Diagnostic Evaluation of Nontraumatic Chest Pain in Athletes.

This article is a clinically relevant review of the existing medical literature relating to the assessment and diagnostic evaluation for athletes complaining of nontraumatic chest pain. The literature was searched using the following databases for the years 1975 forward: Cochrane Database of Systematic Reviews; CINAHL; PubMed (MEDLINE); and SportDiscus. The general search used the keywords chest pain and athletes. The search was revised to include subject headings and subheadings, including chest pain and prevalence and athletes. Cross-referencing published articles from the databases searched discovered additional articles. No dissertations, theses, or meeting proceedings were reviewed. The authors discuss the scope of this complex problem and the diagnostic dilemma chest pain in athletes can provide. Next, the authors delve into the vast differential and attempt to simplify this process for the sports medicine physician by dividing potential etiologies into cardiac and noncardiac conditions. Life-threatening causes of chest pain in athletes may be cardiac or noncardiac in origin, which highlights the need for the sports medicine physician to consider pathology in multiple organ systems simultaneously. This article emphasizes the importance of ruling out immediately life threatening diagnoses, while acknowledging the most common causes of noncardiac chest pain in young athletes are benign. The authors propose a practical algorithm the sports medicine physician can use as a guide for the assessment and diagnostic work-up of the athlete with chest pain designed to help the physician arrive at the correct diagnosis in a clinically efficient and cost-effective manner.

Left Ventricular Non-Compaction in Athletes: To Play or Not to Play.

Isolated left ventricular non-compaction (LVNC) has usually been viewed as a rare cardiomyopathy in athletes. However, with advances in diagnostic imaging techniques and increased use of pre-participation screening electrocardiograms (ECGs), apparent LVNC is being recognized in an increasing number of athletes. Given the lack of a true gold standard for diagnosis, significant debate continues regarding optimal diagnostic criteria. There are increasing data to support the possibility of over-diagnosing this cardiomyopathy in an athletic population due to the physiologic adaptation to the extreme preload and afterload characteristic of intense athletic participation. This appears to be particularly true in African-American or African-Caribbean athletes. The most common presenting symptom in the athlete with true LVNC is exertional syncope. Evaluation of the at-risk athlete will typically include a complete history, with attention to cardiac symptoms, family history of premature cardiovascular disease or sudden cardiac death (SCD), physical examination, 12-lead ECG, two-dimensional echocardiography, and, in some cases, cardiac magnetic resonance imaging with gadolinium contrast. In addition, stress echocardiography, 24- to 48-h Holter monitoring, or 30-day event monitoring for arrhythmias may be necessary to fully evaluate the athlete's risk. Adverse outcomes with LVNC include ventricular dysfunction, arrhythmias, syncope, SCD, and thromboembolism. Asymptomatic athletes with hypertrabeculation of the left ventricle but normal ventricular function likely do not require restrictions on activity. Symptomatic individuals who meet criteria for LVNC, especially those with abnormal ventricular function and exercise-induced symptoms or arrhythmias, should be prohibited from participating in vigorous sports activities.

Venous thoracic outlet syndrome: approach to diagnosis and treatment with focus on affected athletes.

Venous thoracic outlet syndrome is a relatively rare condition. One variety that is related to effort, often referred to as Paget-Schroetter syndrome, is seen more often in persons who are athletic or occupationally active. This condition can have significant morbidity if left untreated. Diagnosis is best undertaken with duplex ultrasound or venogram. The current standard for treatment includes catheter-directed thrombolysis with surgical correction of the thoracic outlet and subclavian vein with some variability of this depending upon the presentation. Some cases may require anticoagulation for approximately 12 wk. Return to play should be expected in successfully corrected cases that include a collaborative rehabilitation program.

Office-based ultrasound in sports medicine practice.

Increasing knowledge, interest, and visibility in the field of sports medicine has equipped clinicians in the field with a novel array of diagnostic and therapeutic options but has also provided a higher level of complexity in patient care. True understanding of the vast spectrum of radiographic technology available to the sports clinician has become more critical than ever. Advances particularly in the areas of magnetic resonance imaging, diagnostic office ultrasound, and 3-dimensional reconstruction computed tomography, as well as nuclear medicine, offer the clinician a myriad of diagnostic options in patient evaluation. As these advances accumulate, the challenge to optimize care, contain cost, and interpret the extensive data generated becomes even more difficult to manage. Improving technology, education, and application of office ultrasound offers an interesting new tool for the bedside evaluation in real time of dynamic motion and pathology of sports-related injuries. As studies continue to validate ultrasound's effectiveness in diagnosing injuries to the upper and lower extremities compared with more costly magnetic resonance imaging and more invasive exploratory surgery, its promise as a cost-effective diagnostic tool is growing. A particularly promising development in the care of sports injuries is the expansion of injection therapies, and in-office ultrasound provides assurance that prolotherapy, platelet-rich plasma, dry needling, corticosteroid, and viscosupplementation are delivered accurately and safely. Communication with patients continues to increase in complexity because a greater understanding of the presence of radiographic abnormalities irrelevant to the current complaint is gained. All the accumulated data must then be interpreted and communicated to the patient with a firm understanding of not only the patient history and physical examination but also the availability, indications, contraindications, sensitivity, specificity, and even the cost implications of the spectrum of diagnostic options.