The Shoulder Pain That Wasn't - Page #4

Working Diagnosis:
Left Non-Displaced First Rib Fracture

He was treated with sling-immobilization for one week, followed by gentle ROM exercises of the left shoulder. Over the next two weeks, he was allowed to progress to non-contact football activity as tolerated.

Three weeks post-injury, the athlete’s pain had improved significantly, and a non-contrast chest CT scan demonstrated interval callus formation around the fracture site. A decision was made to allow him to return to play based on his physical exam and CT scan results. However, he still did not feel comfortable throwing the ball with maximal velocity and opted to defer his return to competition. He continued with a modified, non-contact practice schedule for an additional week, and he returned to full contact and competition four weeks post-injury.

Author's Comments:
Isolated first rib fractures are rare in sports. They typically occur in the groove for the subclavian artery, an area of anatomical weakness. A strong contraction of the scalenus anterior muscle, lying adjacent to the subclavian groove, can result in fracture. Repetitive muscular forces with weight lifting or overhead activities may result in a stress fracture. Patients often present with pain localized to the scapula or the shoulder. The diagnosis is confirmed by CXR or CT scan. Early diagnosis is important as complications can include subclavian artery injury, pneumothorax, and brachial plexus injury. Angiography is indicated when the fracture is posteriorly displaced, there is a widened mediastinum on CXR, a brachial plexus injury, a pulse deficit in the arm, or expanding hematoma. Treatment of uncomplicated first rib fractures includes pain control and rest. There are no evidence-based guidelines regarding return to play, but it is accepted that activity may resume once pain resolves.

Editor's Comments:
As the author noted, first rib fractures are a high velocity injury and are rare in sports medicine. However, they should be included in the differential of any athlete with vague shoulder complaints especially in those that complain of scapular pain. Overhead athletes and weight lifters may also get stress fracture of the 1st rib.
While the author noted many early complications, thoracic outlet syndrome may occur later because of callus formation or mal-union.
There are not any evidence based guidelines for return to play, and case reports have return to play at anywhere from 2 weeks to 9 months. In general, athletes should return to play when pain free, full range of motion, and full strength. Radiographic union may lag behind clinical improvement.

1. O’Neil M, Ganey T, Ogden J. First Rib Stress Fracture and Pseudoarthrosis in an Adolescent Athlete: The role of Costosternal Anatomy. Clin J Sport Med. 2009;19: 65-67.

2. Sakellaridis T, Stamatelopoulos A, Andrianopoulos E, et al. Isolated First Rib Fracture in Athletes. Br J Sports Med. 2008; 34: e5.

3. Wild A, Begley J, Garzon-Muvdi J, et al. First Rib Stress Fracture in a High School Lacrosse Player. Sports Health. 2011; 3(6): 547-49.

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