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Boathouse Doc: Rib Stress Fracture

Dear Boathouse Doc,

I have had several rowers who have had a stress fracture of the ribs. What is the best way to treat this injury to allow them to return to rowing as rapidly and safely as possible?

Sincerely,

A New England Coach

Dear New England Coach,

Not to be facetious, but the best way to keep them rowing is to avoid the injury in the first place. The cause of the vast majority of rib pain is a stress fracture. It is an overuse injury resulting from the torque applied to the ribs by the serratus anterior external oblique muscles with each rowing stroke. Although this is a term that is commonly used, an intercostal muscle strain is rarely seen. Those who have presented to my office with that diagnosis (usually made by the coach) were found to have a stress fracture on bone scan.

If questioned carefully, your rowers will admit to an ill-defined ache in the region of the ribs for several days prior to the extreme pain of the fracture. Generally, they will complain of the discomfort in the area of the posterior lateral fifth to ninth ribs, but it can occur anywhere. A bone scan performed at this time has shown slight uptake consistent with periostitis or “shin splints.” There is not a discrete fracture. If that athlete cross trains by avoiding the erg and water training and rides the bike, they will generally improve within five to 10 days and then be able to return to rowing and erging. Running is allowed as long as it doesn’t cause an increase in the symptoms.

What happens all too often, however, is that the athlete tries to tough it out and then the rib cracks. This causes significant pain. The pain is localized to a discrete spot on the affected rib. The rower can’t take a deep breath; they have pain rolling over in bed, using the arm on the side injured and are unable to train. They could be lost to the team for as long as six weeks. They should be given pain medications.

A three-phase bone scan is diagnostic. X-rays and MRIs rarely show the fracture. At this point, the progression to return to rowing has to be individualized, using symptoms as a guide for the progression of activities.

When the rib initially breaks, generally the pain is such that they are unable to train. As soon as they are comfortable breathing, which is usually in a few days, I recommend that they begin cross training. Riding a spinning bike with a heart rate monitor allows the athlete to get their heart rate into the desired zone to maintain their aerobic base. Generally, the time spent on the bike is about double the time spent on the erg for the same benefit. Running is usually very painful and is to be avoided initially.

As soon as they are able to roll over in bed and can take a deep breath and do not have pain with rib compression, they can slowly and progressively return to rowing. This may take anywhere from two to four weeks. The fracture won’t be completely healed, but the healing will have progressed enough to withstand greater stress. Running and rowing in tanks with moving water can be started if tolerated. If these activities are tolerated, light erging can be started. I recommend that the athlete combine the biking and erging starting with one quarter of the workout on the erg and the rest on the bike, and then increasing the erg percentage by 25 percent every three to five days as long as there is no increase in the symptoms. Trying to progress too rapidly will only lead to a re-injury and extended time away from rowing. On the erg, the drag should be less than 100 and the stroke greater than 22 for steady-state pieces. Blasters and heavy pieces should never be allowed. The basic idea is that we are attempting to increase the rowing activity as the rib healing increases.

If they can tolerate an erg workout, they can begin training on the water. They initially should only train in “light” boats, such as eights and quads. I recommend that they initially row with a couple of clams on the button to lighten the load. Later, they should have the clams available should they find themselves in very heavy conditions such as a strong current or headwind.

They should ice the rib after each workout. Double-day rowing practices are to be avoided for the first couple of weeks after returning to rowing on the water. The athlete can run or bike for the second workout of the day.

The athlete has to be honest with their symptoms and the coach has to be flexible to allow the quickest return to racing. If the rib is getting sore during or after a workout and the pain persists the next day, they should cross train until it resolves.

I also recommend that they begin scapular strengthening exercises when the pain has totally resolved. Click here for a few examples.

Early recognition of a pending rib stress fracture will prevent the long process of returning the athlete to full training -- not to mention losing him or her for the season. The progress after the diagnosis must be based on the rower’s symptoms in order to prevent re-injury and enable the fastest possible return to rowing.

Sincerely,

Boathouse Doc