Injuries to elite rowers over a 10-yr period

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.

The Rowing Spine: A Review of Biomechanics, Injury, and Treatment

OBJECTIVE

We aimed to describe spinal biomechanics and injury patterns in rowing.

METHODS

In this systematic literature review, a Google and PubMed literature search was undertaken using keywords "rowing," "biomechanics," and "spine."

RESULTS

Relevant articles were reviewed and synthesized to describe biomechanics, injury patterns, treatment options, and techniques for injury prevention.

CONCLUSIONS

Rowing has increased in popularity throughout the United States. Up-to-date knowledge of rowing biomechanics and spinal injury patterns is necessary for prompt diagnosis and appropriate treatment of the injured rowing athlete.

The acute effects of kinesio-taping on movement kinematics and muscle co-activation in rowing athletes

BACKGROUND

Rowing-related low back disorders may occur from inconsistent technique, high trunk flexion and training volumes, overactivation of paraspinal muscles, and fatigue.

OBJECTIVE

To examine if kinesiology tape (KT) affixed to the trunk dorsum affects muscular co-activation and neuromuscular control to limit dangerous rowing movements and associated injuries.

METHODS

Participants (n= 18) completed two 2000 m rowing trials under BASELINE and KT conditions. KT was applied to the skin superficial to the paraspinals bilaterally with 60% pre-strain. Participants were instructed to minimize any sensation of tension. Whole body kinematics were obtained using inertial measurement units (IMUs), and surface electromyograms (EMGs) were recorded from trunk and lower extremity. Changes in joint range-of-motion (ROM) and co-activation indices (CAIs) were analyzed for shoulder, lumbar, hip, and knee.

RESULTS

Responding participants (n= 5) were identified by reduced maximum lumbar flexion during the KT condition. As expected, significant differences occurred in maximum and minimum lumbar flexion/extension between responders and non-responders to KT. Additionally, there was significant reduction in mean trunk muscle co-activation in both those who did and did not respond to KT through reductions in maximum lumbar flexion.

CONCLUSION

KT can be an effective at reducing mean trunk co-activation during a rowing trial in the flexed catch position. Variable responses suggest that further work is necessary to optimize the efficacy of sensory cues derived from KT during rowing movements.

Effects of rowing stroke rates on lower extremity intra-joint coordination variability in experienced young rowers

The purpose of this study was to examine the effects of rowing stroke rates on lower extremity intra-joint coordination variability in professional rowers. Fifteen experienced young rowers volunteered to participate in this study. Kinematic data were recorded at different rowing speeds with seven Vicon cameras. The continuous relative phase (CRP) and CRP variability (CRPV) were used to calculate joint coordination and coordination variability, respectively, for the hip, knee, and ankle in the sagittal and horizontal planes, and a comparison was made among different rowing stroke rates. A vector analysis repeated measure ANOVA using statistical parametric mapping revealed that there were statistically significant differences in the hip-ankle, hip-knee, and knee-ankle CRPs for rowing at different stroke rates. Moreover, there was higher CRPV in the mid-drive and mid-recovery phases and less variability in the transition from the drive phase to the recovery phase. The results demonstrate the importance of knee joint in rowing tasks in experienced rowers during submaximal rowing stroke rate and the shift of movement to the hip at higher rowing stroke rate. Moreover, there was a smaller variability during drive-to-recovery transition, which may suggests an increased risk for overuse injuries.

Examining the Peer-Reviewed Published Literature Regarding Low Back Pain in Rowing: A Scoping Review

Background

Low back pain (LBP) is highly prevalent in the rowing population. The body of existing research variously investigates risk factors, prevention, and treatment methods.

Purpose

The purpose of this scoping review was to explore the breadth and depth of the LBP literature in rowing and to identify areas for future research.

Study Design

Scoping review.

Methods

PubMed, Ebsco and ScienceDirect were searched from inception to November 1, 2020. Only published, peer-reviewed, primary, and secondary data pertaining to LBP in rowing were included for this study. Arksey and O'Malley's framework for guided data synthesis was used. Reporting quality of a subsection of the data was assessed using the STROBE tool.

Results

Following the removal of duplicates and abstract screening, a set of 78 studies were included and divided into the following categories: epidemiology, biomechanics, biopsychosocial, and miscellaneous. The incidence and prevalence of LBP in rowers were well mapped. The biomechanical literature covered a wide range of investigations with limited cohesion. Significant risk factors for LBP in rowers included back pain history and prolonged ergometer use.

Conclusion

A lack of consistent definitions within the studies caused fragmentation of the literature. There was good evidence for prolonged ergometer use and history of LBP to constitute risk factors and this may assist future LBP preventative action. Methodological issues such as small sample size and barriers to injury reporting increased heterogeneity and decreased data quality. Further exploration is required to determine the mechanism of LBP in rowers through research with larger samples.

Rib Fractures in Professional Baseball Pitchers: Mechanics, Epidemiology, and Management

Pitching is a complex kinetic chain activity requiring the transfer of energy from the lower body, through the core and trunk, and finally through the arm to generate explosive acceleration of the baseball. As a result, large forces are generated in the trunk musculature and rib attachments from the late cocking phase of pitching through deceleration. The repetitive cumulative load and high pitch velocities put professional pitchers at risk of rib stress fracture. Given the potential for a prolonged recovery course and high rate of recurrence, early recognition of rib bone stress injury is critical to optimize care. Identifying torso strength imbalances, suboptimal pitching biomechanics (such as late or inadequate pelvic rotation), as well as metabolic deficiencies that may adversely affect bone health are essential to expedite safe return to play and prevent future injury. In this review, we discuss risk factors, mechanism of injury, typical clinical presentation, diagnostic imaging findings, and propose treatment and prevention strategies for rib stress fractures in overhand pitchers.

Update on injury epidemiology in rowing: our experience with female NCAA Division I athletes and a systematic review of the literature

OBJECTIVES

(1) To report the distribution of injuries per body site and time lost from participation in female NCAA Division I rowers and (2) to present an updated summary of the existing evidence regarding the analysis of injuries per body site in rowers.

METHODS

Case series: The distribution of injuries per body site in female NCAA Division I rowers and the time lost from participation were retrieved from an institutional registry. Injuries per body site were reported as number of athletes with site-specific injury per total number of injured athletes. Systematic review: Based on the PRISMA guidelines for systematic reviews, three electronic databases were searched for studies reporting the epidemiology of injuries per body site in rowers and analyzed.

RESULTS

Case series: One-hundred and thirty-seven injuries were recorded in 92 female rowers over 5 years. The risk of injury (number of injured athletes over total number of athletes on roaster) was 52% (92/176). Among the 92 injured athletes, 38% sustained injury to the lower back, while 23% and 16% of these athletes sustained injury to the ribs and hip-groin area, respectively. Systematic review: Ten studies were included. The level of evidence was IV and the mean MINORS score was 13.2(9-15) (fair quality). Most studies reported injuries to the lower spine (8/10,80%) whereas injuries to the ribs or other anatomic sites were reported in ≤4 (40%) studies. Significant heterogeneity of the injury reporting methodologies (injury definition; measures of injury occurrence; description of the injury site) was detected and precluded meta-analysis.

CONCLUSIONS

Most injuries recorded in a single team of female NCAA Division I athletes occurred in the lower back followed by injuries to the ribs and the hip. The existing injury epidemiology literature in mostly focuses on injuries to the lower back, while injuries to other anatomic sites were less frequently analyzed. No conclusions can be made regarding the most common injuries in rowers based on the current evidence due to substantial heterogeneity of injury reported methodologies which warrants further investigation.

Spinal and Pelvic Kinematics During Prolonged Rowing on an Ergometer vs. Indoor Tank Rowing

ABSTRACT

Trompeter, K, Weerts, J, Fett, D, Firouzabadi, A, Heinrich, K, Schmidt, H, Brüggemann, GP, and Platen, P. Spinal and pelvic kinematics during prolonged rowing on an ergometer vs. indoor tank rowing. J Strength Cond Res 35(9): 2622-2628, 2021-This investigation aimed to compare spinopelvic kinematics during rowing on an ergometer vs. in a rowing tank and to evaluate changes with progressing fatigue. Spinal and pelvic kinematics of 8 competitive scull rowers (19.0 ± 2.1 years, 179.9 ± 7.6 cm, and 74.8 ± 8.1 kg) were collected during 1 hour of rowing on an ergometer and in a rowing tank using a routine training protocol. Kinematics of the upper thoracic spine, lower thoracic spine, lumbar spine, and pelvis were determined using an infrared camera system (Vicon, Oxford, United Kingdom). There was a greater lumbar range of motion (ROM) and less posterior pelvic tilt at the catch during rowing on the ergometer compared with in the rowing tank (p = 0.001-0.048), but no differences in pelvic ROM. In the rowing tank, the pelvic ROM increased over time (p = 0.002) and the ROM of the lower thoracic spine decreased (p = 0.002). In addition, there was an extended drive phase (when the rower applies pressure to the oar levering the boat forward) and an abbreviated recovery phase (setting up the rower's body for the next stroke) in the rowing tank (p = 0.032). Different rowing training methods lead to differences in spinopelvic kinematics, which may lead to substantially different spinal loading situations. Greater pelvic rotation and lesser lumbar ROM are considered ideal; therefore, the present results indicate that rowing in the rowing tank might facilitate the maintenance of this targeted spinopelvic posture, which might help protect the lower back. Rowers, coaches, and researchers should consider the differences between rowing training methods, especially when giving training recommendations.

Injuries in female and male elite Korean rowing athletes: an epidemiological study

This study aimed to determine the patterns of injury associated with training activities in elite South Korean rowing athletes training for the Olympic Games. Data were prospectively collected between 2010 and 2019 at the Korea National Training Center in South Korea. Three sports medicine doctors assessed athletes, and the data were stratified according to sex, rowing style, weight class, site of injury, and severity of injury. The groups were compared using the c 2 test. The 95 % confidence interval with Poisson rates and exact Poisson test were used for comparison of rates. In total 514 injuries were recorded during the study period, with an average of 2.86 injuries per athlete annually; among these, over half (57.8 %) were mild injuries. Most injuries occurred in the lower extremities (42.0 %), followed by the trunk (30.2 %), the upper extremities (24.9 %), and the head and neck area (2.9 %). Weight class was significantly associated with severity of injury in all rowing athletes (p < 0.001), for both male and female rowing athletes (p = 0.006 and p = 0.014, respectively). Lightweight male athletes demonstrated higher incidence rate of injury than open-weight male athletes (p < 0.001). On the contrary, lightweight female athletes demonstrated lower incidence rates of injury than open-weight female athletes (p < 0.001). These findings on the incidence of training injuries and patterns based on rowing styles, sexes, and weight classes may elucidate the circumstances leading to injuries in elite Korean rowing athletes. Furthermore, these findings may contribute to the development of programs to enhance athletic performance and reduce the incidence of sports injuries.

Prevalence and risk factors for back pain in sports: a systematic review with meta-analysis

OBJECTIVES

We aimed to determine the prevalence of low back pain (LBP) in sport, and what risk factors were associated with LBP in athletes.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Literature searches from database inception to June 2019 in Medline, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus, supplemented by grey literature searching.

ELIGIBILITY CRITERIA

Studies evaluating prevalence of LBP in adult athletes across all sports.

RESULTS

Eighty-six studies were included (30 732, range 20-5958, participants), of which 45 were of 'high' quality. Definitions of LBP varied widely, and in 17 studies, no definition was provided. High-quality studies were pooled and the mean point prevalence across six studies was 42%; range 18%-80% (95% CI 27% to 58%, I2=97%). Lifetime prevalence across 13 studies was 63%; range 36%-88% (95% CI 51% to 74%, I2=99%). Twelve-month LBP prevalence from 22 studies was 51%; range 12%-94% (95% CI 41% to 61%, I2=98%). Comparison across sports was limited by participant numbers, study quality and methodologies, and varying LBP definitions. Risk factors for LBP included history of a previous episode with a pooled OR of 3.5; range 1.6-4.0 (95% CI 1.9 to 6.4). Statistically significant associations were reported for high training volume, periods of load increase and years of exposure to the sport.

CONCLUSION

LBP in sport is common but estimates vary. Current evidence is insufficient to identify which sports are at highest risk. A previous episode of LBP, high training volume, periods of load increase and years of exposure are common risk factors.

Epidemiology of injury and illness in 153 Australian international-level rowers over eight international seasons

Aim

To report the epidemiology of injury and illness in elite rowers over eight seasons (two Olympiads).

Methods

All athletes selected to the Australian Rowing Team between 2009 and 2016 were monitored prospectively under surveillance for injury and illness. The incidence and burden of injury and illness were calculated per 1000 athlete days (ADs). The body area, mechanism and type of all injuries were recorded and followed until the resumption of full training. We used interrupted time series analyses to examine the association between fixed and dynamic ergometer testing on rowers’ injury rates. Time lost from illness was also recorded.

Results

All 153 rowers selected over eight seasons were observed for 48 611 AD. 270 injuries occurred with an incidence of 4.1–6.4 injuries per 1000 AD. Training days lost totalled 4522 (9.2% AD). The most frequent area injured was the lumbar region (84 cases, 1.7% AD) but the greatest burden was from chest wall injuries (64 cases, 2.6% AD.) Overuse injuries (n=224, 83%) were more frequent than acute injuries (n=42, 15%). The most common activity at the time of injury was on-water rowing training (n=191, 68). Female rowers were at 1.4 times the relative risk of chest wall injuries than male rowers; they had half the relative risk of lumbar injuries of male rowers. The implementation of a dynamic ergometers testing policy (Concept II on sliders) was positively associated with a lower incidence and burden of low back injury compared with fixed ergometers (Concept II). Illness accounted for the greatest number of case presentations (128, 32.2% cases, 1.2% AD).

Conclusions

Chest wall and lumbar injuries caused training time loss. Policy decisions regarding ergometer testing modality were associated with lumbar injury rates. As in many sports, illness burden has been under-recognised in elite Australian rowers.

Rowing Injuries in Elite Athletes: A Review of Incidence with Risk Factors and the Role of Biomechanics in Its Management

BACKGROUND

Rowing is an Olympic sport gaining popularity in India and injuries are common in these athletes. Determinants of performance, injury risk and training are all interrelated in rowing. Injuries result from various risk factors including fitness issues and improper techniques. Rowers should have adequate leg extension strength and lumbo-pelvic coordination to produce and transmit power from the legs to the oar handle. Biomechanical analysis of the rowing stroke can help in preventing injuries and optimise technique for best performance. It involves a detailed and systematic observation of movement patterns to establish the quality of the movement and provide feedback to the rower about the key variables affecting performance and injury risk. Kinetics such as foot forces and kinematics such as key joint angles can be accurately measured by instrumented foot stretcher and three-dimensional motion capture.

AIM

To do a detailed review of literature regarding the incidence and risk factors for rowing injuries and to get an insight on the role of biomechanics in its management.

MATERIALS AND METHODS

Literature review was carried out with standard academic search engines and databases including Science Direct, PubMed and Google Scholar using keywords of relevance. A total number of 38 articles were analysed and results were collated to compile this review report.

RESULTS

Lumbar spine is most commonly injured (up to 53%), followed by rib cage (9-10%) and shoulder and other anatomical areas. Rowers with a trunk-driven rowing action will have a lower hip:trunk score and carry a high injury risk. A player with lumbar injury will take a minimum of 3-4 months to recover.

CONCLUSION

Rowing injuries are common. Regular screening of the rowing athletes by comprehensive fitness and biomechanics assessment will help in prevention of injuries. Rowers need to be tested for pain, strength, flexibility, reproducibility of rowing action with modified mechanics, coordination, fatigue level, explosive power, aerobic and anaerobic endurance. Early recognition of risk factors and timely intervention is the key aspect of a successful return to play.

Rib stress injuries in the 2012–2016 (Rio) Olympiad: a cohort study of 151 Australian Rowing Team athletes for 88 773 athlete days

Aim

To describe the demographics, frequency, location, imaging modality and clinician-identified factors of rib stress injury in a cohort of elite rowers over the Rio Olympiad (2012–2016).

Methods

Analysis of prospectively recorded medical records for the Australian Rowing Team in 2013–2015 and the combined Australian Rowing Team and Olympic Shadow Squad in 2016, examining all rib stress injuries.

Results

19 rib stress injuries (12 reactions and 7 fractures) were identified among a cohort of 151 athletes and included 12 female and 7 male cases, 11 open weight, 8 lightweight, 12 scull and 7 sweep cases. The most common locations of injury identified by imaging, were the mid-axillary line and rib 6. Period prevalence varied from 4% to 15.4% and incidence ranged from 0.27 to 0.13 per 1000 athlete days. There were no significant differences in prevalence by sex, sweep versus scull or weight class. There was a statistically significant increase in incidence in the pre-Olympic year (2015, p<0.001). MRI was the most commonly used modality for diagnosis. Stress fracture resulted in median 69 (IQR 56–157) and bone stress reaction resulted in 57 (IQR 45–78) days lost to full on water training.

Conclusions

In our 4-year report of rib stress injury in elite rowing athletes, period prevalence was consistent with previous reports and time lost (median ~10 weeks) was greater than previously published literature. Rib stress injury limits training and performance in elite rowers and MRI should be considered as a first line investigation.

The epidemiology of injuries in adult amateur rowers: A cross-sectional study

OBJECTIVES

To investigate the prevalence, nature and factors associated with injury among adult amateur rowers.

DESIGN

Retrospective cross-sectional study.

SETTING

UK-based amateur rowing clubs.

PARTICIPANTS

160 amateur rowers.

MAIN OUTCOME MEASURES

Frequency, type, location, severity and rowing-related factors associated with injury.

RESULTS

Injury rate was 5.7 per 1000 sessions, with no effect of sex (χ² = 0.195, P = 0.659) or weight class (χ² = 0.800, P = 0.371). The lower-back demonstrated an epidemiological incidence proportion (IP) of 0.39 (95%CI = 0.33 to 0.46). The IP for water- and land-based training was 0.39 (95%CI = 0.31 to 0.47) and 0.57 (95%CI = 0.49 to 0.65), respectively. IP was highest between January and March (0.13-0.15), whilst time loss was 0.49 (95%CI = 0.42-0.57). The IP for 'overuse' and 'traumatic' injuries was 0.71 (95%CI = 0.65 to 0.78) and 0.22 (95%CI = 0.16 to 0.27), respectively. Training volume was positively associated with injury rate (r = 0.418, P < 0.001).

CONCLUSIONS

Injury rates appear higher among amateur rowers with the most common injury site being the lower-back. Our results suggest several contextual factors influence injury risk including seasonal phase, training type and training volume.

Intersection syndrome: an acute surgical disease in elite rowers

Objective

Intersection syndrome is a relatively common condition in elite rowers and continuing conjecture over its pathology and best management often includes prolonged withdrawal from training and changes to the technique that may affect rowing outcomes.

Methods

We reviewed a case series in a national rowing squad and the effect on time loss produced by the condition. We reviewed the pathophysiology. We revisited the aggressive operative management put forward in the 1960s and applied it to modern rowing workload by reviewing a retrospective case series of six international rowers who had early surgical intervention.

Results

Approximately 5% of the squad suffered intersection syndrome during a 3-year period. The effect on training time was between 20% and 40% of their training time in the period. Using our understanding of the pathology as a true tendinitis of the second wrist compartment caused by fascial compression from hypertrophied first compartment muscles, we advocated earlier surgery and almost immediate return to training, which occurred at a median of 7 days postsurgery. We had successful return in five of six rowers in an accelerated programme to minimise muscle wasting and technique modification caused by the condition, achieving career goals in a matter of weeks after surgical intervention.

Conclusions

We encourage early surgical management of intersection syndrome of the wrist to allow almost immediate return to training, and therefore interfere less with technique modification and time out of the water. This minimises career disruption in the elite rowing community.

Sport injuries in international masters rowers: a cross-sectional study

Methods

A cross-sectional study was conducted among 743 masters rowers who participated in the 34th International Federation of Rowing Associations (Fédération Internationale des Sociétés d’Aviron, FISA) World Rowing Masters Regatta held in Zagreb, September 2-9, 2007. A rowing-specific questionnaire was used, followed by an interview about the injuries sustained during the 12-month period before the competition.

Results

The mean injury rate per year was 0.48 injuries/masters rower (2.25 injuries/1000 training sessions/rower). The majority of injuries were chronic injuries (the ratio of acute to chronic injuries was 1:1.7), and did not lead to the loss of training/competition time. Of all acute injuries, 49.6% were acquired during rowing-specific training, 43.7% during cross-training, and 6.7% in the gym. The most commonly affected region was the low back (32.6%), followed by the knee (14.2%), shoulder/upper arm, and elbow (10.6% each).

Conclusion

International masters rowers sustained predominantly chronic injuries of low severity, and the most commonly injured region was the low back. The mean injury rate per rower per year was lower than the rates previously reported for juniors and seniors.

Musculoskeletal Screening to Identify Female Collegiate Rowers at Risk for Low Back Pain

CONTEXT

Rowers are at risk for overuse injuries, including low back pain (LBP). Defining the utility of screening tests for identifying those at risk for LBP can aid in the development of guidelines for injury prevention.

OBJECTIVE

To determine if the Functional Movement Screen (FMS) and impairments can identify rowers at risk for developing LBP.

DESIGN

Prospective cohort study.

SETTING

Athletic training room.

PATIENTS OR OTHER PARTICIPANTS

A total of 31 National Collegiate Athletic Association Division I, female, open-weight rowers (age = 19.9 ± 1.4 years, height = 163.6 ± 30.8 cm, mass = 84.1 ± 37.63 kg); coxswains were excluded.

MAIN OUTCOME MEASURE(S)

We assessed the FMS and 5 impairment measures of the Star Excursion Balance Test, closed kinetic chain dorsiflexion range of motion, and the plank, Sorensen, and sit-and-reach tests before the fall season. Low back pain injuries were tracked by the sports medicine staff. Impairment measures were compared between the injured and uninjured athletes. The FMS cutoff score that discriminated injured from uninjured rowers was determined using a receiver operating characteristic curve analysis. Impairments were compared between those at a higher versus lower risk of LBP.

RESULTS

Eighteen rowers sustained an LBP injury. No differences in FMS or impairments between groups were demonstrated. The FMS receiver operating characteristic curve analysis cutoff score was 16 points (area under the curve = 0.60, specificity = 0.67, risk ratio = 1.4 [95% confidence interval = 0.91, 2.11]). Rowers with an FMS score ≤16 had a shorter plank-test time (109.5 ± 60.2 seconds) than those with less risk (175.3 ± 98.6 seconds, mean difference = 65.9 seconds, 95% confidence interval = -129.4, -2.3; P = .043).

CONCLUSIONS

Those with an FMS score ≤16 had a shorter plank-test hold time, indicating that a lack of core endurance may contribute to the increased risk of LBP in female rowers. An FMS score ≤16 indicated a small increased risk (1.4) of developing LBP compared with rowers who had scores >16; however, the FMS is not recommended for widespread screening of female rowers because the risk ratio was relatively small and had a wide 95% confidence interval.

Comparing para-rowing set-ups on an ergometer using kinematic movement patterns of able-bodied rowers

While numerous studies have investigated the biomechanics of able-bodied rowing, few studies have been completed with para-rowing set-ups. The purpose of this research was to provide benchmark data for handle kinetics and joint kinematics for able-bodied athletes rowing in para- rowing set-ups on an indoor ergometer. Able-bodied varsity rowers performed maximal trials in three para-rowing set-ups; Legs, Trunk and Arms (LTA), Trunk and Arms (TA) and Arms and Shoulders (AS) rowing. The handle force kinetics of the LTA stroke were comparable to the values for able-bodied literature. Lumbar flexion at the catch, extension at the finish and total range of motion were, however, greater than values in the literature for able-bodied athletes in the LTA set-up. Additionally, rowers in TA and AS set-ups utilised more extreme ranges of motion for lumbar flexion, elbow flexion and shoulder abduction than the LTA set-up. This study provides the first biomechanical values of the para-rowing strokes for researchers, coaches and athletes to use while promoting the safest training programmes possible for para-rowing.

Low Back Pain in Athletes

CONTEXT

Low Back Pain (LBP) in athletes is common and has a broad spectrum of differential diagnoses that must be taken in to account when a clinician approaches the patient with LBP. The physicians should take into account spinal and extra spinal causes of low back pain in athletes.

EVIDENCE ACQUISTION

A literature review was performed for the years 1951 through 2013. Keywords used were Low Back Pain and Athletes. We searched MEDLINE, EMBASE, OVID, PUBMED, the Cochrane Library, ELSEVIER, and the references of reviewed articles, for English-language of Low Back Pain in Athletes.

RESULTS

The two most common causes of LBP arising from spine in athletes are degenerative disc disease and spondylolysis with or without listhesis. Although most athletes, respond well to conservative treatment, surgical treatment is indicated when conservative treatment failes.

CONCLUSIONS

The major concern in athletes with LBP is return to play and previous level of their activity after treatment. There is insufficient evidence regarding this issue in literature to define the optimal time of return to play following treatment.

Lower back injuries in rowing national level compared to international level rowers

BACKGROUND

Rowing injuries are common, with lower back injuries having the highest incidence.

OBJECTIVES

This study was to investigate the major rowing injuries seen at a single high performance rowing sports program over a 5 years training period and establish if any relationship exists between these injuries and the level of competition that the rower is partaking in.

PATIENTS AND METHODS

All rowers at the South Australian Sports Institute (SASI) programs were designated as being either international or national level rowers. Injuries that caused greater than 5 days training loss during any one training year were recorded. The number of lower back injuries and rib stress injuries causing training time loss were analysed to assess whether there was any association between the level of rower and the nature and type of injury causing training time loss.

RESULTS

Forty-five national rowers (97 training years) had 15 lower back injuries compared to 12 international rowers 35 training years) with 1 lower back injury. Thus a national level rower was more likely to have a lower back injury compared to an international rower P = 0.05. In contrast an international level was more likely to have a rib stress fracture compared to a national rower P = 0.04. 21% of all injuries in this study were a consequence of cycling injuries.

CONCLUSIONS

Lower back injuries are a significant cause of training time lost in rowers. These injuries are much more likely to occur in national level rowers when compared to international level rowers. In contrast rib stress injuries are associated with international compared to national level rowers.

Low back pain in the adolescent athlete

Clinicians must have knowledge of the growth and development of the adolescent spine and the subsequent injury patterns and other spinal conditions common in the adolescent athlete. The management and treatment of spinal injuries in adolescent athletes require a coordinated effort between the clinician, patients, parents/guardians, coaches, therapists, and athletic trainers. Treatment should not only help alleviate the current symptoms but also address flexibility and muscle imbalances to prevent future injuries by recognizing and addressing risk factors. Return to sport should be a gradual process once the pain has resolved and the athlete has regained full strength.

Bone mineral density, rib pain and other features of the female athlete triad in elite lightweight rowers

OBJECTIVE

To determine bone mineral density (BMD) and the associations among BMD, menstrual history, disordered eating (DE), training history, intentional weight loss (IWL) and rib pain for the first time in female lightweight rowers.

SETTING

9 lightweight rowing clubs, UK.

PARTICIPANTS

29 Caucasian female lightweight rowers volunteered. 21 (12 active, 9 retired) completed the study.

INCLUSION CRITERIA

female lightweight rowers aged over 18 years.

EXCLUSION CRITERIA

participants with a history of bone disease, used medications known to influence BMD or if they were pregnant, lactating or postmenopausal.

MAIN OUTCOME MEASURES

Dual-energy X-ray absorptiometry measured total body (TB) composition and BMD at the spine, femoral neck (FN), radius and TB. DE, oligomenorrhoea/amenorrhoea years; rib pain and training history.

RESULTS

DE was reported in six of the rowers. The active with DE started rowing younger (p<0.05) than those without, and their amount of IWL was associated with Eating Attitudes Test-26 score (p<0.05). Some participants reported a history of oligomenorrhoea/amenorrhoea 17 (76%) and/or rib pain 7 (32%) with those with rib pain having lower spine and TB Z-scores (p<0.05) than those without. Those with oligomenorrhoea/amenorrhoea had lower spine Z-scores (p<0.01) than those without. Twelve participants had low BMD; three at spine; one at FN; and eight at radius. Thirteen per cent of mean total training hours (18.6±9.1 h/week) were spent strength training (2.4±2.2 h/week).

CONCLUSIONS

Upper body exercises incorporating multidimensional high peak bone strain were not reported and may need to be considered in their strength training to improve radial BMD. Results suggest IWL and high-level training at a young age increases the likelihood of DE and there may be a lack of quality nutritional support for these athletes. Thus, multidisciplinary sport science support should be offered at a young age and perhaps also to consider changing the weight rules to prevent the development of the Triad.

Preventive Osteopathic Manipulative Treatment and Stress Fracture Incidence Among Collegiate Cross-Country Athletes

Context: Stress fractures are common among athletes, particularly distance runners, with many theories regarding the etiologic process of stress fractures and various studies identifying risk factors or suggesting preventive techniques. To our knowledge, no previous studies have discussed the possible causative effects of somatic dysfunction or the preventive capabilities of osteopathic manipulative treatment (OMT).

Objective: To apply a preventive OMT protocol for cross-country athletes to reduce the incidence of stress fractures.

Design: Cohort study.

Methods: Examinations of cross-country athletes at an NCAA (National Collegiate Athletic Association) Division I university were performed by supervising physician–examiners and first- and second-year osteopathic medical students during several consecutive academic years. Athletes re-enrolled in the study each year they continued to be eligible. The intervention included osteopathic structural examination and OMT that focused on somatic dysfunction identified in the pelvis, sacrum, and lower extremities.

Results: More than 1800 participant examinations were performed on 124 male and female participants by 3 supervising physician–examiners and 141 osteopathic medical students over the course of 5 consecutive academic years (2004-2005 to 2008-2009). Data from these academic years were compared with data from the previous 8 academic years (1996-1997 to 2003-2004). An average of 20 new participants enrolled yearly. The number of annual stress fractures per team ranged from 0 to 6 for male participants and 1 to 6 for female participants. The cumulative annual incidence of stress fractures for male participants demonstrated a statistically significant decrease from 13.9% (20 of 144) before intervention to 1.0% (1 of 105) after intervention, resulting in a 98.7% relative reduction in stress-fracture diagnosis (P=.019). The cumulative annual incidence for female participants showed a minimal decrease from 12.9% (23 of 178) before intervention to 12.0% (17 of 142) after intervention, an 8.5% relative reduction in stress-fracture diagnosis (P=.671). The cumulative annual incidence of all participants decreased from 13.4% (43 of 322) before intervention to 7.3% (18 of 247) after intervention, a 45% relative reduction in stress-fracture diagnosis (P=.156).

Conclusion: There was a statistically significant decrease in the cumulative annual incidence of stress fractures in male, but not female, cross-country athletes after receiving OMT.

Cognitive functional therapy for the management of low back pain in an adolescent male rower: a case report

STUDY DESIGN

Case report.

BACKGROUND

Contemporary low back pain models propose that the experience of and responses to pain result from a complex interaction of biopsychosocial factors. This supports the need for a management approach that addresses the biological, psychological, and social components that may be related to the pain disorder. This case report demonstrates the application of, and outcomes associated with, a cognitive functional intervention that considers neurophysiological, physical, psychosocial, cognitive, and lifestyle dimensions for the management of a rower with nonspecific chronic low back pain.

CASE DESCRIPTION

An adolescent male club-level rower with nonspecific chronic low back pain was classified as having a motor control impairment with a lower lumbar compressive-loading pattern in flexion. Evaluation of this patient included ergometer rowing analysis (clinical and laboratory) before and after an 8-week intervention, and outcome measures at a 12-week follow-up. The intervention consisted of a cognitive functional approach that targeted optimization of movement behavior, providing the rower with alternative movement strategies to minimize sustained flexion loading.

OUTCOMES

Reduced temporal summation of pain while ergometer rowing and reduced functional disability were observed preintervention to 12 weeks postintervention by changes in Roland-Morris Disability Questionnaire score (12/24 to 1/24) and the Patient-Specific Functional Scale (4/30 to 26/30), and associated improvements in lower-limb and back muscle endurance and changes in hip and spinopelvic kinematics during ergometer rowing. In particular, there was a greater use of available range of movement in the lumbar spine postintervention.

DISCUSSION

The cognitive functional intervention for this patient resulted in reduced pain and functional disability related to ergometer rowing, which was associated with a change in lumbar kinematics and improved lower-limb and back muscle endurance. The results suggest that providing the rower with greater use of his available range of movement may enhance load distribution during the drive phase of rowing. Registered at Australian New Zealand Clinical Trials Registry (ACTRN12609000565246).

LEVEL OF EVIDENCE

Therapy, level 4.

Labral injuries of the hip in rowers

BACKGROUND

Injuries of the hip in the adolescent and young adult athlete are receiving more attention with advances in the understanding of femoroacetabular impingement (FAI), labral pathology, and hip arthroscopy. Labral tears have not been well characterized in rowers.

QUESTIONS/PURPOSES

The purposes of this study were (1) to describe the clinical presentation of labral pathology in rowers; (2) to describe the MRI and radiographic findings of labral pathology in rowers; and (3) to determine the likelihood that a rower with labral injury, treated arthroscopically, will return to sport.

METHODS

We conducted a review from August 2003 to August 2010 to identify all rowers with MRI-confirmed intraarticular pathology of the hip presenting to our institution. Baseline demographics, symptoms and physical findings, and location of the labral tear with associated pathology, management, and early followup were recorded. The review yielded a total of 21 hips (18 rowers, three with bilateral labral pathology) with a mean patient age of 18.5 years (range, 14-23 years). Most of the rowers (85%) were female and the series included prep school (44%) and collegiate rowers (56%). Eighteen of the 21 hips (85%) eventually underwent arthroscopic surgery at our institution.

RESULTS

A large majority of patients had isolated groin pain (71%) and physical findings consistent with impingement (81%). There was no single, dominant location for the labral tears on MRI. Among the 18 patients who had surgery, 10 (56%) returned to rowing, six (33%) never returned, and return data were not available for two (11%) at a mean of 8 months (range, 3-25 months) after surgery.

CONCLUSIONS

The repetitive motions of the hip required for rowing may be a factor leading to intraarticular labral injuries in the athletes. Underlying anatomic abnormalities of the hip such as FAI may predispose certain patients to these injuries. However, many patients treated arthroscopically did not return to sport at a mean of 8 months after surgery.

Gender Differences in Trunk and Pelvic Kinematics During Prolonged Ergometer Rowing in Adolescents

The trunk and pelvis kinematics of 20 healthy male and female adolescent rowers were recorded during an ergometer trial using an electromagnetic tracking system (Fastrak). The kinematics of each drive phase were collected during the 1st and 20th minute, respectively. The mean and range of the kinematics, stroke rate and stroke length were compared between genders and over time. Male rowers postured their pelvis with more posterior tilt and their thoracic spine in more flexion than female rowers (P< .05). Both genders postured their pelvis in more posterior pelvic rotation and upper trunk in more flexion over time. Male rowers were found to have a significantly shorter drive phase than female rowers (P= .001). Differences in trunk and pelvic kinematics between adolescent male and female rowers suggest potentially various mechanisms for biomechanical stress. Assessment and training of rowers should take gender differences into consideration.

The prevalence of low back pain among former elite cross-country skiers, rowers, orienteerers, and nonathletes: a 10-year cohort study

BACKGROUND

Some cross-sectional studies have suggested that the prevalence of low back pain (LBP) may be high among endurance athletes with repetitive back loading, but there are no large, prospective cohort studies addressing this issue.

PURPOSE

To compare the prevalence of symptoms of low back pain (LBP) among former endurance athletes with different loading characteristics on the lumbar region: cross-country skiing (flexion loading), rowing (extension loading), and orienteering (no specific loading), as well as a nonathletic control group.

STUDY DESIGN

Cohort study; level of evidence, 2.

METHODS

Self-reported questionnaire on LBP adapted for sports based on standardized Nordic questionnaires for musculoskeletal symptoms. Responders were 173 rowers, 209 orienteerers, 242 cross-country skiers, and 116 control subjects (88% of the original cohort).

RESULTS

There were no group differences between the athletic groups and the control group with regard to the 2 main outcomes: reported LBP the previous 12 months (P = .66) and frequent LBP the past year (>30 days with LBP) (P = .14). More rowers than orienteerers reported frequent LBP the past year (adjusted OR = 2.32; CI, 1.02-5.28). Occupational changes due to LBP were reported more often by rowers (13%) than skiers (7%) and orienteerers (3%) (P = .002). More rowers and skiers reported having received outpatient medical assistance than orienteerers or controls. A training volume >550 h/y was a risk factor for reporting LBP during the previous 12 months compared with a training volume <200 h/y (adjusted OR = 2.51; CI, 1.26-5.02). A previous episode with LBP was associated with LBP later in life (adjusted OR = 3.02; CI, 2.22-4.10).

CONCLUSION

Low back pain was not more common among former endurance athletes with specific back loading compared with non-athletes. The results indicate that years of prolonged and repetitive flexion or extension loading in endurance sports does not lead to more LBP. However, a large training volume in the past year and previous episodes with LBP are risk factors for LBP. Comparing the sports of rowing, cross-country skiing, and orienteering, it appears that whereas orienteering is protective, rowing can provoke LBP.

Rowing: sport-specific concerns for the team physician

Rowing injuries occur mostly from overuse and are seen primarily in the back, rib, knee, and forearm. Many of these have a specific cause owing to the mechanics of the rowing stroke, which are discussed, as are sport-specific treatment strategies. Also discussed are specific injuries sustained on the rowing machine, emergency issues, and special population concerns.

Rib stress fractures among rowers: definition, epidemiology, mechanisms, risk factors and effectiveness of injury prevention strategies

Rib stress fractures (RSFs) can have serious effects on rowing training and performance and accordingly represent an important topic for sports medicine practitioners. Therefore, the aim of this review is to outline the definition, epidemiology, mechanisms, intrinsic and extrinsic risk factors, injury management and injury prevention strategies for RSF in rowers. To this end, nine relevant books, 140 journal articles, the proceedings of five conferences and two unpublished presentations were reviewed after searches of electronic databases using the keywords 'rowing', 'rib', 'stress fracture', 'injury', 'mechanics' and 'kinetics'. The review showed that RSF is an incomplete fracture occurring from an imbalance between the rate of bone resorption and the rate of bone formation. RSF occurs in 8.1-16.4% of elite rowers, 2% of university rowers and 1% of junior elite rowers. Approximately 86% of rowing RSF cases with known locations occur in ribs four to eight, mostly along the anterolateral/lateral rib cage. Elite rowers are more likely to experience RSF than nonelite rowers. Injury occurrence is equal among sweep rowers and scullers, but the regional location of the injury differs. The mechanism of injury is multifactorial with numerous intrinsic and extrinsic risk factors contributing. Posterior-directed resultant forces arising from the forward directed force vector through the arms to the oar handle in combination with the force vector induced by the scapula retractors during mid-drive, or repetitive stress from the external obliques and rectus abdominis in the 'finish' position, may be responsible for RSF. Joint hypomobility, vertebral malalignment or low bone mineral density may be associated with RSF. Case studies have shown increased risk associated with amenorrhoea, low bone density or poor technique, in combination with increases in training volume. Training volume alone may have less effect on injury than other factors. Large differences in seat and handle velocity, sequential movement patterns, higher elbow-flexion to knee-extension strength ratios, higher seat-to-handle velocity during the initial drive, or higher shoulder angle excursion may result in RSF. Gearing may indirectly affect rib loading. Increased risk may be due to low calcium, low vitamin D, eating disorders, low testosterone or use of depot medroxyprogesterone injections. Injury management involves 1-2 weeks cessation of rowing with analgesic modalities followed by a slow return to rowing with low-impact intensity and modified pain-free training. Some evidence shows injury prevention strategies should focus on strengthening the serratus anterior, strengthening leg extensors, stretching the lumbar spine, increasing hip joint flexibility, reducing excessive protraction, training with ergometers on slides or floating-head ergometers, and calcium and vitamin D supplementation. Future research should focus on the epidemiology of RSF over 4-year Olympic cycles in elite rowers, the aetiology of the condition, and the effectiveness of RSF prevention strategies for injury incidence and performance in rowing.

Slide-based ergometer rowing: effects on force production and neuromuscular activity

Force production profile and neuromuscular activity during slide-based and stationary ergometer rowing at standardized submaximal power output were compared in 14 male and 8 female National Team rowers. Surface electromyography (EMG) was obtained in selected thoracic and leg muscles along with synchronous measurement of handle force and rate of force development (RFD). Compared to stationary conditions, slide-based peak force decreased by 76 (57-95) N (mean 95% CI) in males (P < 0.001) and 20 (8-31) N (P < 0.05) in females. Stroke rate increased (+10.7%) and late-phase RFD decreased (-20.7%) in males (P < 0.05). Neuromuscular activity in m. vastus lateralis decreased in the initial drive phase from 59% to 51% of EMG max in males and from 57% to 52% in females (P < 0.01-0.05), while also decreasing in the late recovery phase from 20% to 7% in males and 17% to 7% in females (P < 0.01). Peak force and maximal neuromuscular activity in the shoulder retractors always occurred in the second quartile of the drive phase. In conclusion, peak force and late-phase RFD (males) decreased and stroke rate increased (males) during slide-based compared to stationary ergometer rowing, potentially reducing the risk of overuse injury. Neuromuscular activity was more affected in leg muscles than thoracic muscles by slide-based ergometer rowing.

Treatment of a female collegiate rower with costochondritis: a case report

Rib injuries are common in collegiate rowing. The purpose of this case report is to provide insight into examination, evaluation, and treatment of persistent costochondritis in an elite athlete as well as propose an explanation for chronic dysfunction. The case involved a 21 year old female collegiate rower with multiple episodes of costochondritis over a 1-year period of time. Symptoms were localized to the left third costosternal junction and bilaterally at the fourth costosternal junction with moderate swelling. Initial interventions were directed at the costosternal joint, but only mild, temporary relief of symptoms was attained. Reexamination findings included hypomobility of the upper thoracic spine, costovertebral joints, and lateral ribs. Interventions included postural exercises and manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility. Over a 3-week time period pain experienced throughout the day had subsided (visual analog scale - VAS 0/10). She was able to resume running and elliptical aerobic training with minimal discomfort (VAS 2/10) and began to reintegrate into collegiate rowing. Examination of the lateral ribs, cervical and thoracic spine should be part of the comprehensive evaluation of costochondritis. Addressing posterior hypomobility may have allowed for a more thorough recovery in this case study.

Differences in spinopelvic kinematics in sweep and scull ergometer rowing

OBJECTIVE

The spinopelvic kinematics of sweep and scull have yet to be investigated, despite evidence suggesting that sweep rowing may be provocative for low back pain (LBP). The aim of this study was to determine whether differences existed in spinopelvic kinematics in high-level rowers without LBP in sweep and scull ergometer rowing.

DESIGN

Repeated measures study.

SETTING

Institute of Sport Laboratory.

PARTICIPANTS

Ten high-level rowers.

INTERVENTIONS

Kinematics of the pelvis, lower lumbar, upper lumbar, and lower thoracic regions during the drive phase of the rowing stroke were measured while rowing on an interchangeable sweep/scull ergometer.

MAIN OUTCOME MEASURES

Total and segmental spinopelvic kinematics.

RESULTS

Sweep rowing showed greater lateral bend (P < 0.05) throughout the stroke, which was predominately due to movement of the upper lumbar and lower thoracic regions. Furthermore, sweep rowing displayed a greater magnitude (P < 0.05) of axial rotation at the catch (created at the pelvis). Both sweep and scull rowing showed values close to end range flexion for the lower lumbar spine at the catch and early drive phases. No difference (P > 0.05) was evident in lateral bend or axial rotation values for the lower lumbar region.

CONCLUSIONS

Some differences exist in spinopelvic kinematics between sweep and scull ergometer rowing. However, it may be speculated that the lack of differences in lateral bend and axial rotation at the lower lumbar spine in sweep rowing may represent an adaptive and protective approach of experienced rowers. This may be the focus of future research studies.

Spine abnormalities depicted by magnetic resonance imaging in adolescent rowers

BACKGROUND

Most lesions of the spine of athletes, which often are detected incidentally, do not cause important symptoms or make the athletes discontinue their physical activities. To better understand the significance of these lesions, new imaging studies have been conducted with asymptomatic athletes in several sports, aiming to detect potentially deleterious and disabling abnormalities.

PURPOSE

To compare the magnetic resonance imaging (MRI) lumbar spine findings in a group of asymptomatic adolescent rowers and in a control group of adolescents matched according to age and sex who do not practice any regular physical activity.

STUDY DESIGN

Cohort study (prevalence); Level of evidence, 3.

METHODS

Our study evaluated 44 asymptomatic adolescent boys distributed in 2 groups of 22 rowers and 22 control subjects. All the examinations were performed using a 0.35-T open-field MRI unit and evaluated by 2 experienced radiologists blinded to the study groups. Each MRI scan was analyzed for the presence of disc degeneration/desiccation, herniated or bulging disc, pars interarticularis stress reaction, and spondylolysis. The Student t test and the Fisher exact test were used for statistical analyses.

RESULTS

Nine rowers (40.9%) had at least 1 abnormality detected by MRI in the lumbar spine, whereas only 2 participants (9.1%) in the control group had at least 1 MRI abnormality (P = .03). Seven disc changes (31.8%) and 6 pars abnormalities (27.3%) were found in the group of elite rowers. In the control group, 3 disc changes (13.6%) and no pars abnormalities were found in the MR scans. The comparison between groups showed statistically significant differences in stress reaction of the pars articularis.

CONCLUSION

Disc disease and pars interarticularis stress reaction are prevalent abnormalities of the lumbar spine of high-performance rowers.

Low back pain in adolescent female rowers: a multi-dimensional intervention study

The aim of this study was to determine whether a multi-dimensional intervention programme was effective in reducing the incidence of low back pain (LBP) and the associated levels of pain and disability in schoolgirl rowers. This non-randomised controlled trial involved an intervention (INT) group consisting of 90 schoolgirl rowers from one school and a control (CTRL) group consisting of 131 participants from three other schools. All participants in the INT group underwent a multi-dimensional programme that consisted of an individualised exercise programme based on an individual musculoskeletal screening (Week 1) and a LBP education session conducted by a physiotherapist (Week 2) and performed an off-water-conditioning programme conducted by a Physical Education teacher. All exercises were undertaken during the season. Primary outcome variables collected at Start-season, Mid-season, End-season and Post-season included the incidence of LBP and related levels of pain and disability. Secondary outcome variables from the bio-psycho-social domain were measured at Start-season and End-season in the INT group only. The INT group had a lower incidence of LBP at Mid-season and End-season and displayed significantly better results than the CTRL group for improvers and non-improvers with respect to the levels of pain and disability. The INT group following the intervention also displayed improved physical fitness levels, sat with significantly less anterior tilt of the pelvis and lumbar kyphosis when in their usual sitting posture and demonstrated positive changes in their behaviour. The multi-dimensional approach to reducing the incidence of LBP, pain and disability in schoolgirl rowers in this study was effective. Several secondary outcome variables measured in the INT group considered to be of importance in LBP significantly improved. These included physical fitness (aerobic conditioning, lower limb and back muscle endurance and sit and reach flexibility) and seated posture (usual and slump sitting).

Changes in kinematics and trunk electromyography during a 2000 m race simulation in elite female rowers

Achieving excellence in rowing requires optimization of technique to maximize efficiency and force production. Investigation of the kinematics of the trunk, upper and lower extremity, together with muscle activity of the trunk, provides an insight into the motor control strategies utilized over a typical race. Nine elite female rowers performed a 2000 m race simulation. Kinematic data of the trunk and extremities, together with electromyography (EMG) activity of spinal and pelvic extensor and flexor muscles, were compared at 250 and 1500 m. At 1500 m, there was greater dissociation in the timing of leg extension and arm flexion and delayed trunk extension. Also at 1500 m, the spine demonstrated a delayed peak extension angular velocity of the T4-T7 and L3-S1 spinal segments in the early drive along with delayed and increased peak extension angular velocity of T10-L1 and L1-L3 spinal segments during the late drive. Trunk muscle fatigue was not evident; however, the abdominals demonstrated larger EMG burst areas at 1500 m. Alterations in trunk kinematics suggest that the trunk acts as a less stiff lever on which to transfer the forces of the legs to the arms and handle. Increased abdominal activity may reflect increased demand to control the trunk, given the altered coordination between the legs, trunk and arms.

Stress fractures: diagnosis and management in the primary care setting

Stress fracture represents an overuse injury of the bone resulting from excessive repetitive stress. Diagnosis in most cases is based on clinical evaluation. Plain radiographs may show characteristic changes 2 to 4 weeks from onset of symptoms. Increasingly, magnetic resonance imaging is recognized as the study of choice in the evaluation of stress injury of the bone. Most stress fractures at low-risk sites can be managed in the primary care setting with conservative measures. From a primary care perspective, orthopedic or sports medicine consultation is considered for stress fractures at high-risk sites. This article reviews general principles of diagnosis and management of stress fractures in adolescents.