Working Diagnosis:
Pneumomediastinum with posttraumatic subcutaneous emphysema.

Treatment:
Serial chest X-rays were used to monitor his condition.
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The patient rehabilitated his musculoskeletal injury with the athletic training department, using over-the-counter medication for pain control. A non-contact aerobic progression was initiated for three weeks.

Outcome:
The player was able to return to play following treatment. The pneumomediastinum and subcutaneous air spontaneously resolved.
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Author's Comments:
Subcutaneous and mediastinal emphysema rarely present as a traumatic, sports related shoulder injury with a chief complaint of shoulder pain. Posttraumatic subcutaneous emphysema with pneumomediastinum is known to be caused by blunt thoracic trauma causing the Macklin effect, blunt neck trauma causing aerodigestive tract injury, and fractures causing pulmonary trauma, which may lead to life threatening conditions.(1-3) Given the mechanism of injury and absence of worrisome symptoms, such as chest pain, shortness of breath, hoarseness, hemoptysis, fracture, and signs of infection, one should be cognizant of the risk of exposing the patient to unnecessary testing and therapies, as the subcutaneous and mediastinal air is likely to respond to conservative management.(4,5) Chest radiography is first line diagnostic testing in thoracic trauma with subcutaneous emphysema, and serial imaging is indicated to monitor progression of the condition.(6) Care should focus on musculoskeletal rehabilitation and getting the player game ready.

Editor's Comments:
Shoulder pain is common in contact sports, especially after blunt force trauma in football. While uncommon, it is important to keep post-traumatic subcutaneous emphysema with pneumodeiastinum on the differential. Importantly, respiratory status should be monitored closely in these individuals with significant forceful impacts. These can result in pulmonary air leaks which despite being rare can have fatal outcomes. As this patient did not show any alarming symptoms after trauma, it was reasonable to pursue conservative management in this case. In this workup, it is also important to examine the radiographs not only for musculoskeletal injuries, but for other etiologies such as this case presented.

References:
1.Vanzo V, Bugin S, Snijders D, Bottecchia L, Storer V, Barbato A. Pneumomediastinum and pneumopericardium in an 11-year-old rugby player: a case report. J Athl Train. Mar-Apr 2013;48(2):277-81. doi:10.4085/1062-6050-48.1.11
2.Wintermark M, Schnyder P. The Macklin effect: a frequent etiology for pneumomediastinum in severe blunt chest trauma. Chest. Aug 2001;120(2):543-7. doi:10.1378/chest.120.2.543
3.Zhang L, Peng J, Yu Y, et al. Intra-thoracic displacement of scapular lateral margin: a case report and literature review. BMC Musculoskelet Disord. May 19 2025;26(1):495. doi:10.1186/s12891-025-08750-5
4.Chouliaras K, Bench E, Talving P, et al. Pneumomediastinum following blunt trauma: Worth an exhaustive workup? J Trauma Acute Care Surg. Aug 2015;79(2):188-92; discussion 192-3. doi:10.1097/ta.0000000000000714
5.Mihos P, Potaris K, Gakidis I, Mazaris E, Sarras E, Kontos Z. Sports-related spontaneous pneumomediastinum. Ann Thorac Surg. Sep 2004;78(3):983-6. doi:10.1016/j.athoracsur.2004.03.017
6.Ho ML, Gutierrez FR. Chest radiography in thoracic polytrauma. AJR Am J Roentgenol. Mar 2009;192(3):599-612. doi:10.2214/ajr.07.3324

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