Management of Precordial Catch Syndrome in a 15-Year-Old Swimmer
Precordial catch syndrome (PCS) is a benign, self-limited condition requiring only reassurance and no restriction from competitive swimming or any other athletic activities.
Clinical Recognition and Diagnosis
PCS is characterized by highly distinctive features that make it a clinical diagnosis, not one of exclusion 1, 2:
- Sharp, sudden onset of severe chest pain that is brief in duration (seconds to a few minutes) 1, 3
- Periapical location that is easily localized and does not radiate 3
- Pain intensified by inspiration, which is the most diagnostic feature 3
- Occurs at rest or during very mild activity, never during exertion 1
- No associated symptoms such as syncope, palpitations, or dyspnea (beyond the voluntary breath-holding patients often do to avoid worsening the pain) 1, 2
The physical examination should be completely normal, with no cardiac murmurs, abnormal heart sounds, or signs of cardiovascular disease 2. While the provided guidelines focus on screening for serious cardiac conditions in athletes 4, PCS does not meet any criteria for concerning cardiac pathology.
Management Algorithm
Immediate Management
- Reassurance is the cornerstone of treatment - explain the benign nature and excellent prognosis 1, 2
- No diagnostic testing is required when the history is典型 for PCS 2
- No medications are necessary 1, 2
Athletic Participation
- Full, unrestricted participation in competitive swimming and all sports is appropriate 1, 2
- The swimmer does not require cardiac evaluation beyond standard preparticipation screening unless red flag symptoms are present 4
When to Reconsider the Diagnosis
Obtain further cardiac evaluation if ANY of the following are present 4:
- Pain occurs during or immediately after exertion (not characteristic of PCS)
- Associated syncope or near-syncope
- Family history of sudden cardiac death before age 50
- Pain is prolonged (>15-20 minutes) or radiates to arm, jaw, or back
- Associated palpitations or documented arrhythmias
Important Clinical Pearls
Common pitfall: The case report of elite swimmers with PCS 5 describes episodes requiring "rescue efforts" during competitive meets. This dramatic presentation can mislead clinicians into unnecessary cardiac workup. However, the key distinguishing feature remains that PCS pain is not exertional - it occurred during swimming but was not triggered by the exertion itself 5, 1.
Asthma consideration: One swimmer in the case series had concurrent asthma 5. While this is coincidental rather than causative, ensure the swimmer's asthma is well-controlled for performance and safety reasons, independent of the PCS diagnosis.
Psychological impact: The sudden, severe nature of PCS pain can cause significant anxiety in young athletes and parents 1, 2. Thorough explanation that this is a benign condition affecting otherwise healthy individuals, with no risk of sudden cardiac death or need for activity restriction, is essential 1, 2.
Documentation
Document the characteristic features elicited in history 3, 2:
- Sudden onset, brief duration
- Sharp, localized periapical pain
- Worsened by deep inspiration
- Occurs at rest or minimal activity
- No radiation, no exertional component
- Normal physical examination
This documentation protects against future unnecessary cardiac evaluations and reinforces the benign diagnosis 2.