Chest Wall Pain In A Marathon Runner

Abstract

HISTORY: A 39-year old male marathon runner presented with 1 year of left-sided anterolateral chest wall pain at ribs 10 and 11. Pain started insidiously, without trauma or other inciting incident. Pain primarily occurred with running, and typically worsened as his pace increased. Lifting weights, deep breathing, and prolonged sitting did not exacerbate pain. He denied cough, dyspnea, or wheezing. PHYSICAL EXAMINATION: Normal chest wall expansion. No visual deformity along the ribs or costal cartilage. Tenderness to palpation was noted along the left 10th and 11th ribs and intercostal muscle anterior to the mid-axillary line. No tenderness at adjacent segments or at the same segment on the contralateral chest wall. Mild left-sided chest wall pain with leftward thoracic rotation. DIFFERENTIAL DIAGNOSIS: 1. Costochondritis 2. Tietze syndrome 3. Slipping rib syndrome 4. Thoracic radiculitis 5. Pleurisy TESTS AND RESULTS: MRI Chest Wall: Focal thickening and edema along left lower ribs at region of pain, with surrounding soft tissue swelling. No pleural or pericardial effusion. No bone marrow edema within visualized osseous structures. Ultrasound Chest Wall: Significant signal impedance and focal thickening noted along the intercostal muscle of the left 10th and 11th ribs at the area of maximal tenderness along the anterolateral chest wall. No comparable signal changes are observed at adjacent segment levels or the same segment on the contralateral chest wall. FINAL/WORKING DIAGNOSIS: 1. Tietze syndrome TREATMENT AND OUTCOMES: 1. Performed corticosteroid/lidocaine injection to left 10th-11th rib intercostal muscle under ultrasound guidance 2. Pain diary for 6 hours immediately following injection 3. Routine marathon training as tolerated 4. Ice as needed after running 5. Pain resolved following injection. Inflammation and intercostal muscle hypertrophy resolved on repeat ultrasound 2 months later. 6. Patient completed Berlin and Chicago Marathons in 2019