Stress fracture of the ribs in female rowers

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.

A Scoping Review of the Epidemiology, Management, and Outcomes of Golf-Related Fractures

ABSTRACT

Golf is a popular sport; however, there is a paucity of data in relation to golf-associated fractures, and the rate and timing of returning to golf. The aim of this review is to describe golf-associated fractures, including epidemiology, management, and timing of returning to golf following treatment. A literature search was performed using MEDLINE/PubMed, Embase, and Web of Science. Data were extracted and summarized in a narrative synthesis. A total of 436 articles were identified with an initial search of which 58 met the inclusion criteria. Twelve anatomical sites of golf swing-related fractures were identified, of which 10 sites were specific for stress fractures. The most common sites of golf swing-related stress fractures were the ribs followed by the hook of hamate. There was a common theme of delay to diagnosis, being initially assigned to a soft tissue injury. Most golfers with swing-related stress fractures were able to return to golf with the exception of osteoporotic associated vertebral stress fractures. Timing of returning to golf was between 4 and 12 months for most of the golfers with stress fractures following conservative management. Operative intervention was an option of hook of hamate nonunion, following a stress fracture, and tibial shaft stress fractures. Golf equipment-related fractures were not rare and were associated with major trauma and in some cases associated with significant persistent morbidity. Golf-related stress fractures commonly involve the ribs and hook of hamate; knowledge of this may aid in early diagnosis and appropriate treatment when symptomatic golfers are encountered. Although golf is a noncontact sport, fractures associated with golf equipment can be life changing, and safety training guidelines should be established.

First Rib Stress Fracture in an Adolescent Elite Tennis Player: A Case Report

CASE

A 16-year-old, right-hand-dominant, Asian male, elite tennis player presented to the clinic with a 1-month history of left shoulder pain. Originally, the pathology was believed to be shoulder-based, but lack of improvement after several weeks of therapy warranted further imaging, which ultimately revealed a nondisplaced fracture of the posterior left first rib.

CONCLUSION

Stress injuries are not uncommon in the sport of tennis, but atraumatic rib fractures are rare. Given the increase in youth sports specialization and overtraining and other risk factors such as adolescent age and race, it is important to keep rib stress fracture on the differential.

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.

Thoracoabdominal Injuries

Trauma to the thorax and abdomen can occur during participation in sports. This chapter reviews some of the more common presentations of such injuries and how such injuries should be best managed. Thoracic injuries reviewed include internal injuries such as pneumothorax, pulmonary contusion, hemothorax, commotio cordis, and cardiac contusion. Chest wall injuries are also reviewed such as rib fractures, costochondritis, and slipping rib syndrome plus sternal and scapular fractures. Abdominal injuries reviewed are focused on internal organ trauma to the spleen and liver, kidney, pancreas, and bowel. There is attention to the effect of Epstein-Barr virus and infectious mononucleosis, seen very frequently in high school and collegiate athletes. Finally, groin pain and athletic pubalgia are described.

In addition to anatomy and clinical presentation, imaging modalities that characterize such trauma are reviewed for each diagnosis. Prevention of thoracoabdominal injuries and return-to-play decisions are described at the chapter conclusion.

Multiscale imaging of bone microdamage

Bone is a structural and hierarchical composite that exhibits remarkable ability to sustain complex mechanical loading and resist fracture. Bone quality encompasses various attributes of bone matrix from the quality of its material components (type-I collagen, mineral and non-collagenous matrix proteins) and cancellous microarchitecture, to the nature and extent of bone microdamage. Microdamage, produced during loading, manifests in multiple forms across the scales of hierarchy in bone and functions to dissipate energy and avert fracture. Microdamage formation is a key determinant of bone quality, and through a range of biological and physical mechanisms, accumulates with age and disease. Accumulated microdamage in bone decreases bone strength and increases bone's propensity to fracture. Thus, a thorough assessment of microdamage, across the hierarchical levels of bone, is crucial to better understand bone quality and bone fracture. This review article details multiple imaging modalities that have been used to study and characterize microdamage; from bulk staining techniques originally developed by Harold Frost to assess linear microcracks, to atomic force microscopy, a modality that revealed mechanistic insights into the formation diffuse damage at the ultrastructural level in bone. New automated techniques using imaging modalities, such as microcomputed tomography are also presented for a comprehensive overview.

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.

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.

Rowing injuries

Context:

Rowing is one of the original modern Olympic sports and was one of the most popular spectator sports in the United States. Its popularity has been increasing since the enactment of Title IX. The injury patterns in this sport are unique because of the stress applied during the rowing stroke.

Evidence Acquisition:

This review summarizes the existing literature describing the biomechanics of the rowing stroke and rowing-related injury patterns. Data were obtained from previously published peer-reviewed literature through a search of the entire PubMed database (up to December, 2011) as well as from textbook chapters and rowing coaching manuals.

Results:

Rowing injuries are primarily overuse related. The knee, lumbar spine, and ribs are most commonly affected. The injury incidence is directly related to the volume of training and technique.

Conclusion:

Familiarity of the injury patterns and the biomechanical forces affecting the rowing athlete will aid in prompt diagnosis and appropriate management.

First-rib stress fracture in a high-school lacrosse player: a case report and short clinical review

A 14-year-old right-hand dominant female lacrosse player presented with a complaint of right shoulder and upper posterior thorax pain of 8 days' duration. She had been playing lacrosse at the attack wing and midfielder positions and experienced insidious pain after a game. She had no history of trauma to that shoulder during that game and had not experienced an injury in the past. Six days after the pain developed, she woke up one night with a sudden increase in the pain, which brought her to tears and caused slight difficulty with breathing. The pain was located anteriorly just lateral to the right sternoclavicular joint and posteriorly in the paraspinal muscles in the upper thoracic region. Physical examination suggested a first-rib stress fracture, which was subsequently confirmed by chest and shoulder radiographs.

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.

Traumatic and overuse injuries among international elite junior rowers

BACKGROUND

Junior rowers have competed internationally for over 4 decades, and there are no epidemiological data available on traumatic and overuse injury in this population.

OBJECTIVE

To define the types of musculoskeletal problems present in international elite-level junior rowers and to determine whether gender, physical stature, rowing discipline, and training programs affect the incidence of reported injuries.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Injury data were obtained from a total of 398 rowers (42% female, 58% male) who completed a 4-page questionnaire on injury incidence while participating at the Junior World Rowing Championships in Beijing, People's Republic of China, in August 2007.

RESULTS

Overall, 290 (73.8%) reported injuries involved overuse, and 103 (26.2%) were related to a single traumatic event. Female rowers were injured more frequently than male rowers (110.2 vs 90.5 injuries per 100 rowers). In both genders, the most common injury site was the low back followed by the knee and the forearm/wrist. The severity of reported injuries was incidental in 65.1%, minor in 21.4%, moderate in 10.4%, and major in 3.1% of cases. The rowers with traumatic injuries had less rowing experience than the uninjured rowers (median [C] +/- interquartile range [Q] = 3 +/- 3 years vs 4 +/- 3 years; P = .043, Mann-Whitney test). Sweep rowers who changed rowing side during the current season had significantly more acute-onset low back injuries (P = .012, chi(2) test) than those who did not change rowing side during the same period. The incidence of traumatic injuries was significantly lower in rowers who regularly performed more than 10 minutes of posttraining stretching (P = .030, chi2) test). Athletes who ran more than once a week had more overuse knee injuries than those who ran once or less per week (P = .033, chi2 test).

CONCLUSION

Elite junior rowers attending the World Rowing Championships reported predominantly overuse injuries of low severity during the current rowing season. Low back injuries were the most frequent complaint of elite-level junior rowers.

The effect of staining on the monotonic tensile mechanical properties of human cortical bone

Microdamage in the form of microcracks has been observed in cortical bone following in vivo and in vitro fatigue loading. It has been suggested that bone has an inherent ability to repair microdamage at physiological activity levels. If the biological remodelling and repair process cannot keep up with the rate of damage accumulation, as in ageing bone and in individuals such as athletes and military recruits, microdamage may accumulate even at physiological activity levels. Such microdamage accumulation is thought to contribute to stress and fragility fractures. It is therefore important to obtain quantitative data on the rate of damage accumulation so as to understand the etiology of skeletal fractures. Sequential labelling of microdamage using fluorochrome stains at different stages of mechanical loading is becoming standard for assessing damage evolution. Although verification of this staining technique is provided in the literature, it has not yet been reported if the stains change the mechanical properties of cortical bone. In this study, monotonic tensile tests were performed to investigate the effect of the staining on the monotonic tensile mechanical properties of cortical bone. Forty-eight specimens were machined from human femora obtained from three male subjects, aged 52-55 years, and all 48 specimens were systematically divided into one control and three treatment groups. Specimens in the first (n = 12) and second treatment groups (n = 12) were stained with alizarin complexone and calcein (0.0005 M), respectively, for 16 h under 50 mmHg vacuum. Specimens in the third treatment group (n = 12) were kept in calcium-supplemented saline solution under the same conditions of the first and second treatment groups. Specimens in the control group (n = 12) were removed from the freezer prior to testing and allowed to thaw at room temperature in saline solution. Differences among the mean values of the mechanical properties for four testing groups were determined by the Mann-Whitney test at a significance level of P < 0.05. The statistical results indicated that the chelating stains and the staining conditions have no significant effect on the mechanical properties of the cortical bone under monotonic tensile loading. This study demonstrated that microcrack labelling with the chelating stains under aforementioned conditions (stain concentration, staining time, etc.) is a reliable method in that staining cortical bone with alizarin complexone and calcein prior to testing does not affect tensile properties.

Stress fractures of the ribs in elite competitive rowers: a report of nine cases

OBJECTIVE

The objective was to report the clinical and imaging patterns of nine cases of stress fractures of the rib diagnosed in Italian Olympic rowers.

PATIENTS AND METHODS

Nine patients with stress fractures of the rib detected from 103 (8.7%) Italian team rowers competing between May 2000 and May 2006 were identified based on the database of a sports medicine institute. All athletes were male. They were aged between 17 and 31 years (mean: 24.4). Patient weight, fracture location, rowing side and imaging methods employed were noted.

RESULTS

The diagnosis was made based on history, clinical examination and Tc-99m MDP bone scintigraphy. Eight of the 9 fractures were located anterolaterally between the fourth and ninth rib. In 1 of the 5 athletes with standard radiographs, a fracture line was visible and in 4 there was callus formation. In 2 athletes sonography was performed, which detected discontinuity of the rib surface and callus formation (1 case each).

CONCLUSION

Stress fractures of the ribs are relatively common in competitive rowers. They are characterized by increasing lateral chest pain and typical scintigraphic, radiographic and sonographic findings.

Exercise-induced rib stress fractures: potential risk factors related to thoracic muscle co-contraction and movement pattern

The etiology of exercise-induced rib stress fractures (RSFs) in elite rowers is unclear. The purpose of the study was to investigate thoracic muscle activity, movement patterns and muscle strength in elite rowers. Electromyographic (EMG) and 2-D video analysis were performed during ergometer rowing, and isokinetic muscle strength was measured in seven national team rowers with a history of RSF and seven matched controls (C). RSF displayed a higher velocity of the seat in the initial drive phase (RSF: 0.25+/-0.03, 0.25 (0.15-0.33) m/s vs C: 0.15+/-0.06, 0.18 (-0.11-0.29) m/s P=0.028) (Mean+/-SEM, median and range). Further, RSF had greater co-contraction of m. serratus anterior and m. trapezius in the mid-drive phase (RSF: 47.5+/-3.4, 48.5 (35.8-60.2)% EMG signal overlap vs C: 30.8+/-6.5, 27.0 (11.2-61.6)%P=0.043). In addition, the RSF subjects showed a lower knee-extension to elbow-flexion strength ratio (RSF: 4.2+/-0.22, 4.3 (3.5-5.1) vs C: 4.8+/-0.16, 5.0 (4.2-5.3) P=0.043), indicating stronger arms relative to legs compared with controls. In conclusion, increased thoracic muscle co-contraction, altered movement patterns and reduced leg/arm strength ratio were observed in the RSF subjects, which may all predispose toward an increased risk of RSF.

Upper Extremity Stress Fractures

Although less common than lower-extremity stress fractures, upper-extremity stress fractures are becoming recognized much more frequently. A majority of these fractures are caused by overuse and fatigue of the surrounding musculature and, as a result, may be prevented by appropriate training and conditioning. Diagnosis is made by history and physical examination with the aid of plain radiographs, bone scans, and MRI. Most of these fractures heal with a period of relative rest followed by a structured rehabilitation program. A small percentage of these fractures, however, may require surgical fixation. The present article reviews the different types of upper extremity and torso stress fractures seen in athletes, starting with the sternum and extending outward to the fingers. The presentation, diagnosis, mechanism of injury, treatment, prevention, and prognosis for each of these injuries will be discussed.

Microcracks in cortical bone: how do they affect bone biology?

Microcrack accumulation in cortical bone has been implicated in skeletal fragility and stress fractures. These cracks have also been shown to affect the mechanical and material properties of cortical bone. Their growth has been linked to osteocyte apoptosis and the initiation of the remodeling process, which also has a role in their repair. Clinically, osteoporosis is diagnosed using dual energy x-ray absorptiometry. However, evidence now indicates that bone mass alone is insufficient to satisfactorily explain the skeletal fragility of osteoporosis and consideration needs to be given to bone quality in the diagnosis and treatment of the disease. Bone quality includes parameters such as trabecular and cortical microarchitecture, morphology, bone turnover, degree of mineralization of the bone matrix, and significantly, the amount of microdamage present in the bone. Current clinical treatments concentrate on the inhibition of osteoclast activity to maintain bone mass in osteoporotic patients. However, these cells have a major role in removing existing microcracks from the bone matrix, and hence the use of bone resorption- inhibiting drugs may lead to insufficient bone repair and therefore an increase in microdamage accumulation and loss of bone quality.

Exercise-induced rib stress fractures: influence of reduced bone mineral density

Exercise-induced rib stress fractures have been reported frequently in elite rowers during the past decade. The etiology of rib stress fractures is unclear, but low bone mineral density (BMD) has been suggested to be a potential risk factor for stress fractures in weight-bearing bones. The present study investigated BMD in seven Danish national team rowers with previous rib stress fracture (RSF) and 7 controls (C) matched for gender, age, height, weight and training experience. Total body scan and specific scans of the lumbar spine (L2-L4), femoral neck and distal radius were performed using a DEXA scanner. The RSF subjects showed significantly lower L2-L4 BMD: RSF: 1.22+/-0.05 g cm(-2) (mean+/-SEM) (median 1.19 g cm(-2), range 1.02-1.37 g cm(-2)) compared to C: 140+/-0.04 g cm(-2) (median 1.41 g cm(-2), range 1.27-1.57 g cm(-2)) (P=0.028). The present results suggest that low bone mineral density may be a potential risk factor for the development of exercise-induced rib stress fractures in elite rowers.

Rib stress fractures

The ribs are an uncommon site of stress fracture. Typical locations are the first rib anterolaterally, the fourth through ninth ribs laterally and posterolaterally, and the posteromedial upper ribs. Muscular forces are predominantly responsible for these fractures. This article reviews the mechanisms of injury in various activities and illustrates the scintigraphic appearance of rib stress fractures.

Rowing Injuries

Participation in the sport of rowing has been steadily increasing in recent decades, yet few studies address the specific injuries incurred. This article reviews the most common injuries described in the literature, including musculoskeletal problems in the lower back, ribs, shoulder, wrist and knee. A review of basic rowing physiology and equipment is included, along with a description of the mechanics of the rowing stroke. This information is necessary in order to make an accurate diagnosis and treatment protocol for these injuries, which are mainly chronic in nature. The most frequently injured region is the low back, mainly due to excessive hyperflexion and twisting, and can include specific injuries such as spondylolysis, sacroiliac joint dysfunction and disc herniation. Rib stress fractures account for the most time lost from on-water training and competition. Although theories abound for the mechanism of injury, the exact aetiology of rib stress fractures remains unknown. Other injuries discussed within, which are specific to ribs, include costochondritis, costovertebral joint subluxation and intercostal muscle strains. Shoulder pain is quite common in rowers and can be the result of overuse, poor technique, or tension in the upper body. Injuries concerning the forearm and wrist are also common, and can include exertional compartment syndrome, lateral epicondylitis, deQuervain's and intersection syndrome, and tenosynovitis of the wrist extensors. In the lower body, the major injuries reported include generalised patellofemoral pain due to abnormal patellar tracking, and iliotibial band friction syndrome. Lastly, dermatological issues, such as blisters and abrasions, and miscellaneous issues, such as environmental concerns and the female athlete triad, are also included in this article.Pathophysiology, mechanism of injury, assessment and management strategies are outlined in the text for each injury, with special attention given to ways to correct biomechanical or equipment problems specific to rowing. By gaining an understanding of basic rowing biomechanics and training habits, the physician and/or healthcare provider will be better equipped to treat and prevent injuries in the rowing population.

Aetiology of rib stress fractures in rowers

Rib stress fractures are a common and significant problem in the rowing population. They occur in approximately 6.1 to 12% of rowers and account for the most time lost from on-water training and competition. This review discusses possible causative factors for rib stress fractures in rowers. Central to the establishment of causative factors is the identification that each rib forms part of a closed ring of bone that is completed anteriorly by the sternum and posteriorly by the thoracic vertebrae. Because of the shared sternum anteriorly each ring of bone is mechanically connected. Subsequently, during rowing individual ribs are not loaded in isolation, rather the rib cage is loaded as a complete unit. Incorporating this functioning as a complete unit a possible mechanism by which different factors contribute to rib stress fracture can be developed. In rowing, muscle factors generate loading of the rib cage. The characteristics of this loading stimulus are influenced by equipment, technique and joint factors. Rib-cage loading generates bone strain in individual ribs with the response of each rib depending upon site-specific skeletal factors. Depending on the characteristics of the bone strain in terms of the magnitude and rate of strain, microdamage may develop. The bone response to this microdamage is reparative remodelling. Whether this response is capable of repairing the damage to prevent progression to a stress fracture is dependent upon training and gender factors. Identification of these factors will generate a better understanding of the aetiology of this injury, which is required for improved prevention and treatment strategies.

Bony pathology in the cancer patient

Bony pathology in the cancer patient represents a significant source of morbidity and mortality. Complications include insufficiency and pathological fractures resulting from either medical treatments or bony metastases that can cause significant functional limitations. Additional complications include spinal cord compression, hypercalcemia, and bone marrow failure. Rehabilitation management of such conditions is reviewed, with an emphasis on diagnostic and therapeutic management. Bracing and focused rehabilitation programs facilitate maximal participation and functional outcomes, which can result in an enhanced quality of life. Specific rehabilitation goals and strategies are discussed, with an emphasis on tailoring these according to the functional staging of the patient.

Musculoskeletal problems of the chest wall in athletes

Chest pain in the athlete has a wide differential diagnosis. Pain may originate from structures within the thorax, such as the heart, lungs or oesophagus. However, musculoskeletal causes of chest pain must be considered. The aim of this review is to help the clinician to diagnose chest wall pain in athletes by identifying the possible causes, as reported in the literature. Musculoskeletal problems of the chest wall can occur in the ribs, sternum, articulations or myofascial structures. The cause is usually evident in the case of direct trauma. Additionally, athletes' bodies may be subjected to sudden large indirect forces or overuse, and stress fractures of the ribs caused by sporting activity have been extensively reported. These have been associated with golf, rowing and baseball pitching in particular. Stress fractures of the sternum reported in wrestlers cause pain and tenderness of the sternum, as expected. Diagnosis is by bone scan and limitation of activity usually allows healing to occur. The slipping rib syndrome causes intermittent costal margin pain related to posture or movement, and may be diagnosed by the 'hooking manoeuvre', which reproduces pain and sometimes a click. If reassurance and postural advice fail, good results are possible with resection of the mobile rib. The painful xiphoid syndrome is a rare condition that causes pain and tenderness of the xiphoid and is self-limiting. Costochondritis is a self-limiting condition of unknown aetiology that typically presents with pain around the second to fifth costochondral joints. It can be differentiated from Tietze's syndrome in which there is swelling and pain of the articulation. Both conditions eventually settle spontaneously although a corticosteroid injection may be useful in particularly troublesome cases. The intercostal muscles may be injured causing tenderness between the ribs. Other conditions that should be considered include epidemic myalgia, precordial catch syndrome and referred pain from the thoracic spine.

Management of rowers with rib stress fractures

Stress fractures of the ribs in rowers occur mostly along the anterior axillary line, but also anteriorly and posteriorly. Management has previously consisted of rest, but symptoms can recur on return to training. Earlier return to rowing can be achieved with management that includes ice and TENS for pain relief, pulsed magnetic field therapy and passive mobilisation of the thoracic spine and costovertebral joints. Aerobic fitness is maintained with stationary cycling. Rowing is progressively introduced according to symptoms and strapping is used to support the ribs during training. Posture and technique is reviewed with the coach to eliminate unusual movements of the shoulder girdle.

Low-risk stress fractures

Stress fractures can occur in almost any bone in the body, with the lower extremity weightbearing bones, especially the tibia, tarsals, and metatarsals, being affected most frequently. Although the cause of these fractures is multifactoral, repetitive physical forces without adequate rest are the primary culprits. Stress fractures may be broadly classified as low-risk or high-risk injuries. Low-risk stress fractures, the topic of this review article, can be diagnosed through a thorough history, physical examination, and radiographs. Nuclear scintigraphy is occasionally necessary for confirmation, especially for fractures of the spine and pelvis. When diagnosed early and treated with restriction of activity, low-risk stress fractures have a favorable prognosis.

Rowing injuries: identifying and treating musculoskeletal and nonmusculoskeletal conditions

Rowing-whether on the water or with machines-is increasingly popular, and, as with any strenuous exercise, the potential for injury is high. Rowers may have common symptoms, such as low-back and knee pain, or more sport-specific problems such as rib stress fractures, nerve impingement, and blisters. Virtually all rowing injuries are due to overuse, and many can be traced to training errors or equipment problems. Understanding the mechanics of rowing, the equipment, and the training procedures is essential for the physician caring for injured rowers.

Rib fractures induced by coughing: an unusual cause of acute chest pain

We report three patients with stress fractures of the ribs induced by coughing. Standard radiographs of the chest and ribs did not reveal evidence of rib fractures in any of the patients. Bone scintigraphy, performed 1 to 2 weeks after initial onset of symptoms, showed a focal area of increased uptake along the chest wall in all cases. Thin section angulated helical CT directly visualized the subtle rib fractures. Initial diagnosis of a cough-induced fracture of the rib may be difficult because of the associated underlying disorder, and unnecessary examinations are commonly performed. Identification of a cough-induced fracture of the rib using helical CT may be clinically important to avoid unnecessary concern and additional examinations.

Rib stress fractures in elite rowers. A case series and proposed mechanism

The potential cause of stress fractures of the rib in elite rowers was examined by a retrospective review of 14 fractures in 10 patients. Fractures occurred on the antero- to posterolateral aspects of ribs 5 through 9 and were most often associated with long-distance training and heavy load per stroke. A review of the literature yields striking similarities between these stress fractures and fractures caused by cough. It is suggested that actions of the serratus anterior and external oblique muscles on the rib cause stress fracture because of the repetitive bending forces in both rowing and coughing. A technique involving less use of both muscles through a truncated arm pull-through and a decreased layback position at the end of the stroke, and equipment changes to decrease length of the lever arm, should yield a decreased risk of rib stress fractures in rowing.

Injuries to elite rowers over a 10-yr period

The purpose of this study was to analyze retrospectively all injuries occurring in a population of elite rowers over a 10-yr period to determine their pattern of injury. The medical records of all rowers at the Australian Institute of Sport from 1985 to 1994 inclusive were reviewed and all injuries included. Injuries were categorized according to time, location, cause, and whether acute or chronic. The study found a significant incidence of chest injuries, rib stress fractures, and low back injuries, and a high number of injuries occurring outside specific training. Elite rowers have little risk of major injury, but mild and moderate injuries are common.

Stress fractures in the pediatric athlete

Stress fractures are a source of significant sports disability in the growing athlete. Early diagnosis and treatment are paramount in the management of these injuries to minimize the morbidity associated with them. In addition, the identification of potential host and/or environmental risk factors, and education of athletes, parents, coaches and physicians about these risk factors are key in the prevention of stress fractures and other overuse injuries in the pediatric athlete.

Increased risk of stress fractures of the ribs in elite rowers

In rowing, stress fractures are rare. However, the intensity of training has increased in terms of more specific rowing movements throughout the year. Simultaneously, new equipment has been developed resulting in faster rowing over the racing distance with increased risk of injuries on bones, muscles and ligaments. We report five cases of chest pain and one case of pain in the shoulder in national elite rowers, diagnosed as stress fractures of the ribs employing 99mTechnetium-MDP bone scan. In all cases, an increase or alteration in physical activity in the weeks prior to the injury and an increase in specific rowing movements with special emphasis on the new equipment, combined with increased biomechanical stress applied to the thoratic skeleton in the catch and the early part of the drive phase of the stroke, most probably caused the injuries.

Stress fractures of the ribs in golfers

During a collaborative review at three institutions, we documented 19 cases of stress fractures of the ribs in golfers. There were 13 men and 6 women with an average age of 39 years (range, 29 to 51). The 4th to 6th ribs were the most commonly injured. All fractures occurred along the posterolateral aspect of the ribs, and nine patients had fractures in more than one rib. Sixteen golfers sustained injury on the leading arm side of the trunk. Eighteen golfers were beginners, and the one experienced golfer had dramatically increased his practice time on the driving range before injury. Plain radiographs were usually diagnostic. However, bone scintigraphy was necessary to reach a diagnosis in three cases. A delay in diagnosis of 6 to 8 months occurred in two cases that were originally misdiagnosed as back strains. Stress fractures of the ribs in golfers may be more common than previously realized and may be incorrectly diagnosed as recalcitrant back strains. Based on the findings of other studies, we think fatigue of the serratus anterior is the mechanism of injury. We recommend strengthening the serratus anterior as rehabilitation after this injury and in a general conditioning program for golfers.

Case report--stress fracture of the rib in a golfer

Stress fractures of the rib have been reported in rowers^1–3 and canoeists^4–5; this is the first report of a similar fracture in a golfer.

Stress Fractures

In brief We studied 3 years of stress fractures that occurred at a major university. We found an annual Incidence of 1.9% among athletes, but 67% of the injuries were in freshmen. In 86% of the cases, patients had abruptly changed their training-such as after summer break-and experienced symptoms an average of 4.5 weeks later. Students took, on average, another 3.5 weeks to seek medical care. These findings emphasize the need to carefully monitor freshman training regimens and to be alert for symptoms of stress fracture.

Occult radiographic fractures of the chest wall identified by nuclear scan imaging: report of seven cases

Between 1985 and 1990 the enactment of state mandatory seat belt laws has reduced the risk of death from auto accident by at least 40% and the risk of moderate to severe injury by 45%. Although head and facial trauma has also been significantly reduced, there has not been a decrease in injuries to other parts of the body. We evaluated seven restrained drivers who complained of persistent anterior and/or lateral chest wall pain after being in motor vehicle accidents. All had normal x-rays of the osseous thorax. Nuclear scan imaging subsequently revealed that all seven had a healing fracture of either the sternum or ribs. In each instance, direct trauma to the sternum and ribs anteriorly by the chest strap itself and/or laterally displaced bending forces transmitted to the postero lateral rib margins was sufficient to produce x-ray occult fractures.

Multiple Rib Stress Fractures

In brief Stress fracture of the ribs, an uncommon overuse injury, may mimic recalcitrant intercostal or back muscle strain. This report describes a 36-year-old man who sustained multiple rib stress fractures after he took up golf. Fatigue of the serratus anterior muscle appeared to be the mechanism for his injury. Relative rest followed by strengthening exercises helped the patient return to pain-free activity.

Stress fractures in the athlete. Diagnosis and management

Stress fractures can be a troublesome injury for the sports medicine clinician. The first description was in military personnel, but recently there is an increasing awareness and diagnosis of stress fractures in the athletic population. Stress fractures have been described in all extremities. Some fractures appear to have a degree of sports specificity. Bone is a dynamic tissue which strengthens and remodels in response to stress. Maladaptation to stress causes osteoclastic activity to supersede osteoblastic activity, thereby allowing weakening of the bone. These areas of weakening may fracture and create prodromal symptoms and clinical findings. Localised pains of insidious onset which are activity related are the hallmarks in the clinical history. The physical examination can exhibit localised tenderness, redness and swelling. Radiographs can be negative for up to 4 months. The gold standard for diagnosis is the triple phase 99mtechnetium bone scan. The treatment of a stress fracture is usually conservative. Very few cases require surgical management. The algorithm of conservative management includes: rest, appropriate education for treatment and preventive care, analgesics, serial radiographs, icing and physical therapy modalities, appropriate exercise to prevent detraining, rehabilitation and a regimented return to participation and competition.