Working Diagnosis:
Sternal fracture secondary to left 6th rib dislocation/subluxation

Treatment:
Given ultrasound findings concerning for sternal fracture and 6th sternochondral joint dislocation, an ultrasound-guided steroid injection was not performed. The patient continued with activity modification, anti-inflammatories, and to work with physical therapy. She was referred to a general surgeon specializing in rib fractures for consultation given persisting pain despite conservative treatment.

Outcome:
The patient was seen by general surgery four months after her initial visit. A CT chest was done and was negative for fracture. By that time her pain was improving with activity modification, anti-inflammatories, and PT.

Author's Comments:
There are many causes for chest pain in an athlete, and ultrasound can be a useful and quick diagnostic tool to evaluate further for occult fracture. Sternal fractures rarely occur in athletes, and are even rarer in a sport without direct trauma. There are limited guidelines for treatment or return to activity for these athletes with persisting pain beyond 12 weeks. Osteopathic manipulative treatment (OMT) to the affected bone, surrounding joints, and other structures is contraindicated in fracture treatment until the fractures have stabilized. Indirect OMT could be helpful in athletes with persisting pain from atraumatic sternal fractures.

Editor's Comments:
Sternal fractures are primarily observed following blunt trauma, and are closely associated with mediastinal, pleural, or other internal injuries. If suspected, further work-up may be warranted to rule out more serious injury.
Sternal stress injuries are exceedingly rare, but have been documented in individuals undergoing intense upper body exercise regimens.

References:
Odell DD, Peleg K, Givon A, et al. Sternal fracture: isolated lesion versus polytrauma from associated extrasternal injuries--analysis of 1,867 cases. J Trauma Acute Care Surg. 2013;75(3):448-452. doi:10.1097/TA.0b013e31829e227e
Lee, Justin, and Karl Bertrand Fields. "Sternal stress fracture in a middle-aged woman." Case Reports 2017 (2017): bcr2016218203.

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