Sternal pain

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Dr. Ice

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20 year old active guy with several weeks of sternal pain distally. Stated it began after pushups. No thoracic pain or radicular complaints. Pain exacerbated by twisting, bending, coughing sneezing, impact acticity. Somewhat improved by rest and nsaids. Physical exam with tenderness over sternum distally. Neuro exam normal, no thoracic pain with movement.

X-rays sternum normal, mri sternum normal. Thoracic mri revealed disc heniations at T5-6 and T6-7. No cord involvement. Work up for osteomyelitis negative.

He has shut down most activity due to pain. Referred to me for consideration of thoracic epidural. Any thoughts?
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Baron Samedi said:
Thoracic radiculopathy doesn't cause sternum tenderness.

Consider costochondritis with topical NSAID or injection.
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His primary already gave him that diagnosis originally and he was treated with voltaren gel and oral nsaids for 3 weeks.

Going to do ultrasound guided sternal injection around point of maximal tenderness but presentation is just very odd
 
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Dr. Ice said:
His primary already gave him that diagnosis originally and he was treated with voltaren gel and oral nsaids for 3 weeks.

Going to do ultrasound guided sternal injection around point of maximal tenderness but presentation is just very odd
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Why do you find it odd? Abdominals insert along the margin and the complaint is consistent with that. Inject at area of tenderness and be done.
 
seems like you've ruled out all the possible severe diseases possible.

only thing left to get is a bone scan, though you "ruled out osteomyelitis" implies you checked CRP/ESR.

you could check an ANA. ask if he has lower back pain and consider SI xrays.
 
pmrmd said:
Why do you find it odd? Abdominals insert along the margin and the complaint is consistent with that. Inject at area of tenderness and be done.
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Think it’s severity of his subjective complaints and his willingness to do any treatment. The guy is a football player. Just seems a little weird
 
Dr. Ice said:
Think it’s severity of his subjective complaints and his willingness to do any treatment. The guy is a football player. Just seems a little weird
Click to expand...
Dr. Ice said:
Think it’s severity of his subjective complaints and his willingness to do any treatment. The guy is a football player. Just seems a little weird
Click to expand...

if he is a high level athlete that needs to get on the field, then an injection isnt unreasonable. i know there is a good doc in san diego who is pretty adept at these sideline injections. but seriously, this just goes away with time
 
My differently would include rib dysfunction, costochondritis, Sternalis syndrome or slipping rib syndrome. Send him to a good therapist or osteopathic physician who does manual medicine. Would definitely at least try a diagnostic anesthetic ultrasound guided injection.
Is the pain around the xyphoid process?
 
Last edited:
PMR2008 said:
My differently would include rib dysfunction, costochondritis, Sternalis syndrome or slipping rib syndrome. Send him to a good therapist or osteopathic physician who does manual medicine. Would definitely at least try a diagnostic anesthetic ultrasound guided injection.
Is the pain around the xyphoid process?
Click to expand...

Good thought and yes around xyphoid
 
Do nothing IMO.

If he's a D1 NCAAF player perhaps I would inject him, but probably not...

I've never seen or done a sternal injxn.
 
Dr. Ice said:
Think it’s severity of his subjective complaints and his willingness to do any treatment. The guy is a football player. Just seems a little weird
Click to expand...

This guy is likely overexerting his pecs and has poor exercise technique. Could be doing some new crazy, stupid exercises for his pecs that he saw on instagram. Assuming he's got college resources, send him to his ATC and strength coach and have them watch his technique and adjust his form, weights, and sets/reps. Stop maxing out like all knucklehead football males his age. He's probably not warming up and stretching correctly and has piss poor flexibility. don't inject or medicate, topical stuff at most. you've ruled out the most important stuff and his bones aren't showing a stress reaction.... yet.
 
If it's the xiphoid, I might ultrasound that thing and drop local/steroid/PRP/etc around things. I would avoid the thoracic ESI as I don't want to send patients to the surgical solutions there. There are some odd issues where the xiphoid can dislocate anteriorly during core exercises, and then it hurts/aches around there for a while. If it's a high functioning athlete, they may not be allowing it time to rest/recuperate.
 
Pec tear. Good grief, don’t do a thoracic ESI
 
caveat in the era of covid, add this to your differential: precordial chest pain in a college football player post covid could be peri/myocarditis, exercise and aerobic exertion would exacerbate symptoms while at rest he would be asymptomatic
 
Gauss said:
caveat in the era of covid, add this to your differential: precordial chest pain in a college football player post covid could be peri/myocarditis, exercise and aerobic exertion would exacerbate symptoms while at rest he would be asymptomatic
Click to expand...

This is every cough/cold/flu season.
 
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