BJSM Online First, published on December 1, 2015 as 10.1136/bjsports-2015-095126
Consensus statement
Great Britain Rowing Team guideline for diagnosis
and management of rib stress injury: part 1
Guy Evans, Ann Redgrave
▸ Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
bjsports-2015-095126).
Great Britain Rowing Team,
London, UK
Correspondence to
Dr Guy Evans, Great Britain
Rowing Team, 6 Lower Mall,
Hammersmith, London
NG7 2UH, UK;
guy.evans@gbrowingteam.org.
uk
Accepted 31 October 2015
ABSTRACT
Background Rib stress injury (RSI) is the development
of pain due to bone oedema caused by overload along
the rib shaft and is commonly seen in rowers. Often
clinicians who manage this injury are experienced with
the condition at the elite level. There may, however, be a
lack of confidence in diagnosing and managing this
condition by clinicians who are not regularly exposed to
this injury. As a result, an evidence-based guideline has
been developed to aid diagnosis and management of
RSI.
Methods A detailed literature search was conducted
reviewing the diagnosis and management of RSI.
Detailed discussions were held by the Great Britain
Rowing Medical Team to identify key issues in diagnosis
and management of RSI. An up-to-date, evidence-based
approach to managing RSI was created using both
expert knowledge and current literature to formulate a
functional guideline outlining best practice in
management of RSI in rowers.
Results A clinical guideline has been created
incorporating 5 key areas: diagnosis, severity grading,
investigation, management and associated risk factors
for RSI. Important indicators for each key area are
incorporated within the guideline using relevant literature
where possible alongside expert opinion. The guideline
has deliberately been kept concise and tailored for use in
the clinical setting.
Conclusions A new clinical guideline for management
of RSIs has been developed to facilitate clinicians in
identifying RSI, aiding accurate diagnosis and providing
effective management. This guideline is to be
disseminated to clinicians, rowing coaches and clubs
throughout the UK.
BACKGROUND
To cite: Evans G,
Redgrave A. Br J Sports Med
Published Online First:
[please include Day Month
Year] doi:10.1136/bjsports2015-095126
Rowing is a repetitive sport with an injury profile
consisting of predominantly overuse injuries.1 2
The most common sites of injury in rowing athletes
are the lower back and knee.2–5 Rib stress injuries
(RSIs) are the next most common injury and comprise approximately 10% of all rowing-related
injuries.6–8 It has been reported that RSI affect 8.1–
16.4% of elite rowers,2 9–13 2% of University
rowers14 and 1% junior elite rowers.1 The incidence of RSI has also been reported to be higher in
international rowers verses national rowers.15 With
recovery times of 3–8 weeks reported,10 16 RSI
poses a significant problem for both coaching staff
and the medical team. Hooper et al17 reported an
average of 47.8 training days lost due to rib stress
reaction and 60.0 training days lost for complete
rib stress fracture. Clearly reducing morbidity
through early identification and appropriate
management is paramount and can lead to earlier
recovery and return to sport.
RSI can be defined as the development of pain
due to bone oedema caused by overload along the
bone shaft and is one cause of ‘chest wall pain’ (a
descriptive term often used in the literature). RSI is
believed to occur due to the repetitive and forceful
nature of thoracic muscle co-contraction. Serratus
anterior (SA) and external oblique (EO) muscles
are commonly implicated;18 however, the exact
mechanism of injury is still debated. Both
McKenzie19 and Karlson13 have hypothesised that
injury may occur due to the increased magnitude of
co-contraction between SA and EO at the end of
the ‘drive phase’ of the rowing stroke. This was
not, however, supported by Vinther et al12 in their
study using electromyography and two-dimensional
video kinematics that added weight to an alternative theory that injury occurs due to repetitive rib
cage compression and excessive isometric thoracic
muscle contraction at the beginning of the drive
phase.10 18 A number of risk factors linked with
the development of RSI have been identified
which, if addressed early, can help prevent recurrence of injury or more importantly reduce the
incidence of RSI when addressed proactively.
Anecdotally, the authors have noted that despite
many clinicians working in sport are aware of RSI
as a diagnosis, early intervention does not always
occur and often the diagnosis can be mistaken for
other conditions such as an ‘intercostal muscle
strain’. This can lead to failure to offload the
athlete early. If the athlete continues to train, symptoms often progress resulting in delayed rehabilitation and return to sport once the correct diagnosis
has been established. It was for this reason, and
due to the large number of direct requests to the
authors from clinicians regarding diagnosis and
management of RSI in rowers, that the decision
was made to create an evidence-based RSI guideline
to help diagnose and manage RSI. It is worth
noting that due to poor understanding of this
injury among clinicians who do not regularly treat
rowers, it is highly likely that the condition goes
under-reported especially beyond international/elite
rowers and that the incidence and thus burden of
injury is in fact much greater than reported in the
literature.
Aim of the guideline
The aim of the guideline was to create a userfriendly, informative, evidence-based flow diagram
that takes the clinician through the diagnosis, severity stratification, investigation and management of
RSI in rowers. The aim was to make the guideline
both fluent and practical for use in the clinical
Evans G, Redgrave A. Br J Sports Med 2015;0:1–4. doi:10.1136/bjsports-2015-095126
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Consensus statement
setting with the aim of disseminating the information through
clubs and relevant clinics throughout the UK targeting those
who may see the rowing athlete as part of their caseload. It has
been designed with the ‘less confident’ clinician in mind but will
also serve as a detailed ‘aide memoire’ for clinicians who deal
with RSI in rowers frequently.
It is worth highlighting that Hooper et al17 published a very
useful ‘clinical management pathway for chest wall pain in elite
rowers’ in 2011. This pathway outlines a practical approach to
managing elite rowers with chest wall pain based on injury surveillance data captured over two domestic and international
rowing seasons. Although this guideline is hugely valuable in
management of elite rowers, it does not address RSI specifically
and is aimed at elite/international rowers. The management
pathway is predominantly ‘time-based’ if RSI is confirmed with
imaging and assumes access to imaging is readily available which
may not be the case in national level athletes or below. As a
result, we chose to develop a guideline specifically for RSI that
uses clinical markers to aid diagnosis and management rather
than a time-based approach and aims to stratify the injury by
severity based on these same clinical markers.
METHODS
A detailed literature research was undertaken to establish the
relevant body of literature regarding RSI diagnosis and management in rowing. PubMed, EMBASE and CINAHL databases
searches were conducted using the terms ‘rib’ OR ‘fracture’
AND ‘rowing’. Seventy-one articles were identified. Abstracts
were reviewed and irrelevant articles excluded. Reference lists
were reviewed to ensure identification of all relevant articles.
Detailed discussions took place within the Great Britain Rowing
Medical Team to identify ‘key points’ in both the literature and
through extensive clinical experience that were felt salient to the
successful identification and management of RSI in rowers.
These ‘key points’ were identified in five main areas: diagnosis,
severity grading, investigation, management and risk factors for
RSI. The ‘key points’ were then used as the basis for the structure of the guideline and assimilated into a flow diagram taking
the reader sequentially through these five main areas. Once the
initial guideline had been developed, it was repeatedly reviewed
by the authors for functionality, readability and accuracy until
the final guideline was agreed on. The guideline then underwent
a short trial in the clinical setting by five of the Great Britain
Rowing Medical Team and appropriate adjustment made where
necessary after feedback.
The finished guideline underwent ‘branding’ by the Great
Britain Rowing Team (GBRT) administration team to ensure it
Table 1 Common diagnostic features of rib stress injury
History
Examination
Insidious, sudden onset or crescendo
pain over a few days or weeks
Pain on deep breathing*
Pain on pushing/pulling doors*
Tenderness commonly mid-axillary line
of chest wall
Ribs 5–8 in particular
Tender spot over oedema and
sometimes palpable callous
Positive spring/compression of rib cage
(AP and lateral)*
Pain with press up or resisted serratus
anterior testing*
Pain on initiating trunk flexion (sit up
position including oblique bias*
Difficulty rolling over in bed or sitting
up from a lying position*
Unable to sleep on affected side*
Possible cough/sneeze pain*
*Clinical markers identified with asterisk.
AP, anteroposterior.
2
conformed to branding policy. The guideline was then reviewed
by the governing body for rowing, the Fédération Internationale
des Sociétés d’Aviron (FISA). Following review, the FISA
medical commission agreed unanimously to endorse the
guideline.
RESULTS
A user-friendly, clinically relevant and evidence-based guideline
for diagnosis and management of RSI was created.
Diagnosis/identification of RSI
Diagnostic features of RSI are included in the ‘diagnosis’ section
of the guideline.20–22 This incorporates ‘clinical markers’ that
help identify RSI and have been highlighted in the guideline in
red and marked with an asterisk*. These are divided appropriately into clinical markers identified in either history or examination. These clinical markers are not just used for diagnosis but
subsequently help to grade the severity of injury and guide the
clinician through the management/rehabilitation. This is a key
feature of the guideline as the identification of these clinical
markers helps the less experience clinician progress an athlete
from diagnosis through rehabilitation based on clinical markers
rather than merely time-based rehabilitation which would not
allow for individual variability between athletes.
The common diagnostically relevant features of RSI can be
seen in table 1.
Grading of severity
The clinical markers identified in the ‘diagnosis’ section of the
guideline are also used to help the clinician assess the severity of
the RSI in conjunction with other features of injury. These
include features such as whether the rower can race or train
‘through the injury’. No previous injury severity stratification
was identified in the literature, and thus the authors propose the
following stratification dividing RSI in to three broad groups
within the guideline: mild, moderate and severe. Each severity
group is based on the level of clinical markers displayed by the
athlete. In addition, a range of visual analogue scores (VAS) for
pain is attributed to each grading scale based on the authors’
experience of RSI severity. The reader is encouraged to interpret
VAS cautiously as these can be highly subjective to the individual
athlete. The VAS should not be used in isolation but helps to
contribute to the overall clinical picture of severity grade. The
purpose of this section of the guideline is to help the less experienced clinician understand the severity of injury, and thus help
to manage the expectation of the athlete/coach. Although the
guideline aims to steer away from ‘time-based’ rehabilitation, it
may be useful to give all parties involved a suggestion of severity
and anticipated time away from the boat. This section can also
be used to track the athletes progress through rehabilitation as
their injury becomes ‘less severe’ through the recovery process.
Investigations
The investigation section encourages the clinician to consider
making a clinical diagnosis in the first instance and manage the
athlete accordingly to avoid delay while waiting for imaging.
Clinically improving RSI may not require confirmatory imaging;
however, the clinician is encouraged to consider further investigation if the RSI is not improving with appropriate treatment or
if the diagnosis remains unclear. Smoljanovic and Bojanic23
report a case of Ewing’s sarcoma of the rib in a 13-year-old
female rower which presented in a similar fashion to RSI and
highlights the importance of remaining vigilant if symptoms of
RSI do not settle with appropriate management or if the initial
Evans G, Redgrave A. Br J Sports Med 2015;0:1–4. doi:10.1136/bjsports-2015-095126
Consensus statement
diagnosis is not clear. In these circumstances, imaging is important in making an accurate and early diagnosis. It was noted at
the recent combined FISA/GBRT Sport Science and Medicine
Conference in January 2015 that there may be international
variation in practice regarding imaging athletes for RSI due to
differences in availability of imaging modalities between countries. MRI is often the imaging of choice in the UK; however,
isotope bone scans may be more commonly used in the USA.
When interpreting imaging of RSI, it is worth noting that
images can be misleading as changes in bone density or the presence of callous do not always correlate with the athletes clinical
recovery.24 It is therefore necessary to interpret imaging with
caution and pay close attention to clinical markers when monitoring an athlete’s recovery.
Intrinsic factors include poor core stability and trunk mobility,
concurrent shoulder pathology or low back injury as well as
factors related to low body weight or energy availability including
any features of Relative Energy Deficiency in Sport (RED-S).10 18
Extrinsic factors include those factors related to change of
load such as increased intensity or volume of training, rowing
against strong wind/current, changing from sweep to sculling
and vice versa, and altered training balance between ergometer
training and rowing.10 18 30
Identifying and addressing risk factors forms an important
part of understanding why injury may have occurred in the first
instance but also to minimise the chance of injury recurrence.
The final section of the guideline on risk factors should serve as
an important ‘aide memoire’ even for the experienced clinician.
Management
CONCLUSIONS
Management of RSI is divided into two stages for simplicity.
Stage 1 broadly consists of immediate interventions, and stage 2
focuses on secondary measures. In reality, there will be considerable overlap between the two stages and the confident clinician
may incorporate much of stage 2 early in the rehabilitation
process. Stage 1 highlights the importance of offloading the rib
by cessation of rowing-based activities. Cross training is permitted if pain free. Analgesia may be used but non-steroidal antiinflammatory drugs are best avoided due to their potential
impact on bone healing.25 26 Taping and soft tissue therapy is
recommended.27 Ultrasound/laser treatment may aid recovery
but is by no means essential.28 29 A gradual return to rowingbased activities is recommended ensuring resolution of all aforementioned clinical markers.10 21 A loose time frame of 3–
6 weeks is suggested to give the less experienced clinician an
indication of likely time frame for recovery.
Stage 2 of management focuses on secondary measures to be
considered. Biomechanical assessment of the athlete should be
undertaken and deficits in thoracic spine mobility should be
improved and maintained as training load increases.27 Technical
errors while rowing should be corrected to minimise areas of
potential thoracic overload. Stage 2 concludes by signposting
the clinician to consider potential risk factors for development
of RSI and implementation of a prevention programme.
Risk factors
The last section of the guideline highlights both intrinsic and
extrinsic factors for the development of RSI (table 2).
A new, evidence-based guideline for diagnosis and management
of RSI has been developed for use in the clinical setting. The
guideline aids the clinician in diagnosis, investigation and management of RSI. It outlines evidence-based risk factors to be
addressed when rehabilitating the athlete.
The guideline has been trialled in clinical practice and has
received positive feedback from clinicians. The guideline is to be
disseminated through relevant clinics and rowing clubs in an
effort to support the clinician working with rowing athletes and
to help with earlier diagnosis and appropriate management of
RSI. It is hoped that this will help to significantly reduce the
morbidity associated with the injury.
Once the guideline is in regular clinical use, it will be
reviewed following clinician feedback. The authors aim to
create a corresponding guideline in the near future focusing in
more detail on a suggested rehabilitation programme for athletes
following RSI.
What are the findings?
▸ An evidence-based clinical guideline has been developed for
the diagnosis and management of rib stress injury (RSI).
▸ The guideline aims to assist in the timely diagnosis and
management of RSI, thus reducing the associated morbidity
through early and appropriate intervention.
▸ Risk factors for the development of RSI are included to
reduce the risk of injury recurrence.
Table 2 Intrinsic and extrinsic risk factors for development of RSI
Intrinsic factors
Extrinsic factors
Poor trunk strength/endurance
Rowing or ergo at high load/low rate or
overgeared
Rowing against strong wind/current
Rapid increases in training load/volume/
intensity
Long steady state rowing
Change from sweep to sculling and vice
versa
Change from large to small boat
Rigging overgeared or too much height
Poor trunk mobility/flexibility
Concurrent shoulder pathology/
injury
Low back injury
Previous rib injury
Lightweight rower
Female
Reduced bone density
Weight loss
RED-S
RED-S, Relative Energy Deficiency in Sport; RSI, rib stress injury.
Evans G, Redgrave A. Br J Sports Med 2015;0:1–4. doi:10.1136/bjsports-2015-095126
How might this impact on clinical practice in the future?
▸ A new guideline has been developed to support clinicians in
the diagnosis and management of rib stress injury in rowers.
▸ It is hoped that the guideline will aid early and accurate
diagnosis of rib stress injury and thus reduce the morbidity
associated with the condition.
Twitter Follow Guy Evans at @drguyevans
Acknowledgements The authors would like to thank Liz Arnold and Mark Edgar
at the Great Britain Rowing Medical Team for their contribution towards
development of the rib stress injury guideline.
Contributors GE was responsible for conception and design of the rib stress injury
guideline. GE drafted and revised the article for publication and approved the final
3
Consensus statement
version. AR revised the rib stress injury guideline and revised the drafted article for
publication. AR approved the final version of the article.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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