Author: Benjamin Mwanika, DO
Co Author #1: Jacklyn D. Kiefer, DO

Patient Presentation:
A 15 year old female dancer, who is also a softball, soccer, and basketball player, presents with lower anterior rib pain.

History:
She reports lower anterior rib pain for the past 2 years. The pain is localized to the right lower anterior ribs and radiates to the back. The pain is exacerbated by certain movements, such as rising from a seated or supine position, and with palpation over the symptomatic area. Mild relief is achieved with activity restriction and the use of Tramadol. There is no trauma or mechanism of injury. The patient was started on physical therapy for postural retraining, core strengthening, and neuromuscular retraining. She also received manipulation for somatic dysfunction at the ribs, thoracic spine, and pelvis.

The patient was lost to follow-up over a 15 month period. Now, the patient returns with the same pain, rating it a 3-4/10 at rest, but an 8/10 with activity. She describes constant symptoms that are worsened with dancing, particularly when she is “giving it her all.� Mild relief is achieved with sitting in a protracted posture and with Tramadol. She states that physical therapy is ineffective, so she discontinued therapy as well as her postural home exercises. Of note, her mother describes an episode during which the pain became so severe that the athlete had to stop mid-dance. At that time, her mother felt a “popping sensation� over her anterior ribs.

Past medical history is significant only for allergic rhinitis. No surgeries. Family history is non-contributory. Social history shows a 9th grader with no history of tobacco, drug, or alcohol use. The athlete participates in all types of dance except ballet and tap, and she also plays softball, basketball, and soccer.

Physical Exam:
Height 5’4� Weight 115 lbs.
She is seated comfortably in a protracted posture. Initial standing exam displayed a thoracic curve to the right, paravertebral humping, scoliosis, and a small degree of pectus excavatum. Somatic dysfunction includes C2FRrSr, C5FRlSl, C7FRlSl, T2 FRlSl, and T4-8 FRrSr. There is tenderness to palpation anteriorly over ribs 9-12 on the right with referred pain posteriorly along ribs 9-10. Upper extremity strength is 5/5 and she is neurovascularly intact. There is tenderness over the right piriformis, there are positive impingement signs for the left psoas, and there is a leg length discrepancy, with the right leg being longer than the left.

She was lost to follow up. One year later, the physical exam demonstrates tenderness to palpation throughout the ribs, particularly at the costochondral junction on the left. Pain is the worst at the lower anterior ribs 8-12, but as high as ribs 4-6 bilaterally. Hooking maneuver performed anteriorly at ribs 9 and 10 causes pain but no click bilaterally. There is noticeable rib cage motion. Patient is quite flexible but does not demonstrate hyperextension at the wrists or elbows. Strength and neurologic exam remain unchanged.

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