Member Question from Ridgelake

"I have an injury to my side.  It has been re-occuring for the last three years and has never gone away. This area was originally injured in 1994.  I had been hiking and then jumped into a river to cool off.  After taking a few strokes, I felt a very sharp pain in the area.  I likened it to being stabbed with a knife.

Most episodes start with the tearing, giving-way sensation.  This is localized about 1-2 cm inside the 10th rib on the side (neither anterior nor posterior).  The length of this sensation (front to back) is perhaps 2-4 cm.

I've been living in various degrees of pain for about three years.  No one seems to be able to give me an answer.  Almost every doctor "passes the buck" to the next one, while giving the appearance that they don't immediately know the answer, and they won't take the time to try to figure it out.  Meanwhile, I've been given the impression that they think its in my head.

I've dealt with enough injuries and experienced enough pain to know the difference between a minor everyday tweak and a real injury.  This is very real and it hasn't gone away in three years. So I ask, 1) do you have any idea how I might get a real diagnosis and 2) how I might get a long term solution to this problem?"

Complete History

Answer from Deanne Eccles- Rotar, MD
Member AMSSM

I am sorry to hear of your longstanding problem with chest wall pain.  Although I am not able to examine the area it sounds like it is related to the attachment of the serratus anterior muscle on the side of your rib cage.  It may have torn from the insertion/attachment initially at the time of injury in 1994.   

The serratus anterior originates laterally on the first 9 ribs and inserts on the medial margin of the scapula.  Its function is to protract the scapula - rotate it away and upward from the spine - and is also known as the “Boxer’s muscle”.  The antagonistic muscle groups are the rhomboids and trapezius.  The action of the serratus is essential for proper shoulder functioning, helping to set the position of the main shoulder joint- the glenohumeral joint.  It is not surprising that you have injured it most of the time while swimming because it is highly activated during swimming.

Regarding treatment to date it seems like most of the focus has been on therapy for the trapezius and rhomboids for scapular stability.  I would recommend physical therapy involving eccentric strengthening of the serratus - protracting and rotating up the scapula with use of theraband-type exercise.  Kinesiotaping could also be employed to retrain the function of this muscle.  For interventional treatment, consider prolotherapy or platelet rich plasma injections into the painful area to try to stimulate healing if scar tissue has formed.  I am not sure if you have had any nerve testing but this could also be done to rule out any nerve pathology as a cause of scapular dysfunction, particularly dysfunction of the long thoracic nerve.

Although you were quite thorough with the history of this injury, you did not comment on your rate of return to activity following each episode.  It is essential to increase by <10%/week (maybe even 5% in your case because of the recurrent problem) to allow your body to properly acclimate to the changes in forces placed on it.  Too often people start training from where they historically were and not at their current physiologic state.

I hope you find this helpful information and it offers a new focus on treatment for your problem.   

Deanne Eccles- Rotar, MD