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Medical Resident Research Case Reports

03 ONE-SIDED STRENGTH: WHEN CHEST DAY LOOKS DIFFERENT - A CASE OF UNILATERAL CHEST WALL MUSCULOSKELETAL ANOMALY IN A YOUNG ADOLESCENT ATHLETE

Sean Thuesen, DO; Nicholas Nguyen, MD; John Tuttle, MD Corresponding author: stthuesen@carilionclinic.org

Virginia Tech Carilion School of Medicine, Department of Orthopedics, Roanoke, Virginia

was marked atrophy of the right pectoralis major and an anterior sternal protrusion (pectus carinatum), but full, painless shoulder range of motion and strength. No scapular winging, tenderness to palpation, or neurovascular deficits were present. All shoulder special tests were negative. Elbow, wrist, and digit motion were full. Shoulder X-ray showed no acute bony injury, but did show mild acromioclavicular joint degenerative changes, suggestive of a prior injury. MRI revealed a partial absence of the right pectoralis major (absent sternal and abdominal heads but a present and intact clavicular head) and absence of the right pectoralis minor. Visualized portions of the left pectoralis major were unremarkable. Comments: While Poland syndrome is a rare condition, it is not uncommon for the diagnosis to be missed in childhood and only discovered after puberty when the deformity becomes more noticeable (Bazewicz, 2018). In this case, even as the deformity became more apparent during puberty, the patient only sought evaluation once functional deficits --particularly weakness --became significant. Notably, the patient did not exhibit other typical features such as rib aplasia, hand anomalies, or nipple hypoplasia, which

might have prompted earlier recognition (Fokin and Robicsek, 2002). This highlights the importance of considering Poland syndrome in adolescent patients presenting with upper extremity complaints. Treatment options for Poland syndrome range from observation to surgical interventions to address cosmetic concerns (Buckwalter V and Shah, 2016; Majdak-Paredes, Shafighi, and Fatah, 2015). Early recognition can facilitate appropriate counseling, activity modification, and consideration of physical therapy or reconstructive options, all of which can promote both physical and psychological well-being in patients with Poland syndrome. Diagnosis: Poland syndrome Treatment/Conclusion: The patient was able to continue his activities, including participation in sports, as tolerated. Initiating a course of physical therapy was discussed, but the patient elected to defer at that time.

Context: Poland syndrome is a rare congenital disorder, estimated to occur in up to 1 in 100,000 live births, and is thought to result from a vascular insult to the subclavian artery during embryogenesis, leading to ischemia in developing structures. In this case, the patient's isolated absence of the pectoralis major muscle --without hand anomalies, rib aplasia, or nipple hypoplasia --is uncommon and likely contributed to the delayed diagnosis. Report of Case: The patient is a 16-year-old male who presented with right shoulder dysfunction and deformity. He reported a noticeable chest muscle abnormality and weakness in the right pectoral muscle, with little to no activation of the muscle during lifting. Neither the patient nor his mother recalled any chest muscle abnormalities during early childhood; the asymmetry between the right and left chest was first noticed a few years prior to the office visit. He noted significant weakness in the right chest, which limits his performance in football and weightlifting, especially bench press. He also described mild, non-radiating, aching right shoulder pain for one month, managed with topical analgesics, and denied nocturnal pain, numbness, or neck symptoms. On examination, there

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134 Edward Via College of Osteopathic Medicine (VCOM)