AUSTRAliAN PH Y SlOTH ERA PY CLINICAL NOTE S 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 therapyand pass ive mobil j sation of the thoracic spine and costovertebral joints. Aerobic fitness is maintained with stationary cycling. Rowing is progressively introduced according to symptoms andstrapping is used to support the ribs during training. Posture and technique is reviewed with the coach to eliminate unusual movements of the shoulder girdle. [Wajswelner H:Management of rowers with rib stress fractures. AustraJianJournal of Physiotherapy 42: 157- 161] Key words: Fractures, Stress; Rehabilitation; Rib; Sports H Wajswelner BAppSc(Phty), GradDipManip Ther, MAPA, MMPAAis alecturer in the School of Physiotherapy, The University of Melbourne, a private practitioner at Olympic Park Sports Medicine Centre, Melbourne .. Correspondence: HenryWajswelner, School of Physiotherapy, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, 200 Berkeley St. Carlton, Victoria 3053 tress fractures of the ribs are frequently diagnosed as a cause of pain in the thoracic region and chest wall in competitive rowers and scullers. In the Australian ·Senior A Rowing Team, there were two cases in 1991,one case in 1992, two cases in 1994 and two cases in 1995 during the team's buildup and competition at the World Championships. More accurate diagnosis and management may account for the stabilisation in numbers in elite performers, but the incidence in the general rowing community appears to be increasing (Coburnet aI1993).Thisinjury is also a cause of prolonged disability and lost training and competition opportunity and, even though it is not as common as low back pain, it is the most problematic injury in rowing (\Vajswelner et al 1995). In Australian teams, scullers and sweep rowers, males and females, lightweights and heavyweights have all been affected. There is no statistically significant pattern to the type of rower who will sustain this injury. The only common factor, discerned from the clinical histories of patients, is that there is increase in trainingintensity leading up to the injury in most cases. These stress fractures have been reported as occuring.in various locations along the length of the middle to lower ribs in rowers, mostly along the.anterior axillary line (Figure 1) but also posteriorly (Holden and Jackson 1985, Wajswelner 1991, Brukner and Khan 1996). McKenzie (1989) reported.a case of a stress fracture of the ninth rib in an elite oarsman, whose pain and symptoms were confined to the area of the figure 1. Bone scan showing rib stress fracture in the anterior axillary line. fracture on the anterolateral aspect of the rib at the origin of serratus anterior. McKenzie blamed errors in training as the primary aetiological factor, without describing these errors specifically. The attachment of the serratus anterior muscle·in this area was implicated as the source ofstress to the rib by McKenzie (1989). A possible cause proposed was the serratus anterior acting to protract the scapula during the recovery portion of the rowing stroke cycle, when the abdominals were also active. The external oblique abdominal and serratus anterior interdigitate in this area and these muscles pulling across the hone could produce enough repetitive stress to cause a fracture (Stanitslci et aI1978),,·However, this proposed mechanism of injury does not explain the cause ofstress fractures -
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AUSTRAliAN PH YSlOTH ERA PY CLINICAL NOTE S
Management of rowerswith rib stress fractures
Stress fractures of the ribs in rowers occurmostly along the anterior axillary line, but alsoanteriorly and posteriorly. Management haspreviously consisted of rest, but symptoms'canrecur on return to training. Earlier return torowing can be achieved with management thatincludes ice and TENS for pain relief, pulsedmagnetic field therapyand pass ive mobil jsationof the thoracic spine and costovertebral joints.Aerobic fitness is maintained with stationarycycling. Rowing is progressively introducedaccording to symptoms andstrapping is used tosupport the ribs during training. Posture andtechnique is reviewed with the coach toeliminate unusual movements of the shouldergirdle.[Wajswelner H:Management of rowers withrib stress fractures. AustraJianJournal ofPhysiotherapy 42: 157-161]
H Wajswelner BAppSc(Phty), GradDipManipTher, MAPA, MMPAAis alecturer in the Schoolof Physiotherapy, The University of Melbourne,a private practitioner at Olympic Park SportsMedicine Centre, Melbourne..Correspondence: HenryWajswelner, School ofPhysiotherapy, Faculty of Medicine, Dentistry,and Health Sciences, The University ofMelbourne, 200 Berkeley St. Carlton, Victoria3053
tress fractures of the ribs arefrequently diagnosed as a cause ofpain in the thoracic region and
chest wall in competitive rowers andscullers. In the Australian ·Senior ARowing Team, there were two cases in1991,one case in 1992, two cases in1994 and two cases in 1995 during theteam's buildup and competition at theWorld Championships. More accuratediagnosis and management mayaccount for the stabilisation innumbers in elite performers, but theincidence in the general rowingcommunity appears to be increasing(Coburnet aI1993).Thisinjury is alsoa cause of prolonged disability and losttraining and competition opportunityand, even though it is not as commonas low back pain, it is the mostproblematic injury in rowing(\Vajswelner et al 1995).
In Australian teams, scullers andsweep rowers, males and females,lightweights and heavyweights have allbeen affected. There is no statisticallysignificant pattern to the type of rowerwho will sustain this injury. The onlycommon factor, discerned from theclinical histories of patients, is thatthere is increase in training intensityleading up to the injury in most cases.
These stress fractures have beenreported as occuring .in variouslocations along the length of themiddle to lower ribs in rowers, mostlyalong the.anterior axillary line (Figure1) but also posteriorly (Holden andJackson 1985, Wajswelner 1991,Brukner and Khan 1996). McKenzie(1989) reported.a case of a stressfracture of the ninth rib in an eliteoarsman, whose pain and symptomswere confined to the area of the
fracture on the anterolateral aspect ofthe rib at the origin of serratusanterior. McKenzie blamed errors intraining as the primary aetiologicalfactor, without describing these errorsspecifically.
The attachment of the serratusanterior muscle·in this area wasimplicated as the source ofstress to therib by McKenzie (1989). A possiblecause proposed was the serratusanterior acting to protract the scapuladuring the recovery portion of therowing stroke cycle, when theabdominals were also active. Theexternal oblique abdominal andserratus anterior interdigitate in thisarea and these muscles pulling acrossthe hone could produce enoughrepetitive stress to cause a fracture(Stanitslci et aI1978),,·However, thisproposed mechanism of injury doesnot explain the cause ofstress fractures-
ClINICAl NOTE S AUSTRAliAN PHYSIOTHERAPY·
figure 3.Possible mechanism of injury to the ribs anteriorly.
From Pagefound both anterior and posterior tothis area of muscle attachment.
The author is not aware of one caseof hilateral fracture in a rower to thisdate, although multiple fractures onthe same side have occurred (Reid et al1989).
Another possible explanation for thisinjury is the bench pull exercise(Figure 2) during which there isconsiderable compressive force appliedto the ribcage (Wajswelner 1991). Theauthor has seen one elite sculler whocaused his rib stress fractures by doingvery heavy inclined leg press exerciseswith one leg pressing heavily againstone side of the ribcage anteriorly(Figure 3).
Signs and symptomsThe symptoms'of a stress fracture ofthe rib include pain in the chest wallwhich may be a constant dull ache withor without sharper pain on movementand deep breathing or coughing. Therower will experience pain during and!or after exercise such as rowing orsculling, weight training, using arowing ergometer or running. Therewill be pain on using the arm on theaffected side, especially against heavyresistance. In the acute stage, there willbe pain during the night with thepatient unable to find a comfortableposition, pain on turning over in bedand on rising from bed and a'variabledegree of sleep disturbance. There maybe radiation of pain along the affectedribs anteriorly or posteriorly in thedistribution of the relevant intercostalnerve. Very often the patient will alsohave stiffness and pain in theinterscapular area of the thoracic spine,generally at the costovertebral junctionof the affected rib.
The clinical signs of a stress fractureof the rib include tenderness over thefracture site, which may be quitedifficult to localise and which is notalways in the anterior .a,xillary line.Tenderness may be found anywherealong the rib,even at its anterior tip orcostochondral junction, but with astress fracture the bone, rather than
surrounding soft tissues, is the site ofmaximum tenderness.
There may be swelling over thefracture site. Springing the ribs in anantero-posterior or lateral directionwith contact distant to·the site ofmaximum tenderness will reproducethe pain and helps to confirm thediagnosis clinically. The pain on deepbreathing may correspond with.areduction in chest expansion on theside of the injury. Patients exhibit apainful restriction of trunk andthoracic spinal movements with painand restriction detectable on palpationof comparable levels of the thoracicvertebrae.
The patient may find it difficult to lieprone on the examination bed, due tothe pressure this exerts on the ribcage,and may need to be examined andtreated in side lying.
Diagnosis\Vhile there appears to be no clearlydefined, comnioncause of this injury,the clinical diagnosis is now widelyrecognised. Arower presenting withsuch signs and symptoms and a historyof an increase in training intensityshould he referred to their doctor forconfirmation of the diagnosis. There is
some question as to whether a bonescan.isnecessary, since the possibilityof false negative (Milgromet a11984)or false positive findings cannot beoverlooked. Currently, a bone scanremains the definitive method, while
Figure 2.Bench pull exercise.
AUSTRAliAN PHYSIOTHERAPY ell Nt CAL NOT E S
Figure 4.Application of fixomull®in preparation for strapping.
Figure 5.AppHcationof strapping tape to splint the injured rib during expiration.
bone healing and maintaining fitnessduring rehabilitation. With an acutestress fracture, a period of rest fromintense physical activity to allow initialhealing of the injury is essential foroptimal management. The acutemanagement of this injury haspreviously consisted of a prolongedperiod of rest from rowing, for up tosix weeks. Despite this prolonged rest,the symptoms often recur on return totraining. An earlier return to pain-freerowing can be achieved using acarefully staged rehabilitation programthat includes correction of thebiomechanical factors that havecontributed to the injury and managingthe problem symptomatically. Closecommunication with the rower'sdoctor and coach will ensure aconsistent approach to management.The optimum period of rest varies
from two days toa week, depending onpain severity. As soon as pain on deepbreathing eases, low grade exercise cancommence.
If there is insufficient time for anoptimal management plan, the rowermay wish to adopt a "treat and train"approach as has been used precedingimportant competitions such as WorldChampionships or Olympic Games.With this approach, there is no restperiod, or a very brief one only, andminimal disruption to training andcompetition, combined with moreintensive treatment, constant use ofstrapping and analgesia and regularicing· and TENS. Because of continuedactivity, pain relief is compromised forthe sake of maintaining fitness and thecrew's competitive edge. It isimportant to explain to the patient thatwith this approach, progress isdependent on the symptoms, and thatthese changes must be accuratelyreported to avoid frustrating delays inthe. rehabilitation process.
Maintaining fitnessThe prescription of rest can beemotionally devastating for a highperformance athlete,so attemptsshould be made to at least allow somelow grade active exercise to maintainfitness and morale. The type and
Management and rehabilitationOnce a diagnosis of rib stress fracturehas been made, management shouldcommence that includes relief of theacute pain, optimising conditions for
the reliability of clinical diagnosis hasyet to be determined. If·there is doubt,a bone scan will help to confirm thediagnosis.
C LI N IC A L NOT E S AUSTRAlIAN PHYSIOTHERAPY
Figure 6.Combined position for mobilisation of the thoracic spine when prone Iving is painful.
Page 159intensity of exercise that is permittedwill depend on the severity and stage ofthe injury. For an acute or very severecase where there is pain at rest, painwith quiet breathing and sleepdisturbance with an inability to find acomfortable position, the level ofactivity may be walking or gentleexercise on a stationary bicycle. If thereis no exacerbation of the pain, this canbe gradually increased. The intensityof training can be gauged using heartrate and suitable target levels ofaerobic workload can be prescribed inconsultation with the coach. Aminimum intensity to aim for initiallyis 60 per cent of maximal heart rate for20 minutes, increasing to 70-75 percent as soon pain permits. Stationarycycling maybe replaced by arm and legcycling, gradually increasing theintensity to include several shortintervals of anaerobic work such as 60to 90 seconds at 85-90 per cent ofmaximal heart rate. If possible, exerciseintensity on the bike should matchthat of the regular training program.
Strapping can be used to splint theaffected rib to allow the patient toexercise without aggravating pain.Running or the use of a push bike canthen be introduced to progress theintensity of training as the patient'scondition improves.
StrappingStrapping is applied with the patientlying on the uninjured side or insupine. Symptoms produced on deepinspiration are assessed to enableevaluation of the effectiveness ofstrapping. The skin should be washedand dried and two strips of Fixomull ®
Stretch (BDFBeiersdorf AGHamburg) are applied along theinjured rib from the thoracic spine tothe costochondral junction or to themidline if there are symptomsanteriorly (Figure 4). Two or threestrips of non-elastic 38mm sports tapeare then applied firmly from back tofront while the patient exhales to limitmovement of the affected rib oninspiration (Figure 5). If there areanterior symptoms, or anteriorsubluxation of the rib is suspected, the
tape can be applied front to back to seeif this relieves pain more effectively.Pain on inspiration.isthen reassessed.Tape should not be left on indefinitely,as skin reactions are common.Removingthe tape often does moreharm to the skin than leaving it on. Iftolerable, this tape can be left on andreinforced with extra·strips of sportstape daily for two or three .days.
Physiotherapy treatmentIn the acute stage, physiotherapy cancommence immediately, with ice andTENS for pain relief applied over thetender area at least twice daily.
The thoracic spine, costovertebraland costotransverse joints areexamined for asymmetry of motion,pain and stiffness on palpation. This istreated with superficial heat andlorultrasound and passive mobilisation, iecentral and unilateral postero-anterior(PIA) accessory glides. Specificmanipulation in· the form of a localisedPIA thrust on the thoracic spine withthe patient in supine, as described byMaitland (1986), can be used·with careto relieve stiffness and pain in this area.Care must be exercised in preventingexcessive compression of the rib cage
with this technique, which may causepain at the fracture site. Central andunilateral palpatory mobilisation is alsoused to restore range ofmotion to thethoracic spine, perhaps using acombined starting position if thepatient has difficulty in lying prone(Figure 6).
Manual resisted movements can beused to simulate the rowing stroke tocheck for weakness or unusual patternsofmovement of the shoulder girdle inparticular. Strength of the scapularstabilising muscles can be assessedusing manual resisted testing,particularly resisted scapularrhomboids and middle trapezius.Remedial strengthening exercises ofany weak muscles are introduced atthis stage, for example single armdumbbell pulls to strengthen theshoulder retractors.
As the reported symptoms improve,so should the signs on clinicalexamination. Thoracic spine signsmust be cleared and there should be nopain on deep breathing before agradual return to rowing training isallowed. On water training cancommence with sculling half slide atsteady state. Sculling, being a
AUSTRAliAN PHYSIOTHERAPY C11 NI CAl NOT ES
symmetrical action, is allowed inpreference to sweep oar rowing, as it isthought to be less stressful and thepatient can concentrate on correctposture, muscle activation andtechnique.
Strapping of the ribs is used tosupport the injured area during theseearly stages, to allow rowing trainingwithout aggravation of the injury.Breathing exercises are taught toregain symmetrical chest expansion.
As symptoms improve, moreintensive training is allowed includingergometer work, perhaps with a mirrorfor posture and movement feedback.Strapping is gradually used less, beingheld in reserve for high risk activitiessuch as ergometer testing, weighttraining and more intense rowing.
Full rehabilitation includesindividualised attention to posture inthe boat and rowing technique isreviewed with the coach, to eliminateunnecessary movements of theshoulder girdle. Regular follow uptreatment of muscle and joint stiffnessin the thoracic area and strengtheningof the scapular muscles is continued toprevent recurrence. This may includeregular massage and manipulation ofstiff thoracic spinal joints and a homeprogram of exercises to maintainflexibility of the thoracic spine.
PreventionWhile the cause of this injury remainsunclear, health professionals andcoaches. involved in the preparationand care of rowers and scullers canonly attempt to minimise the risk byattending to the possible aetiologicalfactors:1.. Weights for the bench pull
exercise should be keptmanageable and trick movementsshould be corrected. Excessivechest compression can beprevented by using a padded benchand using blocks to elevate theweight bar or dumbbells to astarting height that is reachedcomfortably, especially if therower has short arms. Avoid usingexcessively heavy weights thatcause the chest to be compressed.
2. Sudden increases in trainingintensity on. water, in the weightsroom and on the rowingergometer all increase the risk ofrib and other injuries (Coburn etaI1993).
3. Athletes and coaches should beaware that a sudden return totraining after a break due to injuryor illness and changes in boats,rigging or changing sides in a boatare also suspected risk factors.
4. Coaches should be aware of, andtry to correct, unusual or trickmovements of the arms orshoulder girdle during training,especially excessive shoulderelevation or poor control of theposition of the scapula andglenohumeral joint at the catchphase of the rowing stroke.
ConclusionThe aetiology ofstress fractures of theribs in rowers is yet to be determined.The mechanism of injury in each casemust therefore be evaluated on anindividual basis, and the actual causecan only be suspected. However, thisshould not prevent the physiotherapistfrom planning and carrying out arehabilitation program once thediagnosis has been made, with progressbased on close monitoring of reportedsymptoms. Finally, observation andcorrection ofsuspected techniquefaults in consultation with the coachwill assist a more rapid return to fulltraining and prevention of recurrence.
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