Bilateral first rib stress fractures in a female swimmer: a case report

Rib Stress Fractures and a Novel Muscle-Sparing Rib Fixation Plating in an Elite Tennis Player: A Systematic Review of the Literature and Case Report

A nationally ranked Division One female collegiate tennis player presented with pain in the chest and right posterior rib region after feeling a popping sensation during a routine overhead movement. The patient was eventually diagnosed with 2 lower rib stress fractures. After unsuccessful conservative management, the player underwent an open reduction and internal fixation and autologous bone grafting of the sixth and seventh ribs with a muscle-sparing approach and was able to return to full competition. We present this case along with a systematic review of the literature regarding rib stress fractures, which included 6 separate online data sources (PubMed, EMBASE, Cochrane, CINAHL, SportDiscus, and Medline). The successful surgical intervention demonstrates a significant option for elite athletes who wish to return to competition but have been unable to with standard of care conservative management of rib stress fractures.

Stress Fractures of the First Rib Related to Soft Tennis, Associated with the Tennis Ground Stroke

Stress fractures of the first rib are uncommon and thought to be associated with overhead-throwing athletes. Soft tennis is similar to regular tennis but uses a much softer rubber ball. In the current report, a 14-year-old girl suffered from shoulder girdle pain, especially at the end of her tennis ground stroke. Plain radiographs showed overgrowth of bone with a fracture line on the first rib, and a diagnosis of stress fracture was made. She was advised to amend her stroke form to reduce force to the shoulder and was able to continue sports activity without pain 10 months after the appearance of her symptoms and before confirmation of bone healing. The current case is not associated with overhead-throwing, but possibly with repetitive exercises of her tennis ground strokes. Conservative medical follow-up with proper sport-specific professional advice allows continuation of the sport.

Ultrasound Identifies First Rib Stress Fractures: A Case Series in National Collegiate Athletic Association Division I Athletes

Isolated first rib stress fractures in athletes are thought to be rare. In this case series, 3 National Collegiate Athletic Association Division I athletes developed isolated first rib stress fractures over the span of 1 year, indicating that these injuries may occur more often than previously understood. These fractures can be easily missed because of the low incidence, lack of clinical suspicion, and vague presentation. Further, radiographs can fail to reveal such fractures. To our knowledge, this is the largest case series of athletes with first rib stress fractures presenting with vague rhomboid interscapular pain. We also demonstrated that ultrasound successfully visualized these injuries; in the hands of an ultrasonographer or clinical provider trained in musculoskeletal ultrasound, this technique offers an advantageous point-of-care screening imaging modality.

Classification of stress fractures of the first rib in adolescent athletes

Stress fractures of the first rib occur infrequently in adolescent athletes; therefore, there have been few case reports. Initial radiographs do not always lead to the diagnosis of first rib stress fractures. This study proposed a classification system and a possible mechanism for stress fractures of the first rib using three-dimensional computed tomography (3D-CT). The data of 10 stress fractures of the first rib in adolescent athletes obtained using 3D-CT between 2007 and 2018 were reviewed. Fractures of the first rib were classified according to the location and type of the fracture line. Stress fractures of the first rib were classified into three types: type 1, center-transverse fracture; type 2, center to posterior-oblique fracture; and type 3, posterior-transverse fracture. There were three type 1 fractures, five type 2 fractures, and two type 3 fractures. The fracture lines of types 1 and 2 were on the deep groove of the subclavian artery between the anterior and middle scalene muscle attachments, which is the thinnest and weakest portion of the first rib. However, the fracture line of type 3 was across the posterior part of the first rib and located slightly away from the deep groove of the subclavian artery. A 3D-CT classification of stress fractures of the first rib in adolescent athletes was proposed. Our results suggested that there are three types of the fracture and different mechanisms that cause this type of injury. This classification system helped to implement adequate conservative therapeutic plans based on the proposed mechanism.

First-Rib Stress Fracture in Overhead Throwing Athletes

BACKGROUND

First-rib stress fracture is considered a potential cause of nonspecific atraumatic chronic shoulder pain in adolescent athletes. However, the etiology in throwing athletes with first-rib fracture is still unknown. The purpose of this retrospective study was to investigate the characteristic clinical features and radiographic findings of overhead throwing athletes with first-rib fracture.

METHODS

Twenty-four first-rib stress fractures in 23 players were studied retrospectively. Clinical features, including age, initial symptom, sports, pain-related activity, diagnostic method, treatment method, and final follow-up, were reviewed.

RESULTS

The following characteristic clinical features were identified: mean age of 16.8 years (range, 13 to 25 years), 19 dominant arm injuries and 5 non-dominant arm injuries, and an acute increase in pain while swinging the bat or pitching the ball. Sixteen fractures presented with posterior shoulder or upper thoracic back pain. At a mean time of 7.5 months after the initiation of conservative treatment, 17 healing fractures (71%) and 7 nonunion fractures (29%) among throwing athletes with first-rib stress fracture were identified. On image analysis, first-rib stress fractures were classified into 3 types depending on the direction and location of fracture lines: groove, intrascalene, and posterior types. Three symptomatic patients underwent first-rib resection due to thoracic outlet syndrome. On average, 46% of the first rib was visible on the shoulder radiographs and 97% was visible on the cervical spine radiographs. The Cohen kappa coefficient for the above percentages was 0.87 and the percent agreement was 89.4% for the shoulder, and the Cohen kappa coefficient was 0.80 and the percent agreement was 99.0% for the cervical spine.

CONCLUSIONS

First-rib stress fracture should be considered when adolescent overhead throwing athletes have acute-onset posterior shoulder pain while swinging the bat or pitching the ball. Anteroposterior radiography of the cervical spine is available for initial diagnosis. Although 71% of the patients healed at a mean follow-up of 7.5 months with conservative treatment, some patients may have symptoms consistent with thoracic outlet syndrome.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Stress Fractures of the First Rib Related to Swinging of a Baseball Bat: Two Case Reports

Stress fractures of the first rib are uncommon, and few reports have described the occurrence of this injury in overhead-throwing athletes. Furthermore, although there have been a few reports of first rib stress fractures on the throwing side in baseball players, fractures on the nonthrowing side are very rare. Here, we report 2 cases of first rib stress fractures on the nonthrowing side related to swinging of a baseball bat. The cause of the fractures in the present cases may have been repetitive traction and shear force on the first rib resulting from muscle exertion while swinging a bat. Conservative treatment that considered the mechanism of stress fractures resulted in a symptom-free and complication-free return to baseball. The patient's background should be considered for an accurate understanding of the injury mechanism, adequate conservative therapeutic plan, and a successful return to baseball.

Rib Stress Fracture in a Collegiate Softball Pitcher: A Case Report

CASE

We present the case of a twenty-one-year-old right-hand-throwing, right-hand-batting female softball pitcher who presented with a three-month history of right rib pain. A bone scan showed increased uptake in the lateral aspect of the right seventh rib, consistent with a stress fracture. The patient was managed nonoperatively and made a full recovery.

CONCLUSION

The forces created by the attachment of the serratus anterior during underhand throwing are the likely etiology of the injury in our patient. Physicians should maintain a high clinical index of suspicion for stress fracture in underhand athletes with lateral rib pain.

First-rib stress fracture in two adolescent swimmers: a case report

First-rib stress fractures have been described in adolescent athletes in various sports, with only one prior case report of first-rib stress fractures in an adolescent female swimmer. There is a need for research on the cause, management, and prevention of these injuries as they lead to significant morbidity and critical time away from sport for these aspiring athletes. We aimed to describe first-rib stress fractures as a potential cause for non-specific atraumatic chronic shoulder pain in adolescent swimmers and to discuss the different presentations, unique risk factors, treatment, and potential injury prevention strategies of such fractures. We discussed two such cases which were successfully treated with activity modification with restriction of all overhead activity, gradually progressive physical therapy and a return to swimming protocol. First-rib stress fractures can vary in presentation and should be in the differential diagnosis in adolescent swimmers with chronic shoulder pain. These injuries can be successfully managed with rest from overhead activities and physical therapy. Gradual return to competitive swimming can be achieved even with non-union of a first-rib stress fracture. Emphasis on balanced strength training in different muscle groups and proper swimming technique is essential to prevent these injuries.

Stress injury of the rib in a swimmer

Rib stress injuries are uncommonly reported but have been documented among athletes, most notably rowers. There have only been two prior case reports of rib stress injuries in swimmers, both of which were young females. Magnetic resonance (MR) imaging was either not obtained or the imaging characteristics were incompletely described. We present a case of an isolated third rib stress injury in a collegiate male swimmer diagnosed via MR imaging. We briefly discuss the possible etiologies for rib stress injuries, their MR appearance, as well as their treatment.

Stress fractures of the ribs and upper extremities: causation, evaluation, and management

Stress fractures are common troublesome injuries in athletes and non-athletes. Historically, stress fractures have been thought to predominate in the lower extremities secondary to the repetitive stresses of impact loading. Stress injuries of the ribs and upper extremities are much less common and often unrecognized. Consequently, these injuries are often omitted from the differential diagnosis of rib or upper extremity pain. Given the infrequency of this diagnosis, few case reports or case series have reported on their precipitating activities and common locations. Appropriate evaluation for these injuries requires a thorough history and physical examination. Radiographs may be negative early, requiring bone scintigraphy or MRI to confirm the diagnosis. Nonoperative and operative treatment recommendations are made based on location, injury classification, and causative activity. An understanding of the most common locations of upper extremity stress fractures and their associated causative activities is essential for prompt diagnosis and optimal treatment.