Stress fractures - Rib Stress Fractures for Rowers, all you need to know!

Author: HeadStart Sports, Injury & Performance Clinic

- Today, we are doing a live training on stress fractures for rowers. The reason that I have been prompted to do this is because this year, in particular, I've seen more stress fractures and severe stress fractures in clinic than ever. We're gonna go over what are they, the signs and symptoms, the rehab, and then sort of how to train or not train with it, and then most importantly, the prevention. As with all the live trainings, you can add any questions down below. To start off with, we'll just go over what is a stress fracture? You think of a stress fracture as an overuse injury. Just like you would have an overuse injury with a tendon or a muscle, and you can get that fatigue, this is the same thing, but with a bone.

The key thing to remember here is that bones take the longest time to heal out of any tissue at all. So muscles heal the quickest, and then we work through from tendons, ligaments, and bones. This is why a stress fracture's really important to identify early 'cause we're talking, worse case scenario, three months of no training whatsoever. A stress fracture can actually move on to then, a full fracture, so actually fracturing your ribs, which we've all known somebody that's had a rib fracture, and it's not fun at all, whatsoever. So what is a stress fracture? The way that I tend to describe it to patients is to think of a Crunchie bar, so that nice chocolate bar with like a honeycomb center. A stress fracture is where there's been some damage to that honeycomb on the inside, but then that chocolate around the outside is still intact.

You've got some integrity on the bone, but there's definitely some internal damage that's been going on. So why does that actually happen? The way to think about it is it's more to do with the ratio between damage and repair. This is sort of key for why we have certain risk groups for stress fractures. The biggest group of people that are at risk for stress fractures, regardless of whether it's rib or shin, is actually white females in their early 20s, and the reason is, is because they're most at risk for this hormone imbalance, which means that the damage that's happening to the bone is not being balanced by the amount of repair, and that slow decline every time is what can then cause that stress fracture. Often, you'll find rowers will say, "I didn't do anything, I just did my normal training. "All of a sudden, I got this rib pain sort of here, "and then it then, all of a sudden, over two sessions, "just got so bad that I couldn't even train at all." What other signs and symptoms of stress fractures? Well, the biggest one is gonna be rib pain.

The rib pain that we're looking for is either on the side or on the front. If you're a sculler, you can get rib pain around the back. There was a really good review paper that I was looking at and scullers tend to be at risk around the side and back, and sweep rowers tend to be around the side or front. There is no correlation between which side you get the pain and which side you row, if you're doing sweep. Don't just go, "Oh, well, somebody had it on their outside side, "so this pain that I'm getting on the inside side "can't be a stress fracture." It can, so just watch for those signs.

Stress fractures - Rib Stress Fractures for Rowers, all you need to know!

The signs and symptoms you're looking for when it's particularly severe is if it's pain on coughing or pain turning over in bed. If we have that, then we definitely want to stop training all together. The other signs are is that you've got a continued aching in that rib section, which, like I said, tends to be that lower rib section whilst training, but then also, you'll find it going into daily activity, so like reaching up to get something off of a shelf. That tends to be a really common one. We also notice that you tend to have a correlation with pain at the finish of the stroke.

This has to do, they think, with the relationship between your abs working and then your scapula here, and it's that twisting motion that then irritates the bone the most. So what do you do to rehab it? If we're at the stage where coughing or turning over in bed's painful, we need to stop immediately. You need to go get medical attention for that, so go see your GP, go see a physio, go see a sports injury clinic. If you are out of the phase of that acute pain, which is very similar to, like I say, if somebody actually has a rib fracture, then what you need to do is low intensity training. It needs to be UT3 level.

That heavy breathing that you're gonna get from intense training will irritate the rib. Just because it might be rowing, the cause of the problem in the first place, once that bone is irritated, any movements, including heavy breathing, is gonna be a problem. The question I often get, which you can obviously add any other questions below if you're watching live, is, "Can I run?" Well, actually, the answer's no, you can't run if you're getting rib pain for two reasons. One, because of the rotation you get with the upper body when you're running, but then two, because most people I see in clinic, they are not able to run at an intensity that is UT3. The advice you need to take if you've got a stress fracture is you go on the bike, a static bike in the gym at a UT3 intensity. You keep the body ticking over like that, but we don't irritate the rib at all, whatsoever.

Crossing over between rehab and prevention, why do they think people get stress fractures? Apart from this issue with damage and repair, which, like I said, young white females are most at risk of, is actually to do within that strength and mobility of the shoulder blade. We find that if you do serratus anterior exercises, so I will try and pop a link down below of how to do some scapular push ups, which is an example of one of those, that that strength of how you can control the shoulder is really important. I know for a fact that most rowers, and women do tend to be more to blame for this than guys, but your upper body strength and your shoulder mobility is actually really poor. What you need to do is kind of work on improving that shoulder mobility, so doing either stretching drills, or mobility drills, and you can drop us a line if you need some help with those. We can send you some tutorial videos, but then also, it's that strength. Most of you are really struggling to get into positions where you can do push ups correctly, and again, women do tend to be worse with this than men, but also, that you can do things like single arm work. I took someone through some stuff the other day, and we're talking about stuff like Turkish Get Up, Weighter's Carries, doing Ring Rows, just doing a single arm kind of Kneeling Plank position, something like Bird Dog exercise.

All of these sorts of things, Renegade Rows, all of those sorts of things is stuff that rowers should be doing. You sit down, so you're partial weight-bearing sports, you row asymmetrically, and then you then normally go and sit in an office the rest of the day. These are the reasons why we're at risk of those stress fractures. In order to prevent, we need shoulder mobility, we need scapular strength, we need to make sure that we've got high vitamin D and good calcium intake, and then also, we need to make sure that we are keeping good thoracic mobility. That is that upper back and spinal mobility. You can use things like a peanut ball for that, so articulating back up and over the ball.

You can just use a mobility ball to massage around the spine, but any of those things will help prevent your risk of stress fractures, and then if you are somebody that's symptomatic, that's what we'd be recommending. What I'm gonna do is add a link down below for a nice little A4 poster that you can print out and put up in your club. It's got a little checklist that you can work through so you can actually work out, are you at risk for a stress fracture or not, and then what to do about it. So do download that, print that off for the club, and then you can add any questions that you want about stress fractures down there too, and I'll make sure they're answered for you.

Go through and look at and investigate your shoulder mobility if you haven't already, and your scapula strength, and if you are suffering with rib pain, then drop us a line because it's so important that you get on top of this. I've had rowers out for three months for this this season. Alright, that's it for today, guys. Take care, and if you've got any other ideas for questions that you want and topics for future trainings, please pop them down there, and I will speak to you again next week. Bye bye.

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