Author: Kristin Duncan, MD
Co Author #1: Jonathan Schultz, MD

Patient Presentation:
A 57 y/o female presented to the Sports Medicine Center with upper abdominal pain for one year.

History:
A 57 year old female with PMH of hypothyroidism, GERD, and hiatal hernia was referred to the Sports Medicine Center by her PCP after having upper abdominal pain for greater than one year. Prior to seeing her PCP, she was evaluated multiple times by another physician who obtained an abdominal x-ray, diagnosed her with constipation, and gave her a laxative with no improvement in her symptoms. When first evaluated by her PCP, she described a pressure-like sensation underneath her rib and sometimes below her sternum. She reported that her abdomen felt tight and that these symptoms began abruptly about one year ago. She complained of feeling bloated and was taking Prilosec without relief of her symptoms. Her PCP obtained a CT of the abdomen and pelvis, abdominal ultrasound, and EGD which were all normal.

Upon evaluation in the Sports Medicine Center, she noted her pain started one year ago after running a tiller in her garden. She stated that light massage helps the pain but applying deep pressure reproduces her symptoms. She noted her symptoms were made worse by turning at the waist, raising her knees, doing tasks with her arms, and doing valsalva maneuvers. She stated that the pain radiates to the middle of her back. She had tried using ibuprofen, meloxicam and gabapentin, all of which provided minimal relief. She denied having any history of trauma. Her main goal was to return to gardening.

Physical Exam:
She was a healthy appearing, overweight woman in no acute distress. Lungs were clear to auscultation. Cardiac exam revealed normal rate and rhythm. Abdominal exam revealed normal bowel sounds, tenderness to palpation at the tip of the xiphoid, and no detectable hepatosplenomegaly. She had tenderness to palpation in the upper abdomen at the liver edge and some epigastric tenderness. No rebound tenderness or guarding. Musculoskeletal exam revealed a normal appearing sternum without pectus excavatum or carinatum. The xiphoid tip was tender to palpation. No deformities, swelling, erythema, or ecchymosis was noted. She had normal chest expansion. Muscle strength testing of the pectoralis was 5/5 bilaterally and did not reproduce her symptoms. Neurovascular testing revealed normal sensation and perfusion in the sternal area.

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