Working Diagnosis:
The diagnosis was a left nonunion first rib fracture.

Treatment:
The patient was placed in an arm sling for four weeks to encourage relative rest. His training program was modified to avoid all overhead movements, chest presses, and any heavy lifting. A muscle relaxant was added to the regimen for pain relief and to theoretically reduce first rib tension from the scalene, subclavius, and serratus anterior muscles. Lastly, the patient was instructed to use a pulsed electromagnetic field (PEMF) bone growth device which was used consecutively for three hours each day for four weeks.

Outcome:
After four weeks of treatment, his symptoms had abated. A repeat MRI without contrast revealed that the thin linear region of increased T2 signal intensity was no longer present at the cartilaginous junction between the left first rib and manubrium. Range of motion exercises were introduced and a graduated return to play program was implemented. The patient is now in his third year in the NFL with no recurrence of symptoms.

Author's Comments:
The three main takeaways from this case are;
First rib fractures must be included in differentials for athletes with vague shoulder pain and upper anterior chest wall pain.
MRI should be considered for athletes with high clinical suspicions despite normal radiographs and CT scans.
Treatment should be conservative and patients often have great outcomes with less than a 3 month healing process

Editor:

This is a great example of getting the proper diagnosis before interventional treatments. Without known trauma, this makes a stress-type injury more likely. While not as common as bone stress injuries of the lower extremities, rib stress fractures should be considered in overhead athletes, weight lifters and rowers. The first rib has a unique articulation with the manubrium and this may predispose for increased risk of nonunion. A high index of clinical suspicion is necessary as plan films may miss early stress injuries and occult fractures.
Similar to other bone stress injuries, an investigation for predisposing factors (i.e. RED-S) may be appropriate.

Editor's Comments:
This is a great example of getting the proper diagnosis before interventional treatments. Without known trauma, this makes a stress-type injury more likely. While not as common as bone stress injuries of the lower extremities, rib stress fractures should be considered in overhead athletes, weight lifters and rowers. The first rib has a unique articulation with the manubrium and this may predispose for increased risk of nonunion. A high index of clinical suspicion is necessary as plan films may miss early stress injuries and occult fractures.
Similar to other bone stress injuries, an investigation for predisposing factors (i.e. RED-S) may be appropriate.

References:
1) O'Neal M, Ganey TM, Ogden JA. First Rib Stress Fracture and Pseudarthrosis in the Adolescent Athlete: The Role of the Costosternal Anatomy. Clin J Sport Med 2009;19:65-67.


2) Low S, Kern M, Atanda A. First-rib Stress Fracture in Two Adolescent Swimmers: A Case Report. Journal of Sports Sciences 2016;34(13):1266-1270.


3) Funakoshi T, Furushima K, Kusano H, Itoh Y, Miyamoto A, Horiuchi Y, Sugawara M, Itoh Y. First Rib Stress Fracture in Overhead Throwing Athletes. The Journal of Bone and Joint Surgery 2019;101(10):896-903.


4) Yamaji T, Ando K, Wolf S, Augat P, Claes L. The effect of micromovement on callus formation. Journal of Orthopedic Science 2001;6(6):571-575


5) O'Neal ML, Dwornik JJ, Ganey TM, Ogden JA. Postnatal development of the human sternum. J Pediatr Orthop. 1998 May-Jun;18(3):398-405. PMID: 9600571.


6) Cadossi R, Massari L, Racine-Avila J, Aaron RK. Pulsed Electromagnetic Field Stimulation of Bone Healing and Joint Preservation: Cellular Mechanisms of Skeletal Response. Journal of the American Academy of Orthopedic Surgeons 2020;4(5):1900155.

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