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When you palpated the patient’s pectoralis muscles, they were remarkably tender. On examination, the left chest musculature appears more prominent than the right. When you delve more into the patient’s history, you discover that he has been trying to increase the amount of weight he can bench press, and has been “pushing himself” over the past two days because he has been trying to impress his new, female personal trainer.
An ultrasound of his chest demonstrates normal muscle (Figure 1 on previous page & 3), adjacent to a torn muscle with hypoechoic edema interspersed between the injured fibers (Figure 2 on previous page & 4).
You continue to follow the pectoralis muscle laterally towards its insertion site at the bicipital groove of the humerus. You note that a portion of the muscle is contracted and surrounded by a pool of anechoic blood. (Figure 5). This is likely where the largest muscle tear occurred and is why your patient isn’t comfortable extending, rotating, or abducting his shoulder.
The patient’s EKG appears normal, and you decide to cancel the rest of the blood tests and stress test that were initially ordered on him. You remind your residents about the art of medicine and the importance of a good history and physical exam. You use this case to illustrate why physicians have not been replaced by algorithmic, computer-generated treatments based on patient’s responses, and teach everyone a little bit more about how cool musculoskeletal ultrasonography can be.
As you push back the ultrasound machine into its storage area, you can’t help but laugh at the display in the consultant’s room. The end of the shift has inspired your residents to leave the internal medicine team a goalie mask, a stack of bricks, and bright orange warning cones, so that they can construct an actual physical barricade to aid in their next admission “block”.
Continue to next page for tips and tricks for musculoskeletal ultrasound