A CLINICAL GUIDE TO PATHOPHYSIOLOGY, DIAGNOSIS & MANAGEMENT

– Written by Tristan Shipsides, Australia and Liz Arnold, UK

INTRODUCTION

Rib stress injury (RSI) is an umbrella term encompassing the continuum of rib overuse injuries, ranging from a stress reaction to a complete stress fracture¹. RSI are typically seen in athletic populations in sports with high strain magnitudes and rapid loading rates, or high load repetitions through the thorax. Commonly affected sports include baseball^2-4, tennis^5,6 canoeing^7,8 and golf^9,10. 

The mostly commonly cited sport for RSI is rowing¹¹, where they are known to be a leading cause of time-loss from training and competition in elite rowers¹². This high incidence reflects the unique biomechanical and physiological, demands placed upon rowers.  Rowing is a strength-endurance sport which utilises almost all muscles in the body to propel a boat through the water¹³.  Due to the significant physiological requirements, elite rowers typically complete between 11-16 training sessions per week^14,15 subjecting the thorax to significant repetitive loading.

The training time loss associated with the spectrum of these injuries is substantial.  Return to Sport timelines for RSI’s range between 3-8 weeks^16,17, but more recent epidemiological data shows it can take even longer¹⁸. The time loss for rib fractures tends to be significantly longer than a stress reaction. However, both present a burden to athletes, coaches and medical teams. Early rower presentation and diagnosis are therefore vital to minimise this training availability loss.

The aim of this article is to provide clinicians and athlete support personnel with some useful tools to support the assessment and rehabilitation of this niche injury.

PATHOPHYSIOLOGY & BIOMECHANICAL AETIOLOGY

Rowing is a cyclical repetition of strokes. Each stroke is split into 4 phases: the catch, drive, finish, and recovery. At the catch, the rower is compressed forward with the oar in the water. The drive is a triple extension pattern which begins with a powerful leg push, followed by body swing and arm pull. At the finish, legs are straight, the body leans back slightly, and the oar is drawn to the chest. Recovery involves reversing the sequence; the arms extend, the body pivots forward, and knees bend, returning the rower to the catch. Forces are therefore transmitted to the oar, through the rower, via a footplate, to propel the boat forwards. This cyclical motion requires timing, strength, and fluidity to maximize boat speed and efficiency.

The thorax and thus the chest wall and ribs are a critical junction between effective load transmission from the footplate to the oar handle. Upwards of 400N of force are transmitted through the chest wall every stroke¹⁹ and this is repeated over 2000 times a session. Specifically, bone stress occurs in the rib cage from focal failure of bone tissue to this repeated mechanical loading that results in localized pain and/or an increased risk of complete bone fracture to typically tolerable loads²⁰.

There are 3 proposed models for how this mechanical overload occurs in rowing:    

1. A tensile mechanism, due to opposing forces induced by Serratus Anterior and the External Oblique muscles at the end of the drive phase²¹.  (see Figure 1a)
2. Compression of the chest wall at the end of the drive phase when there is a forceful eccentric abdominal contraction coupled with forced expiration²².
3. A secondary compressive mechanism whereby the combined forces of Latissimus Dorsi and shoulder retractors, opposing the protraction moment generated by forces transmitted to the oar handle, may compress the chest wall²³. (See Figure 1b)    

RISK FACTORS FOR RSI

Understanding the aetiology of RSI requires an examination of all the potential risk factors which are presented in Table 1. Tables 2 and 3 propose examples of assessment tools and mitigation strategies that could be employed, engaging the full multidisciplinary team to manage future risk.

CLINICAL ASSESSMENT & DIAGNOSIS

The clinical presentation of rowers with RSI can vary from localised tenderness to diffuse, poorly defined chest wall pain or stiffness. The location of symptoms typically occur anterolaterally between ribs 5-9, although they may also present posteriorly. A battery of subjective and objective tests should be employed to assist your diagnosis (see Table 4), alongside evaluation of risk factors which may have contributed to increased risk of RSI and/or influence optimal healing. Differential diagnoses for RSI are presented in Table 5. 

Unpublished data based on work within one national rowing federation²⁵, suggest that ongoing positive clinical findings, subjective and/or objective findings, after several days of unloading the chest wall strengthen the clinical likelihood of RSI.  These tests appear more accurate for identifying anterior lateral chest wall bony injury rather than posterior rib injury which may often be more vague in presentation.   The prognosis of simple mechanical RSI is such that imaging is often not required as management can often be appropriately guided by clinical assessment alone.

As outlined in Table 1, questions addressing recovery, sleep quality and duration, gut health, recent weight loss, and in females, menstrual health should be included to explore factors which may identify compromised bone health and/or inadequate energy availability as contributing factors. There are useful validated tools available such as LEAF-Q and LEAM-Q and the RED-S CAT2 to support the assessment of low energy availability^26,27.

DIAGNOSTIC IMAGING

There are several modalities that may be employed when investigating RSI.  Ultrasound has been shown to be a promising, accessible and cost-effective tool²⁸, but does require a high level of operator skill.  CT provides excellent detail of cortical bone, which is valuable for identifying periosteal reactions and cortical breach, however this is not recommended for routine diagnosis due to high ionising radiation dose.   MRI is the gold standard for diagnosis due to its superior sensitivity and visualisation of soft tissue and bone without the risk of radiation exposure^29,30. We would however exercise caution with imaging too early. Image findings can lag behind the clinical picture. Suspicion of RSI on initial assessment must be tempered by a clinical observation window prior to imaging to ensure the risk of a false negative is minimised³¹.

It is interesting to note that clinical presentation of pain may not always correlate to the rib injury location on imaging. This is most likely due to the complex innervation of the thoracic spine, ribs and surrounding musculature.

REHABILITATION & RETURN TO SPORT

Initial Management (Range 0-3 weeks)

Initial management of RSI includes relative rest via ‘off-loading’ the chest wall until clinical signs and symptoms abate.  Previous research has advocated that the athlete must be pain free³², however more recent work by Warden et al³³ suggests that it is acceptable to reload the rib before the athlete is completely symptom free. Early reintroduction of a mechanical stimulus aids bone repair and remodelling³⁴. A visual analogue scale for pain (VAS) guide of 1-2/10 is deemed acceptable, providing an initial period of de-loading has occurred.

On initial presentation, even if suspicion of RSI is low, it is recommended that you remove the athlete from all activities that load the chest wall (e.g. rowing, rowing ergometer (ergo) or specific strength and conditioning activities). This early chest wall de-load will likely reduce the injury severity and often aids differential-diagnosis, as many other causes of musculoskeletal, non-bony, chest wall symptoms resolve or significantly improve during this time.

From early on, consideration should be given to addressing all potential contributing factors. Preinjury thoracic mobility and normal movement patterns must be re-established.  Rowers require a large amount of hip flexion range and hamstring flexibility to place their lumbar spine into an optimal rowing position³⁵. These areas must be targeted and/or maintained, particularly with the extended time cross training and out of the boat. This will not only reduce the risk of low back pain³⁵, but inability to achieve these ranges and positions may result in increased loading on the chest wall.

A review by a dietician or sport nutritionist is invaluable. If low energy availability is identified, then sufficient energy intake can be addressed. This supports bone remodelling alongside guidance on other nutritional factors which can contribute to bone health such as calcium and vitamin D²⁸. Dual-Energy X-ray Absorptiometry (DEXA) scanning and Resting Metabolic Rate (RMR) are useful objective measures to track changes in this area³⁶.

Pharmacological support through the use of analgesia can assist pain reduction, but caution should be exercised with the use of non-steroidal anti-inflammatory drugs during this early phase as this may interfere with bone remodelling³⁷. Vitamin D supplementation may also be beneficial at this stage²⁸. The use of parathyroid hormone in stress fractures, due to its osteoanabolic effects is gaining interest.  Currently however there is insufficient evidence to support its use³⁸. and further investigation is warranted.

In clinical practice, Low Intensity Pulsed Ultrasound (LIPUS) has previously been suggested as a treatment adjunct, due to its proposed effect on bone stimulation, however, Hoenig et al’s²⁹, recent Delphi study showed poor consensus for this modality in the management of bone stress injuries.

Maintenance of cardiovascular fitness may be achieved through non-impact cross-training modalities, such as static bike, providing it is pain free and clinically there is no pain or restriction on deep inspiration. In more complex cases of RSI where REDs is a contributing factor, it is important to consider appropriate training requirements to ensure adequate energy availability.

Due to the direct and indirect attachments of the shoulder girdle musculature, upper body weights should be stopped, as should high load trunk exercises. Low level, body weight trunk loading or motor control exercises may be reintroduced providing they do not increase pain levels during or after the session. Lower limb conditioning may be continued throughout the rehabilitation process. Blood flow restriction may assist lower limb maintenance in absence of axial compressive loads through the trunk.

Return to Rowing (2 weeks +)

As discussed above, return to rowing may commence once clinical symptoms (described in Table 4) are less than 2/10 VAS.  For stress reactions with no complicating factors such as REDs, this can be around 2 weeks. Fractures will be longer.

Initial reloading can commence in the gym before progressing onto the ergo. Trunk activation and endurance training should start with isometric loading, then progressing to isotonic training.  Lower limb strength and power can be progressed, initially avoiding compounds lifts such as deadlift or back squat. 

Rowing on the ergo should be observed by the coach and physiotherapist to ensure correct patterning and technique is employed by the rower. Current, or recent biomechanical contributing factors for RSI that have been identified should be targeted and addressed. The benefits of initiating reloading on the ergo are that it removes environmental factors such as wind conditions and river flow.  It also does not impact other rowers’ ability to train, as much on water rowing is carried out in crew boats.

There are no internationally agreed guidelines on what the outline of a return to rowing plan should be. However, Schwanz et al³⁰ recently provided detailed recommendations, initially focusing on short periods (distance or time as per practitioner preference), gradually increasing duration and frequency of days rowed as capacity increases. It is helpful to consider the drag factor when using the ergo, to titrate the loading the rower is exposed to. Once the rower is able to complete 45-60 minutes (approximately 12km) in a session, without pain VAS close to zero during or the day after, then they can return to on water training.      

Training progression is then predominantly completed on water rather than on the ergo to begin to build towards a typical training program. Duration, intensity, rate and rest must be considered here and a balance achieved between them. It is important not to sustain high volumes of training on the ergo as this is known to be associated with other injuries³⁵.

Any identified factors related to technique, that have been worked on whilst on the ergo, should be continued when the rower returns on water and into crew boats.

Strength and conditioning should be an ongoing critical part of the rehab process, building back to pre-injury workloads. Axial loading and trunk peak power can now be reintroduced. 

In exceptional circumstances and in an enhanced care setting, it is possible to accelerate return to rowing times, for example coming into a World Championships or Olympic Games. However, caution must exercised here, with consideration given to the rower’s longer-term health and the performance costs associated with this approach.  It is unlikely the rower will be pain free, and as such they will require close clinical observation and monitoring to ensure there is no deterioration in their presentation or in their ability to produce power in the boat.  In the rare cases where this does happen, the rower usually requires an extended rehab period following the competition. This approach is not recommended in sub-elite or underage rowers. It is important to remember as with many injuries, the biggest risk for injury is history of injury³⁹. Time should therefore ideally be taken to identify and mitigate risk factors while supporting the development of healthy rowers with positive and long-lasting training behaviours. 

Return to Performance (Range 3-8 weeks)

Due to the non-chaotic nature of rowing, the reintroduction of sports specific loading occurs early in the rehabilitation process.  Once the rower has accumulated rowing training volume and is deemed to be completing training at or above their pre-injury levels, they are considered fit to compete. As reported in the literature this can take up to 90 days¹⁸. Rower’s with identified low energy availability or RED’s, should be regularly monitored to ensure they are fuelling sufficiently for their training requirements

CONCLUSION & FUTURE DIRECTIONS

Management of RSI should be a collaborative approach including all facets of the multidisciplinary team.  Early presentation by the rower and thorough assessment of all risk factors by the practitioner should be the mainstay of assessment. Early offload will guide the practitioner to presence of bony injury verses other causes of chest wall pain and thus minimise time loss. 

Evidence around the assessment and management is still predominantly in the expert opinion domain.  There have been multiple calls for the pressing need for high quality research to inform effective prevention and management strategies⁴⁰. The authors second this and suggest that consensus be gained on the optimal management of this niche but challenging injuries

Tristan Shipsides

Senior Physiotherapist

Rowing Australia

Liz Arnold PhD

Athlete Health MSK Lead

Senior Physiotherapist

British Rowing

Contacts:

tshipsides@rowingaustralia.com.au

liz.arnold@uksportsinstitute.co.uk

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Header Image by Huard (Cropped)