This 40+-year-old recreational football player presents with a relatively acute onset of pain felt in the region of his left sternoclavicular joint (SCJ). He developed this while doing a bench-press exercise. The pain has not resolved over the past three months.
On examination there is some modest swelling and tenderness related to the left SCJ. The pain was provoked by cross body adduction.
An x-ray series of the SCJ and chest wall was normal. Given the ongoing symptoms an MRI was then requested. These images demonstrated bone oedema in the manubrium adjacent to the first costal cartilage (this measured approximately 20 x 15 mm). There was a small linear area of fluid in a cleft at the junction of the manubrium and first costal cartilage raising the possibility of a fracture involving the costal cartilage. A very small amount of oedema is present anterior and posterior to the manubrium and first costal cartilage. The medial end of the left clavicle and first rib were normal signal.
This player was successfully treated with a three-month period of relative rest. This largely involved avoiding heavy lifting in the gym – in particular press exercises and dips. He was able to play football during this time without any real restriction.
Fractures involving the costal cartilage do not appear to be common with very little published literature to guide treatment decisions. Most reported cases are in men and are caused by either blunt trauma or a fall. The first and second ribs are less mobile and as a result are more prone to costo-chondral separation. The lower ribs may fracture more easily.
While MRI was used in this case CT imaging and ultrasound scans may also have a role in making this diagnosis. X-ray imaging generally has low sensitivity.
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