I have had the pleasure of serving as team doctor for the football squad of a nearby high school these past seven years. Since my middle son is the starting safety on this team, it is particularly gratifying to be able to help out, to be there, and to watch him play.
Last Friday was the league opener, and their rival was a well-know perennial powerhouse. It figured to be a real “shootout”. There were a number of relatives who came to cheer them on. Anticipating a large crowd, we arrived early, planning to tailgate and situate ourselves in the stands before it became too crowded.
Various family members had congregated near the entrance to the stadium enjoying each other’s company. Suddenly I was almost pounced upon by several teachers and students. “Come quickly,” they frantically said. “One of our cheerleaders can’t breathe!”
Grabbing my medical bag I ran to the training room where I found a cheerleader sitting in a chair, breathing into a brown paper bag. Her trembling hands indicated how frightened she was. The crowd around her was also concerned and worried. Before I could make my way to her side I heard a myriad of diagnoses, ranging from asthma to a heart attack.
Identifying myself I knelt in front of her. The girl’s coach, standing next to her, had been the one who had her breathe in the bag. I was informed that the pulse had been taken and seemed strong. As I was obtaining the history from the cheerleader, I watched her breathe, very closely. Her respirations were not at all labored, but they were shallow and rapid. I could not detect a wheeze or any adventitious sounds. Continuing to talk to her I felt her pulse and, indeed, it was strong and regular.
The history indicated that she had not felt well for the past two days, although there was no fever or any specific symptoms. Warming up with the other cheerleaders she had felt as if she could not get enough air into the lungs. Suddenly she felt light-headed and began seeing spots. The more frightened she got, the worse the symptoms. Then her fingers began to spasm and tighten up. I was called when she lost control of her fingers.
Her lungs were clear and there were good breath sounds throughout the lung field. The heart was regular and completely normal. Her coach and the faculty members who had gathered around were perplexed. “Well then, what’s the matter with her? Should we call 911?” they asked.
By now the cheerleader had calmed down and said she felt better. She was able to take deep, normal breaths, and her fingers were “working normally” again. Before I dismissed her there was one more thing that needed to be done. That was to press on her chest laterally to the sternum, or breastbone. This brought consternation to the onlookers. “You wanna do what??? What does that have anything to do with?”
Carefully I palpated along the area where the ribs join the sternum. There was no pain or discomfort along the right. Then I started on the left side. No problem with the first 2-3 ribs from the top. When I hit the 4th and 5th ribs I thought she was going to jump out of her chair. She actually had tears in her eyes, even thought I had not palpated that hard.
Looking at her coach I said, “She has costochondritis, but will be just fine.” I went on to explain in detail what this condition was and what could be done for it.
This is a common condition seen in children as well as adults. The exact cause is unknown, but it is a safe assumption that some cases of costochondritis are caused by a virus. Others are probably the result of overuse of the muscles in the chest. The sternum is obviously made up of bone, as are the ribs. When one thinks about it, if the ribs attached directly to the breastbone, there would be no way the chest could expand each time we took a deep breath. Consequently, cartilage connects the ribs to the sternum. This functions as an expansion joint. In costochondritis, it is the cartilage that becomes inflamed and sore, not the bone. In many cases patients do not complain of pain. Because of the inflammation of the cartilage, the surrounding muscles may spasm. This can lead to a sense of “chest tightness”, or the feeling that one cannot get enough air. The body may try to compensate for this inflammation by breathing rapidly and shallowly. Hyperventilating, the chest wall expansion is kept to a minimum. As a result of hyperventilating, the patient blows off carbon dioxide and can change the tightly regulated acid-base balance in the blood stream. This causes the light-headedness, tingling of the fingers, spasm of the fingers and even severe headache. An easy remedy is to have the patient re-breathe in a paper bag. In a matter of seconds it literally corrects itself, such as the case with the cheerleader.
Some children with costochondritis may complain of chest pain. When it involves the left side of the chest parents worry that their child might be having a heart attack or a serious lung problem. Clearly, in costochondritis, when pressing on the cartilage where the ribs join the sternum, there is exquisite tenderness. This in NOT the case in a heart attack or lung pathology. Think about it. The heart and lungs are within the rib cage, fully protected. No degree of pressing on the chest wall will cause these organs to be tender. Costochondritis involves the chest wall itself; therefore, it causes chest wall tenderness by definition.
Costochondritis is a self-limiting inflammatory process that will resolve in time. It is very responsive to anti-inflammatory medications. Should one hyperventilate as a result of the chest wall pain, a prompt response will occur by re-breathing in a paper bag. In very rare instances, costochondritis can be severe and persistent, and interfere with one’s daily activities. This may necessitate a visit to an orthopedic surgeon who can inject the involved rib junctions with an anti-inflammatory agent along with a steroid to calm the inflammation.
I had to chuckle to myself; the game had not even started and already I had my first “medical call”. I hoped that this was not an omen of things to come during the game. Our cheerleader did just fine. In fact, by the second half, she was performing as if nothing had even happened.