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Case History: Chest and Rib Pain in the
Martial Artist
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
Prolotherapy injections. The sodium morrhuate increases the inflammatory response and thus the healing
response. James received approximately 30
Prolotherapy injections,
(Watch where do
Prolotherapy injections go and do they hurt?)
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
Prolotherapy 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 I’m 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 can’t 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 wasn’t 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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