Hernia • 2002, Kumar et al. • Majority had >1 lesion. • 56% - External oblique tear • 50% - Bulge in the posterior wall • 12% - Conjoined tendon disruptions • 32% 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

30. Sports Hernia • Consider ultrasound and herniographyto evaluate for an attenuated abdominal wall • MRI to evaluate pubic bone edema, attenuated musculature, and edema within pathologic tissue • Rule out confounders to the best of your ability • Find a believing consultant • sports hernia review.pdf

31. Summary • Musculoskeletal injuries common in truncal area • Knowledge of pertinent anatomy is critical • Medical common sense rules the day • Maintain vigilance for rare but potential life-threatening situations • Remember my uncle