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A 25-year-old man presented at the clinic complaining of pain in his right anterior chest. About 1 month previously, the patient had experienced a sudden and sharp pain in his right posterior chest at the midscapular level during a tug of war game at his company’s picnic. The posterior chest pain subsided very quickly and did not bother him for the rest of the game. However, the next morning, pain was felt in the anterior aspect of the chest. This anterior chest pain eased off over the next few days with rest, but recurred as soon as the patient returned to weight lifting.

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Given the mechanism of injury, what types of structure(s) could be at fault?

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The most likely structures to be involved are muscle/tendon or ligament. A thoracic disk herniation is less likely but should still be considered given the traumatic mechanism.

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Should the report of anterior chest pain concern the clinician in this case?

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Anterior chest pain is normally a cause for concern but in this case, given a clear mechanism of injury, it should be of less a concern.

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What is your working hypothesis at this stage? List the various diagnoses that could present with anterior chest pain, and the tests you would use to rule out each one.

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The best working hypothesis would be a thoracic strain/sprain with possible rib involvement. The differential diagnosis for anterior chest pain can appear overwhelming and should include a mediastinal tumor, pancreatic carcinoma, gastrointestinal disorders, pleuropulmonary conditions, spontaneous pneumothorax, myocardial infarction, herpes zoster, acute thoracic disk herniation, vertebral fracture, rib fracture, intercostal neuralgia, costochondritis, osteoarthritis, rheumatoid arthritis, diffuse idiopathic skeletal hyperostosis, and manubriosternal dislocations. However, most if not all of these can be ruled out with a detailed history and systems review.

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Does this presentation/history warrant a scan? Why or why not?

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If the information gleaned from the history and systems review was able to rule out the other causes, a detailed physical examination of the thoracic region should suffice. In fact, following such an examination, this patient was diagnosed with a fifth costotransverse or costovertebral joint subluxation, or both, with a loss of anterior rotation of the rib. The costochondritis probably resulted from abnormal stresses being imparted to this area as a result of the subluxation and provides a good example of the silent hypomobile joint producing pain in a nearby joint.

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Having made the provisional diagnosis, what will be your intervention?

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How would you describe your findings to the patient?

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In order of priority, and based on the stages of healing, list the ...

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