Abstract
Chest pain in the athlete has a wide differential diagnosis. Pain may originate from structures within the thorax, such as the heart, lungs or oesophagus. However, musculoskeletal causes of chest pain must be considered. The aim of this review is to help the clinician to diagnose chest wall pain in athletes by identifying the possible causes, as reported in the literature. Musculoskeletal problems of the chest wall can occur in the ribs, sternum, articulations or myofascial structures. The cause is usually evident in the case of direct trauma. Additionally, athletes’ bodies may be subjected to sudden large indirect forces or overuse, and stress fractures of the ribs caused by sporting activity have been extensively reported. These have been associated with golf, rowing and baseball pitching in particular. Stress fractures of the sternum reported in wrestlers cause pain and tenderness of the sternum, as expected. Diagnosis is by bone scan and limitation of activity usually allows healing to occur. The slipping rib syndrome causes intermittent costal margin pain related to posture or movement, and may be diagnosed by the ’hooking manoeuvre’, which reproduces pain and sometimes a click. If reassurance and postural advice fail, good results are possible with resection of the mobile rib. The painful xiphoid syndrome is a rare condition that causes pain and tenderness of the xiphoid and is self-limiting. Costochondritis is a self-limiting condition of unknown aetiology that typically presents with pain around the second to fifth costochondral joints. It can be differentiated from Tietze’s syndrome in which there is swelling and pain of the articulation. Both conditions eventually settle spontaneously although a corticosteroid injection may be useful in particularly troublesome cases. The intercostal muscles may be injured causing tenderness between the ribs. Other conditions that should be considered include epidemic myalgia, precordial catch syndrome and referred pain from the thoracic spine.
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References
Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil 1992; 73: 147–9
Thomas PL. Thoracic back pain in rowers and butterfly swimmers: costo vertebral subluxation. Br J Sports Med 1988 Jun; 2 (2): 81
Fam AG, Smythe HA. Musculoskeletal chest wall pain. Can Med Assoc J 1985; 133 (5): 379–89
Epstein S, Gerber L, Borer J. Chest wall syndrome: a common cause of unexplained cardiac pain. JAMA 1979; 241 (26): 2793–7
Alderson BR. Further observations on fracture of the first rib. Br J Radiol 1947; 68: 655–9
Etter LE. Osseous abnormalities of the thoracic cage seen in forty thousand consecutive chest photoroentgenograms. Am J Roentgenol 1944; 51: 359–3
Freiberger RH, Mayer V. Ununited bilateral fatigue fracture of the first ribs. J Bone Joint Surg Am 1964; 46A: 615–8
Curran JP, Kelly DA. Stress fracture of the first rib. Am J Orthop 1966; 8: 16–8
Jenkins SA. Spontaneous fractures of both first ribs. J Bone Joint Surg 1952; 34B: 9–13
Lorentzen JE, Movin M. Fracture of the first rib. Acta Orthop Scand 1976; 47: 623–43
Richardson JD, McElvein RB, Trinkle JK. First rib fracture: a hallmark of severe trauma. Ann Surg 1975; 181: 251–4
Joshi SG, Panday SR, Parukar GB, et al. Bilateral first rib fracture of the first rib: report of two cases. J Bone Joint Surg Br 1965; 47B: 283–5
Rademaker M, Redmond AD, Barker PV. Stress fracture of the 1st rib. Thorax 1983; 38: 312–3
Mitchell JP. Cough fracture. BMJ 1951; 2 (1): 1492–3
Rasad S. Golfer’s fractures of the ribs. Am J Roentgenol Rad Nucl Med 1974; 120: 901–3
Blichert-Toft M. Fatigue fracture of the first rib. Acta Chir Scand 1968; 135: 675–8
Gershon-Cohen J, Delbridge RE. Pseudoarthrosis, synchondrosis and other anomalies of the first ribs. Am J Roentgenol 1945; 53: 49–54
Moore RS. Fracture of the first rib: an uncommon throwing injury. Injury 1991; 22 (2): 149–50
Proffer DS, Patton JJ, Jackson DW. Nonunion of a first rib fracture in a gymnast. Am J Sports Med 1991; 19 (2): 198–201
Barrett GR, Shelton WR, Miles JW. First rib fractures in football players: a case report and literature review. Am J Sports Med 1988; 16 (6): 674–6
Gupta A, Jamshidi M, Robin JR. Traumatic first rib fractures: is angiography necessary? A review of 73 cases. Cardiovasc Surg 1997; 5: 48–53
Aitken AP, Lincoln RE. Fracture of the first rib due to muscle pull. N Engl J Med 1939; 220: 1063–4
Brooke R. Jive fracture of the first rib. J Bone Joint Surg Br 1959; 41B: 370–1
Leung HY, Stirling AJ. Stress fracture of the first rib without associated injuries. Injury 1991; 22 (6): 483–4
Bailey P. Surfer’s rib: isolated first rib fracture secondary to indirect trauma. Ann Emerg Med 1985; 14: 346–9
Lankenner PAJ, Micheli LJ. Stress fractures of the first rib: a case report. J Bone Joint Surg Am 1985; 67: 159–60
Mamanee P, Weinberg J, Curl LA, et al. Bilateral first rib fractures and unilateral second rib stress fractures in a female athlete. Clin J Sports Med 1999; 9 (3): 177–83
Mintz AC, Albano A, Reisdorff EJ, et al. Stress fracture of the first rib from serratus anterior tension: an unusual mechanism of injury. Ann Emerg Med 1990; 19 (4): 411–4
Gurtler R, Pavlov H, Torg JS. Stress fracture of the ipsilateral first rib in a pitcher. Am J Sports Med 1985; 13 (4): 277–9
Sacchetti AD, Beswick DR, Morse SD. Rebound rib: stress-induced first rib fracture. Ann Emerg Med 1983; 12 (3): 177–9
Tullos HS, Erwin WD, Woods GW, et al. Unusual lesions of the pitching arm. Clin Orthop 1972; 88: 169–82
Hirata S. Fracture of the first rib: case report of left non-traumatic chronic fracture and review of 35 cases of non-traumatic cases reported in Japan. Jpn J Thor Dis 1982; 20: 762–9
Brukner P, Khan K. Stress fracture of the neck of the seventh and eighth ribs: a case report. Clin J Sport Med 1996; 6 (3): 204–6
McKenzie DC. Stress fracture of the rib in an elite oarsman. Int J Sports Med 1989; 10 (3): 220–2
Karlson KA. Rib stress fractures in elite rowers: a case series and proposed mechanism. Am J Sports Med 1998; 26 (4): 516–9
Holden DL, Jackson DW. Stress fracture of the ribs in female rowers. Am J Sports Med 1985; 13 (5): 342–8
Lin HC, Chou CS, Hsu TC. Stress fractures of the ribs in amateur golf players. Chung Hua I Hsueh Tsa Chih 1994; 54 (1): 33–7
Bojanic I, Desnica N. Stress fracture of the sixth rib in an elite athlete. Croat Med J 1998; 39 (4): 458–60
Christiansen E, Kanstrup IL. Increased risk of stress fractures of the ribs in elite rowers. Scand J Med Sci Sports 1997; 7 (1): 49–52
Lord MJ, Ha KI, Song KS. Stress fractures of the ribs in golfers. Am J Sports Med 1996; 24 (1): 118–22
Derbes VJ, Haran T. Rib fractures from muscular effort with particular reference to cough. Surgery 1954; 25: 294–321
Taimela S, Kujala UM, Orava S. Two consecutive rib stress fractures in a female competitive swimmer. Clin J Sport Med 1995; 5 (4): 254–7
Goyal M, Kenney Jr A. Golfer’s rib stress fracture (Duffer’s fracture): scintigraphic appearance. Clin Nucl Med 1997; 22 (7): 503–4
Hsu CY, Lin HC, Kao CH, et al. Stress fracture of the ribs in amateur golfers diagnosed by TC-99m MDP scintigraphy. Kao Hsiung I Hsueh Ko Hsueh Tsa Chih 1993; 9 (6): 381–4
Pohle W, Schumichen C, Hoffmann G, et al. Scintigraphic diagnosis of sport injuries: multiple fractures of ribs by golf-players [inGerman]. ROFO Fortschr Geb Rontgenstr Nuklearmed 1981; 134 (2): 196–8
Read MT. Case report: stress fracture of the rib in a golfer. Br J Sports Med 1994; 28 (3): 206–7
Miles JW, Barrett GR. Rib fractures in athletes. Sports Med 1991; 12 (1): 66–9
Horner DB. Lumbar back pain arising from stress fractures of the lower ribs. J Bone Joint Surg Am 1964; 46A: 1553–6
Orava S, Ala-Ketola L. Avulsion fractures in athletes. Br J Sports Med 1977; 11: 65–71
Maffulli N, Pintore E. Stress fracture of the sixth rib in a canoeist. Br J Sports Med 1990; 24 (4): 247
Boland AL, Hosea TM. Rowing and sculling and the older athlete. Clin Sports Med 1991; 10 (2): 245–56
Cyriax EF. On various conditions that may stimulate the referred pain of visceral diseases and a consideration of these from the point of view of cause and effect. Practitioner 1919; 102: 314–22
Davies-Colley R. Slipping rib. BMJ 1922; 1: 432
Heinz GJ, Zavala DC. Slipping rib syndrome. JAMA 1977; 237 (8): 794–5
Mooney DP, Shorter NA. Slipping rib syndrome in childhood. J Pediatr Surg 1997; 32 (7): 1081–2
Lum-Hee N, Abdulla AJ. Slipping rib syndrome: an overlooked cause of chest and abdominal pain. Int J Clin Prac 1997; 51 (4): 252–3
Taubman B, Vetter VL. Slipping rib syndrome as a cause of chest pain in children. Clin Pediatr (Phila) 1996; 35 (8): 403–5
Porter GE. Slipping rib syndrome: an infrequently recognized entity in children: a report of three cases and review of the literature. Pediatrics 1985; 76 (5): 810–3
Vincent FM. Abdominal pain and slipping-rib syndrome [letter]. Ann Intern Med 1978; 88 (1): 129–30
Spence EK, Rosato EF. The slipping rib syndrome. Arch Surg 1983; 118 (11): 1330–2
Eastwood NB. Slipping-rib syndrome. Lancet 1980; II (8198): 809
Wright JT. Slipping-rib syndrome. Lancet 1980; II (8195 Pt 1): 632–4
Copeland GP, Machin DG, Shennan JM. Surgical treatment of the ’slipping rib syndrome’. Br J Surg 1984; 71 (7): 522–3
Abbou S, Herman J. Slipping rib syndrome. Postgrad Med 1989; 86 (6): 75–8
Arroyo JF, Vine R, Reynaud C, et al. Slipping rib syndrome: don’t be fooled. Geriatrics 1995; 50 (3): 46–9
Greida BP. The slipping rib syndrome in athletes [in Russian]. Vestn Khir Im I I Grek 1985; 134 (4): 77–8
Mayo P, Saha SP, Crawford P, et al. Slipping rib syndrome. South Med J 1981; 74 (8): 1027
Bass J, Pan HC, Fegelman RH. Slipping rib syndrome. J Natl Med Assoc 1979; 71 (9): 863–5
Blackman NS. Slipping rib syndrome. NY State J Med 1963; 63: 1670–5
Ballon HC, Spector L. Slipping rib. Can Med Assoc J 1938; 39: 355–8
Bisgard JD. Slipping rib. JAMA 1931; 97: 23–4
Darby JA. Slipping ribs. Northwest Med 1931; 30: 471
Razaque MA, Singh BK. Rib tip syndrome. Indian J Chest Dis Allied Sci 1980; 23 (4): 193–6
McBeath AA, Keene JS. The rib-tip syndrome. J Bone Joint Surg Am 1975; 57 (6): 795–7
Wise DI. Rib tip syndrome with unilateral renal agenesis. J R Coll Surg Edinb 1991; 36 (3): 194
den Dunnen WF, Verbeek PC, Karsch AM. Abdominal pain due to nerve compression [in Dutch]. Ned Tijdschr Geneeskd 1999; 143 (11): 576–8
Mynors JM. Clicking rib. Lancet 1973; I (7804): 674
Parry W, Breckenridge I, Khalil YF. Bilateral clicking ribs. Thorax 1989; 44 (1): 72–3
Wright JT. Clicking rib. Lancet 1973; I (7809): 935
Abrahams P. Interchondral subluxation or ’clicking rib syndrome’. Practitioner 1976; 217 (1298): 256–7
Holmes JF. Slipping rib cartilage with report cases. Am J Surg 1941; 54: 326–38
Holmes JF. A study if the slipping rib-cartilage syndrome. N Engl J Med 1941; 224: 928–32
Scott EM, Scott BB. Painful rib syndrome: a review of 76 cases. Gut 1993; 34 (7): 1006–8
Stevenson FA. Nerve nipping at the intercostal margin. Lancet 1951; II: 969–70
Broadhust N. Musculoskeletal medicine tip: twelfth rib syndrome. Aust Fam Physician 1995; 24 (8): 1516
Machin DG, Shannan JM. Twelfth rib syndrome: a differential diagnosis of loin pain. BMJ 1983; 287: 586
Jalovaara P, Ramo J, Lindholm R. Twelfth rib syndrome simulating intraabdominal disease. Acta Chir Scand 1988; 154: 407–8
DeLisi N. Slipping rib syndrome: ’there’s an easier way’. Geriatrics 1995; 50 (7): 7
Dyer NH. Painful rib syndrome. Gut 1994; 35 (3): 429
Smith GW. Editorial comment on Spence EK, Rosato EF. The slipping rib syndrome. Arch Surg 1983; 118 (11): 1332
Jones MW, Matthews JP. Rupture of pectoralis major in weight lifters: a case report and review of the literature. Injury 1988; 19 (3): 219
Robertsen K, Kristensen O, Vejen L. Manubrium sterni stress fracture: an unusual complication of non-contact sport. Br J Sports Med 1996; 30 (2): 176–7
Buckman R, Trooskin SZ, Flancbaum L, et al. The significance of stable patients with sternal fractures. Surg Gynecol Obstet 1987; 164: 261–5
Keating TM. Stress fracture of the sternum in a wrestler. Am J Sports Med 1987; 15 (1): 92–3
McCurdie I, Etherington J, Buchanan N. Sternal fracture in a female army officer cadet. Br J Sports Med 1997; 31 (2): 164
Barbaix. Stress fracture of the sternum in a golf player. Int J Sports Med 1996; 17 (4): 303–4
Calabro JJ. Costochondritis. N Engl J Med 1977; 296 (16): 946–7
Lipkin M, Fulton LA, Wolfson EA. The syndrome of hypersensitive xiphoid. N Engl J Med 1955; 253: 591–7
Jelenko CI. Tietze’s syndrome at the xiphisternal joint. South Med J 1974; 67 (7): 818–20
Disla E, Rhim HR, Reddy A, et al. Costochondritis: a prospective analysis in an emergency department setting. Arch Int Med 1994; 154 (21): 2466–9
Ikehira H, Kinjo M, Nagase Y, et al. Acute pan-costochondritis demonstrated by gallium scintigraphy. Br J Radiol 1999; 72 (854): 210–1
Miller JH. Accumulation of gallium-67 in costochondritis. Clin Nucl Med 1980; 5 (8): 362–3
Hannan MT, Anderson JJ, Pincus T, et al. Educational attainment and osteoarthritis: differential associations with radiographic changes and symptom reporting. J Clin Epidemiol 1992; 45 (2): 139–47
Mendelson G, Mendelson H, Horowitz SF, et al. Can (99m)- technetium methylene diphosphonate bone scans objectively document costochondritis? Chest 1997; 111 (6): 1600–2
Malghem J, Vande Berg B, Lecouvert F, et al. Costal cartilage fractures as revealed on CT and sonography. Am J Roentgenol 2001; 176: 429–32
Tietze A. Über eine eigenartige Haufüng von Fäuen mit Dystrophie der Rippenknorpel. Berl Klin Wochenschr 1921; 58: 829–31
Dunlop R. Tietze revisited. Clin Orthop 1969; 62: 223–5
Gill G. Epidemic of Tietze’s syndrome. BMJ 1977; 2 (6085): 499
Calabro JJ, Marchesano JM. Tietze’s Syndrome. Am Fam Physician 1966; 33: 101–5
Honda N, Machida K, et al. Scintigraphic and CT findings of Tietze’s syndrome: report of a case and review of the literature. Clin Nucl Med 1989; 14 (8): 606–9
Aeschlimann A, Kahn MF. Tietze’s syndrome: a critical review. Clin Exp Rheumatol 1990; 8 (4): 407–12
Harkonen M. Tietze’s Syndrome. BMJ 1977; 2 (6097): 1087–9
Mudgal C, Waters PM. Isolated fracture-subluxation of the second sternocostal synchondrosis: a case report. Am J Sports Med 1998; 26 (5): 729–30
Morgan-Hughes J. Painful disorders of muscle. Br J Hosp Med 1979; 360: 362–5
Ikeda RM, Kondracki SF, et al. Pleurodynia among football players at a high school. JAMA 1993; 270 (18): 2205–6
Alexander J, Chapman L. Coxsackievirus B2 infection and aseptic meningitis: a focal outbreak among members of a high school football team. J Infect Dis 1993; 167: 1201–5
Pickering D. Precordial catch syndrome. Arch Dis Child 1981; 56 (5): 401–3
Sparrow M, Bird E. ’Precordial Catch’: a benign syndrome of chest pain in young persons. N Z Med J 1978 Oct 25; 88 (622): 325–6
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Gregory, P.L., Biswas, A.C. & Batt, M.E. Musculoskeletal Problems of the Chest Wall in Athletes. Sports Med 32, 235–250 (2002). https://doi.org/10.2165/00007256-200232040-00003
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DOI: https://doi.org/10.2165/00007256-200232040-00003