1. Thoracic Back Pain in an Intercollegiate Female Rower
Mike Lawler M.A., ATC, LAT
Senior Associate Athletic Trainer
The University of Iowa

2. Introduction
Case presentation
Discussion
Conclusions

3. Rowing at Iowa Beginning 16th year as an intercollegiate sport
60-70 rowers on team
Varsity and Novice
Practice for 2½ hours on water and 1 hour with strength & conditioning coach

4. Case Presentation
20 YO female rower for the University of Iowa. No previous experience as a rower prior to enrolling at Iowa in 2005.
Onset: April 12, 2007 during spring season - 3 weeks left in her season
CC:
Swelling and pain at left anterior rib cage
Painful left upper back;
Pain while rowing in practice
Numbness at left mid back below scapula
Occasional dyspnea
Previous hx: None; gradual onset with no acute episode
Continued to participate in practices until symptoms worsened and performance became affected
Symptoms initially only with rowing but now during ADL’s

5. Examined by certified athletic trainer in athletic training room
Assessment: Possible costochondritis; posterior rib stress reaction; paraspinal strain
treated with therapeutic modalities
Cold/ice bag
allowed to continue rowing, as tollerated
After one week her symptoms failed to improve
She was referred to UISMC and orthopaedic physician on April 18, 2007

6. Musculoskeletal Injuries 1994 - 2006
Low Back %
Knee %
Chest/Rib %
Upper Back %
Ankle %
Wrist %
Shoulder %
Patella %
Hip %
Foot %
Tibia %
Neck %
Elbow %
Forearm %
Fibula/Calf 3 0.8%
Finger %
Other %
TOTAL %

7. Physical Examination by Orthopaedic Team Physician – 4/18/07
Examination findings:
Slight prominence of the costochondral joint from anterior left side of chest
Palpable tenderness in left paraspinal muscles
Numbness noted in the left thoracic paraspinal area
Posterior thoracic pain is aggravated with motion in all directions
Upper extremity function was normal
Neurologic exam: normal
Radiograph studies:

8. L-Spine Standing AP & Standing Lateral Flexion/Extension views
X-rays
L-Spine Standing AP & Standing Lateral Flexion/Extension views
Findings/Impression:
There is no evidence of a fracture or dislocation. The osseous structures are in gross anatomic alignment. There is no soft tissue abnormality
Negative exam

9. Impression Costochondritis left anterior rib cage
Referred pain posteriorly
Thoracic radiculopathy

10. Plan Provided prescription for naproxen – 500 mg BID
MRI imaging was offered to rule out thoracic disk herniation if sx.’s fail to improve or worsen
Progress to be followed by staff athletic trainer
She was able to finish out spring season but not without resolution of symptoms; treated symptomatically.

11. Status as of August 22, 2007 prior to start of 2007-2008 season
2-3 months of no rowing during summer
Unproductive chiropractic treatments during summer
Resolution of left anterior chest swelling
Same amount of continuous pain, described as a “pinching” just below scapula on left side
When active, pain increased but was less severe than when she would row
Patch of numbness was still present just below left scapula
Numbness had slightly migrated to right side of back and up right side of her back to just above right scapula
She had not noticed any UE weakness

12. Return Visit to Orthopaedic Team Physician – 8/22/07
Examination findings:
Palpable tenderness about T10 just to left of thoracic spine. No other tenderness
Numbness noted inferior to left scapula
No palpable tenderness of anterior chest wall
Increase of pain with lateral bending and twisting. No pain with flexion & extension
Chest X-rays - normal

13. Plan MRI imaging was scheduled to rule out thoracic disc herniation
Reasoning?
Persistent pain
Patch of numbness
Pain with movement
To look deeper for a cause

17. Thoracic & Cervical MRI Findings
A small syrinx within the midthoracic spinal cord from the T6 through portion of T8 levels, measuring 1.8 mm max. diameter
Above and below syrinx, thin central high T2 signal appeared most consistent with normal spinal CSF central canal
No abnormal focus on enhancement
No underlying lesion was identified
Spinal cord signal was otherwise unremarkable
No central stenosis
Cervical & thoracic spine exhibited no degenerative changes
Normal configuration of the intra cranial posterior fossa structures, without evidence for Chiari malformation

18. Syrinx
A syrinx is a fluid-filled cavity within the spinal cord (syringomyelia) or brain stem (syringobulbia).
Taber’s Cyclopedic Medical Dictionary
Symptoms include flaccid weakness of the hands and arms and deficits in pain and temperature sensation in a capelike distribution over the back and neck
Sx.’s not reported by this patient

19. Syrinxes usually result from lesions that partially obstruct CSF flow.
At least ½ of syrinxes occur in patients with congenital abnormalities of the craniocervical junction (eg, herniation of cerebellar tissue into the spinal canal, called Chiari malformation), brain (eg, encephalocele), or spinal cord. For unknown reasons, these congenital abnormalities often expand during the teen or young adult years.
A syrinx can also develop in patients who have a spinal cord tumor, scarring due to previous spinal trauma, or no known predisposing factors. About 30% of people with a spinal cord tumor eventually develop a syrinx.
Source: Merck Manual online

20. Referral to Spine Team Physician - 8/27/07
Exam Findings
LE neurovascular exam – normal
Tenderness to palpation over posterior rib at T8 level on left
Chest x-ray showed a possible lytic lesion on left 8th rib posteriorly
No indication of myelopathic findings – syrinx is not likely cause of her symptoms
Plan: Obtain CT scan of 7th – 9th posterior ribs

21. CT Scan of Ribs
Axial CT scanning of the mid and lower thoracic spine and medial aspect of of the ribs was performed without intravenous contrast
FINDINGS:
No lytic or sclerotic lesions were identified in the medial aspects of posterior ribs.
No abnormal soft tissue masses were identified.
There were no degenerative changes of the visualized thoracic spine
IMPRESSION: No abnormality in the medial aspects of the mid and lower thoracic ribs.

22. Where do we stand at this point?
Ongoing symptoms of back pain in middle aspect of spine, left side
“Numbness” in her back on left side
Mid thoracic spine and left paraspinal tenderness
MRI showed syrinx that was determined to not be cause of symptoms
CT scan showed no abnormal findings
Chest x-ray read as normal
Treatment with therapeutic modalities: heat, e-stim, ice
Prior pain in left anterior aspect of ribs has resolved
Still experiencing pain while rowing – participation is limited

23. Plan Continue local therapeutic modalities
Neurosurgery consult for possible facet or nerve root injection
Medrol dose pack for competitions
Follow-up with team orthopaedic physician and/or Spine Team orthopaedic physician prn
Allowed to participate, as tollerated

24. Referral to UIHC Pain Clinic – Neurosurgery Consult
Received costovertebral/costotransverse injection on 11/02/07
Allowed to return to rowing activity
Patient reported that “the injection helped for a little while but then wore off.”

25. Additional Referral and Treatment
Medication changed from Naproxen to Piroxicam
Second series of 2 injections at T9 and T11 on 11/28/07
Prescribed Lidoderm patches by Pain Clinic physician
Treatment with iontophoresis in athletic training room
Treatment with T.E.N.S.

26. Spring 2008 Rowing Season 2008 Winter Training Trip
Stationary bicycle – no erging, only drill work on water
February – May 2008
Continued to row until pain forced her to rest
Repeated this pattern throughout spring 2008
Reported previous injections had somewhat helped because pain was not as intense
Persistent symptoms of skin sensitivity and “numbness”
Attended follow-up care with UIHC Pain Clinic
Allowed to finish out season, as tolerated

27. Fall 2008 Rowing Season
Resumed practicing with recurrent symptoms of pain, tenderness over posterior ribs, just to left of thoracic spine, and mid-back and left side numbness
Symptoms presented during rowing and strength training activities, diminished with rest
Continued to participate in most practices and competed in all fall races
End of fall season follow-up with Spine team orthopaedic physician

28. Follow-up Examination with Spine Team Orthopaedic Physician – 12/15/08
Review of 8/22/07 MRI findings
Benign other than incidental thoracic syrinx not felt to be contributing to her symptoms
Neurovascular exam was normal
Plan:
Repeat thoracic spine MRI with contrast to evaluate any progression of syrinx
Renew prescription for Lidocaine patches

29. Repeat Thoracic Spine MRI with Contrast
IMPRESSION:
Stable mid thoracic small syrinx
No lesion visualized
PLAN:
Refer back to team orthopaedic physician and Pain Clinic for continuation of care

30. Spring 2009 Rowing Season
Participated, as tollerated, in Winter Training Trip
Continued to experience pain and numbness sx.’s
Treatment with:
Lidoderm patches
T.E.N.S.
Iontophosesis
NSAID - Piroxicam
Participated in spring practices and races
“good days and bad days”
Finished out rowing career on May 17, 2009
Graduated from the University of Iowa

31. Discussion Hx. of chest/rib pain in rowers
Discovery of benign syrinx by MRI
Multidisciplinary team approach to care of patient
Multiple treatments used with varied results
Even with best efforts, there was a failure to achieve complete relief of symptoms
Conclusive diagnosis?

32. Conclusions
MRI showed a midthoracic small spinal cord syrinx that was concluded to not be cause of her symptoms
Persistent mid-thoracic back pain and numbness
“It’s not about what it is, but what it isn’t”
No rib stress fracture
No herniated thoracic disc
No abnormal soft tissue masses
No degenerative changes of thoracic spine

33. Thank you