163. Rib Stress Fractures in Athletes

In this episode of the PT Snacks podcast, your host Kasey dives into the often-overlooked topic of rib stress fractures. Aimed at physical therapists and PT students, this segment focuses on identifying, understanding, and managing these injuries, particularly in rowers and overhead athletes. Learn about the prevalence, symptoms, risk factors, and treatment strategies for rib stress fractures, along with expert tips for differential diagnosis and patient management. Whether you’re prepping for your SCS or looking to improve patient outcomes, this episode offers valuable insights delivered in an engaging, bite-sized format.

00:00 Introduction to PT Snacks Podcast
00:17 Understanding Rib Stress Fractures
01:32 Prevalence and Affected Populations
03:26 Symptoms and Diagnosis
08:42 Differential Diagnoses
10:45 Management and Treatment
14:05 Imaging and Final Thoughts
15:14 Conclusion and Additional Resources

Transcript

0:30

Hey guys. Welcome to PT Snacks podcast. This is Casey, your host, and if you're tuning in for the very first time, what you need to know is that this podcast is meant for physical therapists and physical therapists, students who are looking to grow their fundamentals and bitesize segments of time. Now, today, what we're gonna cover is actually on rib stress fractures. How often do you hear about that? And the goal of today is really just to bring awareness to it. Especially if you are treating rowers or really overhead athletes as well who see a lot of high volume. But before we go into that, if you've been listening to the show for at least three episodes and you found it to be helpful, it would mean the world to me if you would stop, pause this podcast and leave a review wherever you are listening to this podcast.'cause that really does make a difference. But. With that being said, let's go ahead and move into just exactly what do we mean by rib stress fractures in who gets them, how do we identify them, and what do we do about it? So first off, this is something that comes up pretty frequently on SCS board questions, so if you're studying for your SCS, I'm sure you might have come across this as a topic to know, but it might be something that sees you, you just don't see it, meaning your patient may have it if you're treating specific populations, but it's good for you to be able to catch signs for it. It's something that we should be aware of. It can cost our athletes weeks of training. And if we don't recognize it and we keep loading it, it can make it worse. In terms of how common this is and who gets it? It depends on, again, who you're treating with. Rowers, I would say this is definitely more common, something that should be on your differential diagnosis list. McConnell et all reported rib stress fractures in 8.1 to 16.4% of elite rowers. 2% in university rowers and 1% of junior elite rowers. Ali's systematic review reinforces that these injuries are frequent in elite rowers and significantly affect training and performance. Where does this usually happen? Usually in ribs four through eight and often along the anterolateral or lateral rib cage in our overhead throwing athletes, especially think first rib. Koho and Ito's work gives us a nice snapshot of first rib stress fractures and throwers. So they did a retrospective study of 24 first rib stress fractures in 23 overhead throwing athletes, but their mean age of about 16 to 17-year-old, and most injuries were on the dominant side. Could present as posterior shoulder or upper thoracic back pain, not necessarily an obvious rib pain. So something to consider if you're treating high school and collegiate pitchers, overhead throwers, sometimes other overhead sports that create repetitive traction and compression through the first rib via the scalings and the surrounding musculature. Sos. Again, big picture rowers, especially elite and serious rowers who have a high volume of training. And then overhead throwers, pitchers, other overhead sports with high throwing volume, and potentially other athletes who have high repetitive chunk rotation, heavy upper quadrant loading or bone health issues, things reds, low bone mineral density, maybe some other comorbidities that affect their bone quality. So when we're with these patients, what might they say? Sometimes this can be from insidious onset of pain, not necessarily a single traumatic event, like I pulled and I felt a crack. It's usually the pain is described as a deep ache around the posterior lateral thorax in the mid and lower ribs and rowers or posterior shoulder or upper thoracic back pain. For first rib stress fractures, there's a strong association with an increase in training. Load. Could be volume, intensity, TER work, changes in programming, technical changes in form, or competition periods if they have changed as well.'Cause remember often. In most tissues, we are looking at a mismatch between the mechanical load that tissue is able to handle and the load that is being applied to it. In a stress fracture, it's typically more load than is able to be handled over a longer period of time. So if someone is increasing their training load, this is an example of how that can happen, right? Now pain often can worsen with training, especially if they're doing high force movements or high velocity. And it can improve with rest. It just may not really resolve with rest. Just depends on the degree of the injury, really. So some intrinsic factors that we can identify according to McConnell would be if someone has low bone mineral density, right? They're already starting from behind in terms of stress that their bone can handle. If we are identifying any menstrual dysfunction or hormonal issues in men and women, that is also something that we want to be able to have on our radar when we're asking. Could this possibly be something that the athlete in front of us, or person in front of us is dealing with nutritional deficiencies, low calcium, low vitamin D, disordered eating. These are all things that can lend to having poor bone quality, extrinsic factors. As I mentioned, rapid spikes in training volume or intensity. Technique issues that can increase rib loading equipment or gearing choices that change force transmission so essentially beyond asking about. Their pain, what happened? We wanna know their training history, if there's been any change in that. If they have noticed any hormonal issues or things that we might think reds for skipped periods, big weight changes, chronic low injury bone health. Do they have a history of other stress fractures, low bone mineral density, any endocrine issues? Are they seeing anyone for this already? In other specialties? And then in terms of our exam, we don't wanna just assume, oh, it's some sort of muscle strain, right? We are taking a look at it. We're palpating, there's not often an obvious swelling or deformity, but they can't have very focal tenderness over where the problem is. So for instance, like if rowers, it's most commonly in the ribs four through eight. Those are gonna be the ones that are typically have that focal tenderness, more specifically, probably in the mid axillary to an lateral line, and then over the first rib, supraclavicular, or paraspinal region near the upper thorax in throwers, direct palpation of the rib will reproduce their pain more clearly than general paraspinal palpation. Do they have pain with deep breathing, coughing, sneezing? These are all things that are important to note.'cause remember, if we're thinking of the function of the ribs, they protect some pretty vital organs. But they're also involved in our breathing patterns too. So it's a good way for us to identify, can we reproduce this and loaded positions that mimic their sport. Such as for rowers and their catch or finish or in pitchers, for instance, in the late caulking or acceleration, ask them what this is. Ask them when they feel the pain and then try and replicate that. You don't necessarily have to be an expert about every single sport, although it does help at least if you're treating a high volume of that patient population. And then you can look at resisted testing pain with resisted serratus anterior abdominal work. Scaling's upper trap, depending on the level that's involved. Essentially you're using your knowledge of anatomy to differentiate on is there a passive component, is there an active component? What muscles are, or joints or nerves, et cetera, are in this area so that I can tease out other things that might be involved. A range of motion of the shoulder and spine might be relatively normal, but you might see guarding an in range pain with combined movements. Things that are essentially adding stress to the rib that you are suspicious of. It's always good to screen out other tissues. You're looking at general range of motion of the thoracic cervical shoulder you're taking their, you're looking at their muscle testing, things like that, that we call basic, but for the purpose of being able to rule out other things. For instance, let's think about our differential diagnoses, right? Some differentials to keep in mind could be some sort of cost of vertebral or cost of transverse joint dysfunction where they may have localized joint pain, might be sharp with certain movements and PA pressures, but no clear training load story or focal bony tenderness along the rib shaft. Myofascial pain or muscle strain. Looking at atera interior, external oblique lats the muscles in this area. Usually more diffuse muscle tenderness and improves more quickly with load modification and soft tissue work. Thoracic spine facet, or disc related pain might give similar regional pain, but often with more spinal movement provocation and less discreet rib tenderness. I will say symptomatic herniated disc in the thoracic region are very rare. It can show up on imaging, but the key word here is symptomatic, also visceral and cardiopulmonary causes. Pulmonary embolism. Hopefully your athlete doesn't have that pneumonia, spontaneous pneumothorax, cardiac ischemia, red flags like dyspnea, abnormal vitals, systemic symptoms or non mechanical pain patterns. That's why it's important for us to not assume if it doesn't behave like we think it is, that it's probably some weird musculoskeletal issue.'cause we do wanna make sure it's not a red flag for something that is not musculoskeletal. And speaking of which red flags, we also want to keep in mind if there's any signs of cancer or infection, like night pain, weight loss, systemic signs, atypical imaging. All these definitely need further investigation from other specialties. So make sure that you're looking, that this is a musculoskeletal issue that the tissue that you are suspicious of is actually behaving the way you expect it to if it is under pain and you're screening for red flags to make sure that this isn't something more sinister. Now, let's say, okay, this patient has a stress rib fracture. What's next? So essentially, if we are already at a point where we have loaded the bone beyond as mechanical capacity, we have to take stress down to a level where that bone that has already a decreased mechanical capacity has a chance to actually catch up and heal. So the amount of time can vary that these athletes are away from sport. That's why we wanna catch these on the earlier side. Sometimes they can lose four to six weeks. Sometimes it could be one to 16. Essentially in McConnell's review, it suggested initial management involves one to two weeks of cessation of rowing with pain control, and then a slow return to rowing with low impact pain-free training building gradually. This might, obviously, we need to keep in mind the degree of the. Injury that's happening, the capability of the patient to handle certain types of stress and bone healing timelines. Other factors other than rest.'cause we don't want our patient to be completely deconditioned beyond just getting them back into the sport. Maybe you're strengthening the areas around. The particular site such as like the Radus, interior Rhomboids or whatever we're looking at here and the surrounding limbs, core, et cetera. Things that they need to be able to maintain their strength in a way where we're not adding too much stress and hindering the healing process. If there are any mobility deficits that might be forcing the ribcage to take on more stress, we wanna address those. Is it. Is there a thoracic or hip mobility? Is there a shoulder mobility deficit problem that we wanna incorporate? Is there a technique issue that caused this in the first place? Let's work with coaches on rowing or throwing technique, unless you're an expert in this too. For me personally, I am not a rowing expert. So I would refer to the professionals in that aspect. And then is there any sort of underlying bone health aspect that we need to address? Do they need a dietician? A therapist? Fill in the blank. I think the more experts that can work together to handle a ta a task, especially if someone's really trying to get back to 110%, the more we use more brains to put them together. So essentially, ideally before they're going back, pain at rest is gone. Palpation, tenderness, pretty much gone or very minimal. And then sports specific loading, we are gonna start off with low force, short duration, maybe light, easy technical work or low velocity throwing. And then we progress volume and then intensity, and then we can add more progressive loading. Then we can add more aggressive loading, such as like at a race pace or a full amount of work later in the progression. The good thing is, at least in the first rib case series that I looked at, most athletes were managed conservatively, although healing could take several months, and non-union occurred in a small subset, which is why you don't wanna rush or ignore this. Now in terms of imaging, we've gotta make a point to acknowledge this. Plain radiographs can miss early stress fractures, especially in the first rip so bone scans, MRIs and cts are often used when suspicion is high and the x-rays normal. So take home from this should be that rib stress fractures are something to have in your radar, especially if you're working with rowing and overhead throwers. And the story is usually linked to. Their pain is of insidious onset. It's linked to a higher training volume or some sort of abnormal change to their training. They have focal rib tenderness and pain that worse is with sports specific loading. And management is typically about relative rest, correcting whatever might have lent to them, developing this in the first place, and then a graded progression of stress, volume, et cetera, to help get our patients back often over four to six weeks could be more so if you have any questions at all, feel free to reach out to PTs Snacks podcast@gmail.com, or I just started an Instagram page relatively recently at PTs Snacks podcast. If you wanna shoot me a DM, if you are there, as well as make sure that you sign up for the newsletter.'cause every week I send out just a summary of the email, helps you know what's going on and what's current. Other than that, if you are in the need for getting some more CCUs, med Bridge is actually offering listeners PT snacks over a hundred dollars off for several plans that they offer. Last I looked, they have over 2000 courses. They have a ton of webinars and specialty exam prep for if you're studying for tests like your OCS and SCS. I use them for my OCS and it was super helpful. So make sure you use the promo code, PT Snacks podcast. You can find it down in the show notes and students, there's an even better deal for you, so make sure you use that as well. That's it for day guys and into next time.