Chest Wall Pain In A Peri-menopausal Triathlete

Abstract

History A 50 year-old female triathlete and marathoner presents with constant, aching right sided chest pain of approximately two months duration. Pain worsens with prolonged exercise (biking >30 miles) but is not exacerbated by cough or deep inspiration. LMP was 3–4 months ago. Denies peri-menopausal symptoms. Past Medical History lobular carcinoma in-situ of the breast, migraine headaches, multiple stress fractures in the feet Physical Examination: General: thin white female Chest: tenderness to palpation in the 4th and 5th intercostal space along the anterior axillary line. Resisted provocation of pectoralis muscle failed to reproduce symptoms. Lungs: CTAB Breasts: mild tenderness over biopsy/lumpectomy incision, no masses. LNS: no axillary lymphadenopathy Differential Diagnosis: Intercostal muscle strain Stress fracture of rib Metastatic carcinoma of breast Tests and Results DEXA scan:L-spine T score of −3 Chest x-ray (PA, lateral and rib films): transverse fracture of 11th rib posteriorly Bone scan: three foci of increased uptake in right ribs involving anterior 6th rib and the posterior 8th and 11th ribs. FSH: 60 (23–116 is post-menopausal range) Ferritin: 51 (10–232) Pre-albumin: 30 (17–34) CMP: WNL except for ALT 60 (2–40) Final/Working Diagnosis Multiple stress fractures-right ribs, osteoporosis in a menopausal female Treatment/Outcomes Decrease training with goal to remain pain-free. Monthly follow-up with variable adherence to regimen resulted in continued symptoms suggestive of delayed healing. Fosamax 70 mg per week. Nutrition consultation was recommended but was not covered by patient's insurance and she opted not to pay out of pocket. Prempro 0.625/2.5mg dosage after discussion with breast surgeon. Patient reports that she is pain free 6 months after initial presentation.