Author: Daniel Hamilton: 4th year physiotherapy student at La Trobe University

In Brief

A 23-year-old male presented to the emergency department one hour post a 160kg deadlift with right sided arm/flank pain and dyspnea. The patient was seen by a fourth-year physiotherapy student completing their ‘mixed’ core placement in the emergency department. Clinical examination revealed strong suspicion for a non-musculoskeletal cause of the pain. A chest x-ray (CXR) was ordered, confirming a large right sided pneumothorax. The patient’s care was then handed over to the emergency department medical team. An intercostal catheter and underwater seal drain were placed to resolve the pneumothorax. The patient was discharged 4 days later. Following this, the patient represented at 1 week for scheduled follow up. X-ray revealed a re-occurrence of a large right sided pneumothorax. Patient underwent emergency intercostal catheter and was transferred to a metropolitan health service for pleurodesis, following which the patient spent 7 days in hospital before discharge home. This case report demonstrates the need for systematic assessment process underpinned by strong clinical reasoning. It is an important reminder to keep an open mind to alternative and uncommon diagnoses when working as a primary contact clinician. Spontaneous pneumothorax in weightlifters is rare, but cases have been reported (Marnejon, 1995). Symptoms may vary but the healthy individual or younger athlete can mask the severity via compensatory methods, which can result in dire consequences.

Case Details

A 23-year-old male self-presented to a major regional emergency department service at 4pm on a Friday afternoon, 1 hour post deadlifting 160kg. Nurse triage assessment reported acute onset of right sided arm and back pain post deadlifts at gym (160kg). Equal grip in limbs. Musculoskeletal injury. Nil analgesia. Vital signs taken by the triage nurse showed normal respiratory rate (16 breaths per minute), 98% oxygen saturation on room air, heart rate 80 beats per minute. The patient was triaged category 4, according to the Australasian Triage Scale Category.
After a 25-minute wait, the patient was assessed. Walking from the waiting room to the ambulatory care assessment room he ambulated with a hunched posture toward his right side. Endone was prescribed by one of department’s medical Interns.

Subjective Assessment

The patient reported warming up with 7 sets of deadlifting, starting at 60kg and building to 160kg. Then the patient aimed to complete 5 sets of 5 repetitions lifting 160kg. The patient completed the straight bar deadlift with a hook grip with his right hand underneath the bar and held his breath for the lift. The patient finished his first set of 5 reps and sat to rest between sets, then felt a sharp onset of pain in his right arm and back.

The patient reported the location of his pain was from right upper trap, over his shoulder and down over the right-side ribs. Pain was intense and constant with nil improvement since onset. There was no feeling of pop, crack or strain during the lift.

The pain was aggravated by ambulating and maintaining an upright posture. The patient reported being short of breath during rest and when ambulating. Prior to attending gym, patient was well with nil issues. Patient stated not having any injuries from weightlifting before.

His past medical history includes pericarditis 4 years prior which was caused by a virus and was treated conservatively with nil medications. The patient had no family history of pneumothorax’s or Marfan Syndrome. He takes no regular medications or steroids, however protein powder, creatine monohydrate and pre-workout powder are taken as supplements. 

He works as a specialised IT worker. Hobbies included powerlifting and computer games. He is not a current smoker and denies previously smoking.

He had previously trained for 3 years, training 5-6 days per week in the gym. Most sessions involve a warm-up of 7 sets which aimed to build weight in a chosen compound lift until the target weight is reached. From there, 1-2 compound lifts with accessory work are involved in the session. Previously he has competed in powerlifting competitions with his previous deadlift 1 repetition maximum being 212.5kgs. The most recent competition was in December of 2019.

Based on his presentation and subjective assessment findings the likely clinical diagnosis included:  Rib fracture, shoulder dislocation/subluxation, biceps rupture, sternoclavicular dislocation/sprain, upper trap tear, pec rupture, thoracic disc injury, referred pain from spinal injury, latissimus dorsi strain, rotator cuff tear, intercranial pressure injury, subarachnoid aneurism, spontaneous pneumothorax, spontaneous diaphragmatic rupture, spontaneous abdominal aortic aneurysm.

Objective Assessment

On assessment, the patient was 178cm in height and weighed 81.4kg. Sitting posture showed thoracic kyphosis favouring his right side secondary to pain. No obvious deformity was noted with the patient having no ‘pop-eye’ sign in biceps and pectoralis major was symmetrical bilaterally. Also noted was the patients flushed face along with shallow breathing pattern. Palpation revealed no palpatory tenderness over the biceps, pec major, deltoid and surrounding right sided musculature with all tendon origins and insertions intact. Active range of motion showed full range of shoulders and elbows bilaterally.

The patient reported intense pain over right sided ribs during deep breath inspiration, with the same reported pain during cough. Auscultation revealed no breath sounds into right lung in the upper, middle and lower lobes. The left lung had clear breath sounds with no abnormality detected in all lobes. The patient’s oxygen saturation levels were 94% on room air and a respiratory rate of 20 breaths per minute.

Based on his presentation and subjective assessment findings the likely clinical diagnosis included:  fractured rib, posteriorly dislocated sternoclavicular joint, spontaneous pneumothorax, spontaneous diaphragmatic rupture, spontaneous abdominal aortic aneurysm, intercranial pressure injury and subarachnoid aneurism.

CXR was ordered and senior doctor consulted. Patient was immediately taken to radiology for urgent CXR which revealed a large right sided pneumothorax.

Medical Management

The patient was taken to the resuscitation unit and handed over to medical staff. At the time of hand over the patient’s respiratory rate was 22 breaths per minute along with 94% oxygen saturation levels. From there the medical management was as follows:

• 20/03/20: Underwent anterior chest aspiration of air. Follow up CXR showed nil significant improvement in pneumothorax.
   
• 20/03/20: Intercostal catheter (ICC) inserted into right mid axillar to prevent tension pneumothorax and re-inflate lung. CXR ordered to check positioning.
   
• 20/03/20: Position not optimal, re-position. CXR.
   
• 20/03/20: Position not optimal, re-position. CXR.
   
• 21/03/20: Post suction CXR. Nil improvement, ICC removal.
   
• 21/03/20: New ICC positioned. CXR showed good positioning.
   
• 23/03/20: ICC was clamped with CXR to monitor response. Good response, ICC was removed later that day.
   
• 24/03/20 Patient discharged home with moderate size pneumothorax.

Pneumothorax Reoccurrence

The patient presented 6 days post discharge for a routine CXR which revealed re-occurrence of large right sided pneumothorax and was immediately sent to the emergency department for ICC re-insertion. Prior to this routine CXR, the patient had nil abnormal symptoms or shortness of breath and denies completing any strenuous activities that could have caused this reoccurrence. He was transferred to a metropolitan health service the following day to undergo a pleurodesis procedure. The patient then spent 7 days in hospital before being discharged home. Upon discharged the patient’s weight was 73.9kg, down from 81.4kg upon initial presentation.

Epidemiology of Spontaneous Pneumothorax

A pneumothorax is defined as the presence of air in the pleural space (Luh, 2010). A primary spontaneous pneumothorax is that which occurs from no trauma or underlying lung disease and usually occurs at rest (Luh, 2010). The incidence rate for primary spontaneous pneumothoraxes is between 7-18 cases per 100,000, with much fewer cases resulting from weightlifting (Noppen, 2010). This condition occurs primarily in younger males aged between 20-40 years old (Curtin, Tucker, Gens, & sportsmedicine, 2000). Other common factors that predispose an individual to a spontaneous pneumothorax include tobacco smoking, low BMI and Marfan Syndrome (Luh, 2010) (Ayed et al., 2006). The exact pathogenesis is still unknown, however spontaneous rupture of a subpleural bleb or bulla is a widely accepted cause (Light, 1993).

Weightlifting related spontaneous pneumothorax may be a result of the sustained breath hold (Valsalva) method when lifting heavy loads, i.e. deadlifting. This maneuver can increase intrathoracic pressure and may rupture the subpleural bleb or bullae of the lungs leading to a spontaneous pneumothorax (Curtin et al., 2000). If untreated, a large pneumothorax can lead to a tension pneumothorax, which can be fatal without rapid intervention (Roberts et al., 2015). Therefore, if the subject is left untreated or the primary contact physiotherapist fails to recognise the condition, the outcome can be fatal.

Conclusion

This is a rare case of spontaneous pneumothorax during weightlifting, with the only predisposing factors being male and aged between 20-40 years old. This highlights the need for a thorough subjective and objective assessment of patients to exclude potential life-threatening presentations in both primary and secondary contact roles, without presumptions from prior assessment. It is a reminder that as primary contact practitioners we should always follow a systematic framework for our assessment, allowing the symptoms and presentation to guide our clinical reasoning processes and to ensure we rule out serious pathologies first.

References

Ayed, A. K., Bazerbashi, S., Ben-Nakhi, M., Chandrasekran, C., Sukumar, M., Al-Rowayeh, A., & Al-Othman, M. (2006). Risk factors of spontaneous pneumothorax in Kuwait. Medical principles and practice, 15(5), 338-342.

Curtin, S. M., Tucker, A. M., & Gens, D. R. (2000). Pneumothorax in sports: issues in recognition and follow-up care. The Physician and sportsmedicine, 28(8), 23-32.

Light, R. W. (1993). Management of spontaneous pneumothorax. American Review of Respiratory Disease, 148, 245-245.

Luh, S. P. (2010). Diagnosis and treatment of primary spontaneous pneumothorax. Journal of Zhejiang University SCIENCE B, 11(10), 735-744.

Marnejon, T., Sarac, S., & Cropp, A. J. (1995). Spontaneous pneumothorax in weightlifters. The Journal of sports medicine and physical fitness, 35(2), 124-126.

Noppen, M. (2010). Spontaneous pneumothorax: epidemiology, pathophysiology and cause. European Respiratory Review, 19(117), 217-219.

Roberts, D. J., Leigh-Smith, S., Faris, P. D., Blackmore, C., Ball, C. G., Robertson, H. L., ... & Stelfox, H. T. (2015). Clinical presentation of patients with tension pneumothorax: a systematic review. Annals of surgery, 261(6), 1068-1078.