Gabriel Betancourt, D.O. - American Osteopathic Academy of Sports

4/1/14 AOASM
CASE PRESENTATION
Gabriel Betancourt, D.O.
NSU-COM Primary Care Sports Medicine Fellow
Diplomate of the American Osteopathic Board
of Family Physicians
CHIEF COMPLAINT
„ “It
hurts just under my ribs.”
[Patient points to right lower anterior ribs.]
HISTORY OF PRESENT ILLNESS
„ 18-year
„ 136
„ 5
old Caucasian female.
pounds.
feet, 4 inches.
„ NSU
Student Athlete – Competitive Swimmer
„ Presents
with RUQ Subcostal Abdominal Pain.
1 4/1/14 PAIN
„ Location
- Right costochondral/abdominal margin
„ Onset
– Abrupt; 6 weeks ago. Pain began while
she was performing a 100-meter butterfly stroke.
„ Duration
„ Quality
– Intermittent; Lasts 2-3 minutes, 5-10x/day
– Dull/Achy.
„ Severity
– 5/10 at Best; 9/10 at Worst
„ Radiation
– None.
PAIN
„ Aggravating
Factors – Lying in the right lateral recumbent
position, taking deep breaths, and swimming activities like
butterfly strokes and dolphin kicks.
„ Alleviating
Factors – Rest. Pain was not responsive to NSAIDs.
denied any recent illness, recent travel, recent
surgery, or recent injury.
„ Patient
„ There
was no association between eating and
exacerbation of her pain.
„ The
patient had never experienced this type of pain prior to
its onset 6 weeks ago.
DOLPHIN KICKS
SOURCE: “J. Meric/Getty Images North America – August 29, 2009”
2 4/1/14 DOLPHIN KICKS
SOURCE: “How to improve your underwater dolphin kick.”
BUTTERFLY STROKES
SOURCE: “Learn to Swim: Butterfly Stroke”
BUTTERFLY STROKES
SOURCE: “Swimming Butterfly – How to Breathe”
3 4/1/14 BUTTERFLY STROKES
SOURCE: “Butterfly Stroke – Swim Competition”
REVIEW OF SYSTEMS
„ The
patient denied any fever, chills, night sweats, dyspnea,
cough, nausea, vomiting, diarrhea, fatigue, general
malaise, changes in bowel habits, weight loss, weight gain,
loss of appetite, paresthesia, and muscle weakness.
PAST MEDICAL HISTORY
„ Attention
„ Mild
Deficit Hyperactivity Disorder (Inattentive Type)
Intermittent Asthma
„ Appendicitis
(resolved)
4 4/1/14 SURGICAL HISTORY
„ Appendectomy
– 2 years ago.
MEDICATIONS
„ Adderall
15mg PO BID
„ Albuterol
90mcg Metered Dose Inhaler
Q4-6H/PRN for Dyspnea
ALLERGIES
„ Amoxicillin
- Hives
5 4/1/14 SOCIAL HISTORY
„ Tobacco
„ Alcohol
„ Drugs
- Denies
- Denies
- Denies
PHYSICAL EXAM
VITAL SIGNS
„ Blood
Pressure: 114/76
„ Pulse:
58
„ Respirations:
12
„ Temperature:
„ Pain:
98.6
0/10 (at time of clinic visit)
„ FDLMP:
2 weeks prior to clinic visit.
6 4/1/14 PHYSICAL EXAM
„  General
- No Acute Distress; Alert and Oriented x3; Well
Developed; Well Nourished
„  HEENT
- Pupils Equal Round and Reactive to Light and
Accommodation; Extraocular Muscles Intact; Neck is
Supple; No Pharyngeal Erythema or Exudates; No
Thyromegaly; Trachea is Midline and Mobile
„  Heart
- Regular Rate and Rhythm; S1>S2; No Murmurs;
No Rubs; No Gallops
„  Lungs
- Clear to Auscultation and Percussion Bilaterally;
No Wheezes; No Rales; No Rhonchi; Bilaterally
Symmetrical Chest Excursion
PHYSICAL EXAM
„  Abdomen
- Soft; Non-Tender; Non-Distended; Bowel Sounds
x4 Quadrants; No Guarding; No Hepatosplenomegaly; No
Palpable Masses; Equivocal Murphy’s Sign
„  Skin
- No Ecchymosis, Erythema, Edema, or Discoloration of
Abdomen or Chest Wall
„  Musculoskeletal
- Tenderness along right costochondral/
abdominal margin; Positive Hooking Maneuver on Right.
„  Osteopathic
the Right.
Exam - Exhalation Dysfunction of Ribs 8-10 on
HOOKING MANEUVER
SOURCE: “The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain”
7 4/1/14 HOOKING MANEUVER
SOURCE: “The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain”
DIFFERENTIAL DIAGNOSIS
„ Somatic
Dysfunction of the Ribs
„ Intercostal
„ Rib
Muscle Strain
Fracture
„ Cholecystitis/Cholelithiasis
„ Abdominal
Adhesions
„ Hepatitis
„ Slipping
„ Lung
Rib Syndrome
Cancer / Metastatic Disease
LAB TESTS
„ CBC
– Within Normal Limits.
„ Lipase
- Within Normal Limits.
„ CMP
- Showed slightly elevated levels of
Direct and Total Bilirubin.
8 4/1/14 IMAGING STUDIES
„ Chest
„ Right
X-rays (PA and Lateral) - Negative.
Rib Series X-Rays – Negative.
„ Abdominal
„ CT
Ultrasound - Negative.
Scan of the Chest - Negative.
RIB SERIES 1
RIB SERIES 2
9 4/1/14 RIB SERIES 3
RIB SERIES
4
ABDOMINAL ULTRASOUND 1
10 4/1/14 ABDOMINAL ULTRASOUND 2
ABDOMINAL ULTRASOUND 3
ABDOMINAL ULTRASOUND 4
11 4/1/14 ABDOMINAL ULTRASOUND 5
ABDOMINAL ULTRASOUND 6
ABDOMINAL ULTRASOUND 7
12 4/1/14 ABDOMINAL ULTRASOUND 8
ABDOMINAL ULTRASOUND 9
FINAL DIAGNOSIS:
SLIPPING RIB SYNDROME
(AFFECTING RIBS 8 AND 9 ON THE RIGHT)
13 4/1/14 RIBS
„ True
Ribs: Ribs 1-7
Directly attach to the sternum through the costal cartilage.
„ False
Ribs: Ribs 8-10
Connect to the sternum indirectly via the costal cartilages of
the ribs above them.
„ Floating
Ribs: Ribs 11 and 12
Attach only to the vertebrae.
RIB CAGE ANATOMY
SOURCE: “Skeletal Series Part 5: The Human Rib Cage”
SLIPPING RIB SYNDROME
„ Slipping
Rib Syndrome is a rare condition
that occurs when one of the ribs
intermittently slips out of place, causing a
stretching of the ligaments that support the
front and back of the rib. Ribs 8-10 are
usually the culprit because unlike ribs one
through seven which attach to the
sternum, the eighth, ninth, and tenth ribs
are attached anteriorly to each other by
loose fibrous tissue.
14 4/1/14 SLIPPING RIB SYNDROME
„ In
many cases a rib slips out of place because the
sternocostal ligaments that hold the ribs to the
sternum and/or the costotransverse ligaments that
hold the ribs to the vertebrae are weak. Without
muscles to hold the ribs in place, the loose
ligaments allow slipping of the rib which causes
further stretching of the ligament which results in
severe pain.
SLIPPING RIB SYNDROME
„ A
simple coughing attack due to a cold may
cause the development of Slipping Rib Syndrome.
Conditions such as bronchitis, emphysema,
allergies, and asthma cause additional stress to
the sternocostal and costochondral junctions.
Slipping Rib Syndrome can also be caused by
surgery to the lungs, chest, heart or breast with
resection of the lymph nodes, all of which put a
tremendous amount of stress on the rib
attachments because the ribs must be separated
to remove the injured tissue.
SLIPPING RIBS
SOURCE: “The Slipping Rib Syndrome - Case Review Series”
15 4/1/14 CHARACTERISTICS OF SLIPPING RIB SYNDROME
„ Pain
„ A
in the lower chest or upper abdomen
tender spot on the costal margin
„ Reproduction
of the pain by pressing the tender spot or
performing the Hooking Maneuver.
TREATMENT OPTIONS
„ Prolotherapy
„ Corticosteroid
Injections
„ Surgery
„ After
undergoing a diagnostic intercostal
nerve block to confirm the diagnosis of Slipping
Rib Syndrome, the patient underwent a
surgical resection of the tips of the eighth and
ninth ribs on the right.
SLIPPING RIBS
SOURCE: “The Slipping Rib Syndrome - Case Review Series”
16 4/1/14 RETURN TO PLAY
„ The
patient was allowed to resume limited
physical activity 25 days after the
operation. These activities included use of
the elliptical machine, treadmill, and
stationary bicycle as well as freestyle
swimming as tolerated. She was not
permitted to lift, push, or pull any weights
greater than 10 pounds. The patient was
able to return to full swimming and all other
physical activities without any restrictions 45
days after the operation.
1 YEAR POST-OP
REFERENCES
„  Brian
E Udermann. Slipping Rib Syndrome in a
Collegiate Swimmer: A Case Report. J Athl Train.
2005 Apr–Jun; 40(2): 120–122. Level 3B
„  E M Scott and B B Scott. Painful rib syndrome--a
review of 76 cases. Gut. 1993 July; 34(7): 1006–1008.
Level 3A
„  Heinz GJ, Zavala DC. Slipping rib syndrome.
JAMA1977; 237(8): 794-5
„  DeLisi N. Slipping rib syndrome: ’there’s an easier
way’. Geriatrics1995; 50 (7): 7 level 5
„  Gregory P.L., BISWAS A.C., Batt
M.E.,Musculoskeletal problems of the chest wall in
athletes, Sports Med., 2002;32(4):235-50. Level 3A
17 4/1/14 THANK YOU!
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