Author: Caitlyn Nicholson, MD
Co Author #1: Kathleen Weber, MD
Editor: Richard Uribe, MD, MPH
Editor: Margaret Gibson, MD, FAMSSM

Patient Presentation:
A 30-year-old male aerial acrobat presented with right-sided anterior chest wall pain.

History:
While doing his usual aerial performance in Cirque du Soleil involving straps, he had acute onset of pain over his right anterior chest wall near the rib margin. There was no direct trauma, but he was concerned for a rib fracture. Evaluation in the emergency room that evening included a chest x-ray and CT chest without IV contrast, which were both negative for fracture. He followed up with orthopedic surgery via telemedicine due to the COVID-19 pandemic and he was diagnosed with a right upper abdominal wall strain. He rested from acrobatics for 5 weeks, then began physical therapy. His pain improved over time, but it never resolved. After 3.5 months of physical therapy, he was able to perform ground-based acrobatics with minimal pain, but he was unable to hold a pike position while suspended. At the Sports Medicine clinic visit, an abdominal wall MRI was ordered for further workup.

Physical Exam:
General: Well-nourished, in no acute distress.
Pulmonary: Normal work of breathing.
Chest wall: No visible deformity. Focal tenderness to palpation in the right anterior lower rib region in the midclavicular line as well as just inferiorly at the costal margin. Sternum is nontender to palpation. Supine double-leg lift and rotational sit-up to the left provoked pain. Lateral and anterior-posterior rib squeeze did not provoke pain.
Skin: No ecchymosis, swelling, or overlying skin lesions.

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