Physio’s corner: How to treat and manage rib-related injuries

This article endorses and features content from Sophie’s free eBook on managing rib injuries in rowing

We have all heard of ‘rib stress fracture’ and panicked about a season-ending injury. But how much of the panic is worth it and how much is just worrying to worry? 

Let’s break it down. 

Rib stress fractures are rare. They take a considerable amount of training volume, time and pain to get. They are not a “rowing badge of honour”. 

In a previous JRN article, I provided a diagram that illustrates the types of chest wall and rib-related injuries that occur. A rib stress fracture was at the top of the pyramid because it is most unlikely.

The evidence is now pointing towards using an umbrella term diagnosis – ‘rib stress injury’ which includes rib stress fractures, stress reactions and muscle-related injuries.

The key to treating and managing any rib-related injury is recognising the red flags early. Just like the social media trend of red flags, they are similar in physiotherapy: identifying unusual and possibly sinister things.

Anyone presenting with chest wall or rib-related injuries will be asked the following about their injury history:

• A sudden onset of pain that has been gradually increasing over a few days or weeks with no direct reason.
• Pain on deep breathing.
• Pain coughing and/or sneezing.
• Pain when pulling or pushing doors (in the gym this can be bent over rows, bench pull, bench press, pallof press or similar movements).
• Difficulty rolling over in bed or sitting up from the affected side.
• Unable to sleep on the affected side.

Other useful indicators that help build the clinical picture are below: 

• Tenderness along the middle of the chest wall when looking from a side in view.
• Possible tender spot over swelling and may be able to feel.
• Pain with press-ups.
• Pain when creating trunk flexion like sit-ups, V sit, and dish hold.

Understanding an athlete’s history and using the examination and testing to build a clearer picture is very important for the next step: treatment.

Let’s keep it simple and think about two different spectrums: the severity of the injury and the injury timeline. The severity will be classed as mild, moderate or severe, per Diagram 1 below. The injury timeline, as shown in Diagram 2, outlines the time at which injuries progress from acute, to sub-acute, to chronic.

Diagram 1 – physiotherapy severity spectrum of rib-related injuries

Diagram 2 – physiotherapy-defined timeline of rib-related injuries

Combining these two spectrums is useful to plan a rehabilitation program and estimate the duration. Although recovery duration is never set, is it a good indicator of how long the body may need, of course, this varies for everyone.

Things to consider for rib rehabilitation:

• Recovery is your new best friend – prioritise sleep, ensure you are eating enough to support your training and maybe you require more.
• Deload your rib cage and thoracic spine – reducing the load means you will be reducing the training stress on your body and allowing more time for healing. This is the first part and helps to reduce your symptoms. Once the symptoms are gone or very low, then we can begin to very slowly increase the training load again.
• Change up your cardio – swap the ergo for bike or RP3 (depending on how intense your symptoms are). 
• Move in different ways – we want to make sure that our upper body is still moving and we don’t neglect or become stiff. Focus on how your shoulder blades move, strengthening these muscles and moving through the full range in your upper body.
• Breathing exercises are essential – these can be especially helpful to move your ribs and gradually desensitise the pain. Your diagnosis will dictate when you should reintroduce; the general rule is the closer to green the nicer they will be.  
• Gradually increase your load! Don’t try and be a hero about getting back to training. Especially with rib-related injuries, slow and steady wins the race! Once you are in the green box and almost back to normal, begin to try short and low-intensity workouts on the erg. Lower the drag factor, try the RP3 or slides over the static and increase the rest period. For example, 2×10 minutes with a 3-5 minute rest. 

For more information or advice, please contact @sophiehudsonphysio

Diagram credit: Sophie Hudson

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Sophie Hudson

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