Rib Stress Fracture

A competitive rower with localised, activity-related chest-wall pain and normal radiographs most likely has a rib stress fracture, which is the classic overuse injury in rowers. It is a fatigue fracture of a rib from the repetitive cyclical loading of the thoracic cage during the drive and recovery cycle, typically affecting the posterolateral mid-ribs; the same injury occurs in throwers, where the first rib is characteristic, in golfers on the leading side, and from load carriage. The presentation is localised chest-wall pain with point tenderness over the affected rib, worse with the causative activity, deep breathing, coughing and trunk rotation. The key diagnostic point is that plain radiographs are often negative in the early stress-reaction phase, so when clinical suspicion is high I would confirm the diagnosis with a bone scan or MRI, and I would exclude a pathological fracture if the history were atypical. Management is predominantly non-operative and must address both the load and the bone. I would institute relative rest from the causative activity with load management and a graded return, provide analgesia, and identify and correct any training or technique error. Crucially, I would assess and address the contributory bone-health factors: rowing is associated with low bone mass, and low energy availability - relative energy deficiency in sport, especially in female athletes, with its links to low bone mineral density and menstrual disturbance - is a key contributor, so I would screen and correct nutrition, calcium and vitamin D, and hormonal status to promote healing and prevent recurrence. With this approach rib stress fractures heal, and surgery is rarely needed.