HISTORY - 17 yr old high-school football player was seen for right anterior chest/shoulder pain which began following football practice. No direct trauma. Review of systems was non-contributory. X-ray showed fracture of right first rib. He was kept off further contact activities. His pain improved. Six weeks later x-ray showed non-healing fracture. He had no pain and wanted to return to football. PHYSICAL EXAMINATION - General exam was unremarkable. There was no deformity, swelling, asymmetry over the right shoulder. He had full range of motion. No pain or tenderness over the rib area. Right upper limb neurovascular exam was normal. Normal strength and reflexes. DIFFERENTIAL DIAGNOSES: Acute traumatic fracture with delayed or non-union Stress fracture Congenital pseudoarthrosis Pathological fracture TESTS AND RESULTS. Plain film-fracture right first rib, with separation and no evidence of healing. Bone scan-increased activity in right first rib in location identical to fracture seen on plain film, no evidence to suggest pathological process. CT scan chest-fracture first rib, no abnormality to suggest pathological process WORKING DIAGNOSIS - Right first rib fracture with non-union or delayed union or fibrous union, acute trauma versus stress. COURSE AND TREATMENT - Patient did not return to football, started basketball after five weeks. Also thoracic surgeon consultation was ontained and athlete was allowed all activities. Over the next 6-8 weeks as he started lifting weights he noticed increased pain at the fracture site. Right transaxillary first rib resection was performed because of persistent pain and non-healing.