Injury Centre | Chest | Abdominal

 

 

Chest

Chest pain is a common complaint in many athletes and has a number of possible underlying causes. It may be related to the structures of the anterior chest wall i.e. those that are contained within the chest e.g. heart and lungs or referred from the neck, shoulders or back.

Chest Injuries Overview

A chest injury can occur as the result of an accidental or deliberate penetration of a foreign object into the chest. In sport thhis can be as a consequence of a direct impact e.g a rugby tackle.

Symptoms

• Difficulty breathing, failure of the chest to expand normally, crunching sounds in the ribs, bruising, coughing up blood
  
  
• One segment of the chest wall may not move with breathing or move opposite to the rest of the chest wall (flail chest).
  
  
• Even without an obvious external injury, a significant internal injury can occur.

The chest wall is composed of 12 ribs and the two layers of intercostal muscles that lie between them. Beneath each rib lies a neurovascular bundle, containing an intercostal nerve, artery and vein. It is via these nerves that pain from the neck is sometimes referred to the chest wall.

The ribs articulate at the front of the body with the sternum via costochondral cartilages. The sternum articulates with the clavicles via synovial joints.

The back of the chest wall is in continuity with the spine, and at the sides with the shoulders and arms. Thus an athlete may injure the chest wall either indirectly, as a result of forces transmitted through the chest, or because of direct trauma to the chest. In any case of chest injury it is important to rule out the possibility of an associated injury to the intrathoracic organs

The possible causes of chest pain in athletes can be divided into those arising from the ribs, the sternum and the joints.

The Ribs

Stress fractures

Stress fracture is most likely to occur in the first rib. Overhead athletes such as squash or tennis players are typically at risk here. Through repeated contraction of the anterior scalene muscle exerts bending stresses on the subclavian sulcus - a small recess in the rib bone and the most common site of fracture.

The athlete will feel pain around the shoulder or front of the neck, and possibly tenderness at the top of the shoulder blade in the root of the neck. Diagnosis is usually confirmed by bone, CT or MRI scan at hospital.

A stress fracture of the first rib needs the arm on that side to be immobilised in a sling. A soft neck collar may be useful in dealing with painful contraction of the anterior scalene. Pain usually resolves in two to eight weeks, with a return to sport permitted between four and eight weeks after injury.

Stress fractures to the other ribs are less common but seen for instance, in golfers and rowers. The serratus anterior muscle inserts on the outside end of the first to ninth ribs, interweaving with external obliques. When these muscles contract together they produce a bending stress at the far outside corner of the ribs - the likely site for stress fracture.

In such cases, pain is often felt in the back, with tenderness over the affected rib. Plain X-rays may be sufficient to make the diagnosis, which will result in the athlete ceasing activity for up to four or six weeks. The return to activity should be graduated, resuming normal training intensity at eight to 10 weeks.

Acute rib fractures
These are the result of direct injury. Fractures of the first and second ribs suggest a very significant transfer of energy and can be associated with underlying injuries to the thoracic aorta, brachial plexus or subclavian vein.

The patient complains of a sharp pain in the chest, aggravated by deep breathing or coughing, or by compression of the chest wall. In most cases treatment is only needed for pain - an injection of local anaesthetic will bring about immediate relief. Breathing exercises are then encouraged, alongside complete cessation sport for four to six weeks and a gradual return to normal training at 8 to 10 weeks.

Slipping rib syndrome
This is pain in the lower chest or abdomen together with a tender spot at the bottom of the ribcage, and reproduction of symptoms by pressing that spot. It is thought to arise when the cartilaginous inner ends of the false ribs are hypermobile – not securely attached to the sternum or surrounding ribs. The rib rides up and exerts pressure on the neurovascular bundle above. This loss of stability may be the result of a previous injury or reflect a congenital defect.

The patient may complain of sharp, stabbing pains in the upper abdomen or rib cage, which can last up to several minutes before giving way to a duller ache which may last up to several days.

Management of thisis primarily rest. The therapist should prioritise flexibility training and core stability work. Corticosteroid injection may be needed in recalcitrant cases; in severe cases, surgery will remove the anterior portion of the rib.

Sternal fractures
Fractures of the breastbone tend to be the result of direct high-energy trauma. The vast majority result from road traffic accidents, with the steering wheel striking the sternum, but a small number may arise from direct blows such as those received in rugby or wrestling. However, sternal stress fractures can result from repetitive hyperflexion of the torso, such as performing vigorous sit-ups over a long period of time.

With a stress fracture or minimally displaced traumatic fracture, the patient is treated conservatively, avoiding provocative movements for four to six weeks, followed by progressive strength work. If fragments are severely displaced, surgery under general anaesthetic will be necessary and recovery time may range from 2 to 12 months.

Sternoclavicular dislocation
This is sometimes seen without any history of trauma, but the most common tear, a minor subluxation, usually results from a fall or blow to the front of the shoulder, or a fall on to an outstretched hand. The impact forces the inner end of the clavicle on the affected side downwards and forwards, creating a clear asymmetry of the collar bones. There is local tenderness.

With minor subluxations, the patient should avoid painful activities for two to four weeks. Resting the arm in a sling allows any associated soft tissue injury to settle. Activity can then be gently reintroduced. Some prominence of the inner end of the clavicle may persist but a pain-free result is usual. Gross displacements need surgery, after which the patient will wear a clavicular brace and a broad arm sling for four to five weeks.

 

Table 1: Chest wall injuries, summary

Condition	Symptoms & signs	Investigations	Treatment
1st rib stress fracture	Shoulder and neck pain Neck root tenderness	Bone scan CT MRI	Broad arm sling Soft neck collar Rest
Other rib stress fracture	Posterior pain Tenderness Chest spring pain	X-ray	Rest Analgesia
Slipping rib syndrome	Acute pain Activity related Hooking test	Nerve block	Rest Analgesia Technique modification Steroid injection Surgery
Sternal stress fracture	Pain Local tenderness	X-ray	Rest
Costochondritis	Localised pain and tenderness		Reassurance Analgesia Steroid injection
Tietze’s syndrome	Localised pain and tenderness Inflammation		Reassurance Analgesia Steroid injection

 

 

 

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