The ribs are an uncommon site for a stress fracture, however, through repetitive or increased loading, they can occur. Typically, rib stress fractures occur in the 1st rib anterolaterally (front/side), the 4th – 9th ribs laterally (side) and posterolaterally (back/side), and the posteromedial (front/middle) upper ribs. These fractures are particularly painful and early identification plays a huge role in the prognosis of the injury.
The fracture itself is quite different from your normal fracture where a single incident causes the bone to crack or break. Rib stress fractures appear as a weakened area in the bone due to the aforementioned repetitive loading through the ribs causing the formation of microscopic cracks.
What Causes Stress Fractures of the Ribs?
More often than not, rib stress fractures occur in the sporting population, particularly rowers and other sports involving highly repetitive forceful movements. Research (Rumball, Lebrun, Di Ciacca & Orlando, 2005) has identified two main factors that contribute to the development of rib stress fractures:
- The amount of rib loading (related to muscle, joint, technique, equipment and weight training), and
- Your body’s response to rib loading (sex, age, skeletal and training)
Muscular factors for the onset of rib stress fractures include:
- Muscle weakness resulting in the shock absorption capabilities of the muscle being decreased and consequently an increased level of stress at the selected focal point of the rib(s).
- Muscular pull across the bone exerting considerable repetitive forces
- A muscular imbalance between serratus anterior and external oblique muscles/abdominal muscles.
- Anterior Scalene muscle in the neck repeatedly pulling on the 1st rib
Training, sex, age or skeletal factors for the onset of rib stress fractures include:
- Poor sport-specific technique – incorrect structures being unnecessarily/excessively loaded
- Equipment problems – old or damaged equipment
- Lack of flexibility and or strength
- Non-graduated increase in training load
- Stiff joints between the ribs and the vertebrae decrease the ability to dissipate forces through-loading
- Female sex steroid hormones can be involved in the pathogenesis of rib stress fractures
- Decreased bone mineral density with age
Common Rib Stress Fracture Symptoms
Symptoms of rib stress fractures include:
- Gradual onset of chest or back pain with no single mechanism of injury – often eased with rest
- Pain is exacerbated by coughing, sneezing, rolling over in bed, doing a push-up or sit up and pushing open a door
- As time goes on, the vague chest or back pain can become more specific and often a very tender palpable bony formation results.
Rib Stress Fracture Investigations
A plain film x-ray will more often than not appear negative in its investigation for a rib stress fracture. The gold standard in imaging for rib stress fractures is a bone scan (black spots) or an MRI (white spots). However, this is only indicated if the pain has persisted for up to or greater than 3 weeks and the patient is not responding to conservative treatment.
Rib Stress Fracture Treatment
Phase 1: Early Injury Protection – pain reduction and anti-inflammatories
- A relative period of rest as determined by your physiotherapist – this will depend on the extent of your injury.
- Supported cough – this decreasing the pain associated with coughing, sneezing and laughing.
- Ice – to decrease pain and swelling
Phase 2: Range of Motion Restoration
- Soft tissue release work of the surrounding musculature.
- Joint mobilisations to stiff joints
- Pain-free exercises to prevent atrophy (muscle wasting)
Phase 3: Return to Sport
- Sport-specific technique addressed – modifying the technique to prevent regression in the improvement and decrease the likelihood of re-injuring.
- Graduated return to sport commenced – pain is the main mediator in the amount of exercise you can perform
- Must be able to complete the seven criteria pain-free before returning to modified training:
- Push up
- Sit up
- Deep Breath
- Rib Spring
- Night Pain
- Activities of Daily Living
For rowers experiencing rib stress fractures, please see the attached Australian Institute of Sport, National Rowing Centre of Excellence guidelines
Common Causes of Upper Back Pain & Injury
Thoracic Spine Conditions
- Scheuermann's Disease
- Spinal Stenosis
- Rib Stress Fracture
Nerve-Related / Referred Pain
Article by John Miller
Youth Spinal Pain
Teenager Neck & Back Pain
Teenagers can be particularly vulnerable to back pain, mainly due to a combination of high flexibility and low muscle strength and posture control.
The competitive athlete and most individuals who exercise regularly or maintain fitness and core stability control are less prone to spine injury and problems due to the strength and flexibility of supporting structures. Luckily, issues involving the lower lumbar spine are rare in athletes and account for less than 10% of sports-related injuries. Injuries do occur in contact sports and with repetitive strain sports. Your physiotherapist can assist in the resolution of any deficits in this area.
Sports such as gymnastics, cricket fast bowlers, and tennis have a higher incidence of associated lumbar spine problems related to repetitive twisting and hyper-bending motions.
Spondylolisthesis is a significant concern and needs to be appropriately treated by a physiotherapist with a particular interest in these types of injuries. Luckily, most injuries are minor, self-limited, and respond quickly to physiotherapy treatment.
Common Adolescent Spinal Injuries
Lower Back (Lumbar Spine)
Midback (Thoracic Spine)
Neck (Cervical Spine)
For specific advice regarding youth neck or back pain, please seek the professional advice of your trusted spinal physiotherapist or doctor.