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Abstract

Background: A 21-year-old male collegiate baseball player reported to the athletic training staff after experiencing acute pain in his left side following throwing a pitch. The patient experienced immediate difficulty with active lateral flexion and trunk rotation. Palpation revealed spasm and tenderness along the internal and external oblique muscle. The patient reported having subluxed a rib on a previous occasion. While the pain experienced was similar, the patient stated that there was more pain along the muscle bellies of the internal and external oblique muscles compared to the previous injury. No difficulties with breathing, bowel movements, or urination were reported. Differential Diagnosis: Oblique strain, subluxated rib, intercostal cartilage irritation. Treatment: At the time of the initial evaluation, the patient was diagnosed with a strained oblique. The patient was instructed to avoid vigorous physical activity, throwing, deep stretching, and any other painful activities until symptoms began to improve. The patient began a rehabilitation program centered around core and hip strengthening. Treatment was initiated using cupping therapy and electrical stimulation Following a week of relative rest and rehabilitation, the patient reported no improvement in pain or range of motion. At this time, the patient was referred to the team physician for diagnostic ultrasound. Musculoskeletal ultrasound revealed edema consistent with a high-grade external oblique strain. Given the amount of edema the patient had, the physician opted to postpone an MRI until edema had begun to resolve. Ten days after the previous evaluation, the patient was seen again in clinic to be consented for an MRI. A second musculoskeletal ultrasound was performed, revealing a cortical disruption at the 12th rib. Given the new finding, the physician ordered a CT scan for further evaluation. The CT scan confirmed an avulsion fracture of the distal aspect of the 12th rib as a result of the previous oblique strain. These findings provided context for the patient’s delay in decreased symptoms and healing. The patient continued relative rest and combined with treatment and rehabilitation for the following four weeks, at which point the fracture was confirmed to have healed. At this time, the patient began a return to throwing protocol, and was able to return to full activity with no complications. Uniqueness: While avulsion fractures of the ribs have been previously reported in athletic populations, there appear to be no documented cases of an avulsion of the 12th rib. Additionally, previous documented injuries have primarily involved the serratus anterior avulsing seventh through ninth ribs. Conclusions: When providing care, clinicians must consider all patient reported signs and symptoms. In the event that a patient’s symptoms do not follow an anticipated progression, clinicians should use all available resources to obtain a diagnosis. Evaluation and re-evaluation of patient progress is critical to ensure optimal outcomes following injury.

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