Case History: Chest and Rib Pain in the Martial Artist
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James Heugh, a 19 year-old mixed martial arts fighter from Ontario, Canada, first came to Caring Medical in late December 2008, complaining of severe pain around the right side of his sternum. As you can imagine, the very nature of his chosen sport resulted in numerous strikes to the chest, not only in competitive matches, but also during many sparring sessions. This combat sport combines the hand blows of boxing, the kicks of karate, and the throws of wrestling and judo. James remembers sometime in mid 2008 receiving a knee to the chest. A few months later as he was throwing a heavier opponent from atop of him, he felt some movement around his sternum. From that point, most of the ribs in his right chest began to pop out of place with certain motions. His pain increased as the injuries mounted, and only inactivity relieved his pain, which was not an option for a mixed martial artist. After allowing three and a half months to rest and take joint repairing supplements, along with anti-inflammatory medications, James was still in pain and not competing. An internet search led him to Prolotherapy and Caring Medical.
James told us at his initial examination that he usually had no pain at rest on the right side of his sternum, but even the slightest amount of pressure would cause nauseating pain and shortness of breath. He was avoiding all physical activity and gaining weight. The physical examination revealed tenderness around his sternum and also at the costosternal and costochondral junctions from T1 through T8. The exam and oral history led us to believe that he was a good candidate for Prolotherapy.
We usually treat athletes with a stronger Prolotherapy solution for two reasons, the first being that their body is strong enough to handle it and the second is that time is usually of the essence for these athletes who desire to return to practice as soon as possible. James had already missed several months of training and was anxious to get back. We added 0.5 cc of sodium morrhuate (an extract of cod liver oil) to each 10cc syringe along with the normal dextrose solution, and some extra procaine for his comfort, as this stronger solution tends to hurt more with the injections. The sodium morrhuate increases the inflammatory response and thus the healing response. James received approximately 30 Prolotherapy injections on the right side of his chest, including the sternocostal junction, radiate sternocostal ligaments, costoxiphoid ligaments, and the anterior sternoclavicular ligament.
We sent James home with instructions to take it easy on the treated area for a few days, avoiding any activity that reproduced the pain, and avoiding motions that caused any cracking or popping in his chest. We encouraged him to work on his conditioning however, by doing some simple balance work and cycling. Perhaps most importantly, we instructed James on performing deep-breathing exercises at home. James had to begun to guard his chest after the injury, never allowing his lungs to fully expand when inhaling because of the associated chest pain. Long-term, this would hamper his athletics and general health, because if it were to continue, he would lose lung capacity. He listened to our instructions and said he would return in about four weeks for his second treatment.
James told us at his second visit in early February, 2009 that his overall pain was approximately 40% less. The location of the pain had changed, as he was having more pain on his left side now and ribs were popping out of place on that side.
Before they had only gone out on the right. In the month between visits he had e-mailed the clinical staff several times (as we encourage patients to do if they have any concerns.) James was pretty sore from the treatment itself and wanted to make sure this was a normal response. We told him yes, but by applying heat, taking acetaminophen as needed, and continuing with his deep breathing exercises, he could help reduce the discomfort. It is not uncommon for many of our patients to call in the weeks following their first Prolotherapy treatment, expressing concern at how their bodies are responding. Every case is a little different. Some report the quality the pain has changed, or its location has moved. While others worry that they are too inflamed, some fear too little inflammation. The doctor and clinical staff take into account all aspects of each individual case, and reassure the new Prolotherapy patient regarding their experiences. Most reported findings post treatments are normal occurrences. We make recommendations to lessen discomfort and promote healing. We reminded James that certain natural supplements could help him with some of the symptoms he was experiencing after his initial set of injections, and he began to take them regularly during his course of treatment, and he found them to be helpful. He asked if he should go to a chiropractor or massage therapist when his ribs went out of place. We advised him that a massage therapist may be able to relax the muscles to allow the affected rib or ribs to go back in proper position, and that a chiropractor may be able to do the same thing using heat, electrical stimulation, activator treatments or other modalities, but we also told James that we did not recommend that he receive any high-velocity manipulations in the areas we were treating. This could weaken the very areas we were trying to strengthen with Prolotherapy.
James received his second Prolotherapy treatment with the treated areas being expanded to the left side of the chest, including bilateral clavicles, ribs #1-10, intercostalis and pectoral muscles, along with the previously treated areas. The number of injections increased from approximately 30 at first treatment to 45 at second. A successful outcome with Prolotherapy sometimes depends on adapting to the changing presentation of the patient. Most probably James had a previous injury on the left side of his chest, the pain of which was being masked by the more severe pain on the right. A practitioner may have guessed that at an initial consult, but we believe it is not good medicine to treat non-tender areas unless a physical exam gives you reason to believe that a non-tender area is directly related to the painful area.
Our young pugilist returned in late February for his third visit reporting that he was 50-60% better overall, chest/ribs no longer going out of place, but he was experiencing new pain in his mid back region. So we revised his treatment plan to include injecting the posterior T6-T8 area on his right side, along with all the other previously treated areas. It looked like James was definitely heading in the right direction. He was slowly increasing his activity level, but was not fighting yet.
James returned in early April for his fourth and what turned out to be his final visit to Caring Medical. He reported that he was 80% improved. He experienced only one incident of a rib popping out of place, his 5th rib on the right side, and only after he sneezed. It went back into place after four hours on its own. It seemed that the muscles had little reason to continue in spasm anymore. The sternum and rib attachments were much stronger and more stable, giving little impetus for the muscles to attempt to stabilize the area with resultant muscle spasms. He was feeling so much better that he began to increase his sprint intensity and started to work out on the heavy bag. He was so confident that he was almost there that he scheduled a fight for late June. He thought treating his posterior thoracic area was a great idea and wanted to make sure we did it again as he felt getting it stronger contributed greatly to making his chest much better. We proceeded to inject all the same areas as the previous treatment with the same strong sodium morrhuate solution. He was sent on his way with instructions that he could begin sparring as soon as the inflammation from this session of Prolotherapy had subsided.
We received an e-mail from James in late May. He wrote, I have had no popping or anything this month so Im very satisfied. You gave me my life back. No other doctor or individual outside my gym actually understood what I was going through and how my life was being taken away from me until I came to Caring Medical. I just cant thank you enough for showing me your support and finally curing me of what I thought was a career-ending injury.
James had his bout as scheduled in late June. He won in the first round by putting his opponent in a shoulder lock submission hold. He sent us a video clip of him dominating his opponent, along with more thanks, saying, Well, as promised, I had my fight and it went extremely well. You gave me my life and passion back and that night never would have happened if it wasnt for you guys at Caring Medical.
We thought we may have had to see James after his fight, but he has held up pretty well and has not had the need to return to Caring Medical for Prolotherapy. Some of our patients want to get back to high-level athletics like James, as do the triathletes and marathoners we see every week, but many just want to get rid of their pain so they can bend down and pick up their grandchildren or go for a long walk with their husband or wife. Whatever your health goals are, we will work with you to reach them here at Caring Medical.
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