These two case studies show how rowers can keep their thoracic spine flexible
Most of us know how demanding the sport of rowing can be. Crawling out of bed at 4am for a sleepy two-hour row on a cold winter morning and then backing up in the afternoon for an ergo or a hard session in the gym. Then try and fit everything else in to a normal day, get some 40 winks and do it all again the next day. When you put that much hard work in and make that many sacrifices, injury is devastating. Especially when it could be avoided by doing some simple flexibility work.
A question of technique
Rowing consists of repeating the same cycle of body movements with a large output of force. It is for this reason that rowers suffer mostly from overuse injuries. Thoracic-spine injuries or injuries relating to the thoracic spine in rowers are no different. When dealing with overuse injuries, many aspects of the athlete must be considered and addressed. In rowing, like all sports that involve continually performing the same sequence of movements, technique plays a vital role in preventing injury.
However, perfect technique in sport is something we all strive for but very few actually achieve. Poor technique will cause athletes to become tight in certain areas. If a rower is weak or has poor muscle endurance, then he/she will not be able to row with good technique. A rower must have good core stability and strength around his/her scapulas to hold the correct body position in the boat. Technique and strength are areas where the athlete should continue to try and improve, but excellence in these areas is a long process. In the meantime, rowers are still training hard to improve performance and consequently parts of their body will become tight or stiff. The thoracic spine is one such area.
Sitting too long!
The thoracic spine is the second most commonly injured area in rowers after the lumbar spine. It is considered to be the least mobile area of the vertebral column. This is due to the length of the transverse processes, the costovertebral joints, the decrease in disc height when compared to the lumbar spine and the rib cage. Movements that occur in the thoracic spine are mostly rotation and flexion/extension. Rowers inherently become limited into extension. This is because of the amount of time that rowers are in a seated position and the tendency for rowers to fall into thoracic spine flexion, especially when fatigued. With extension stiffness often comes an associated limitation of movement into rotation. It is essential that rowers do regular flexibility exercises to maintain their thoracic extension and rotation. Otherwise, they place themselves at risk of rib stress fractures, facet and costovertebral joint irritation, which can often refer pain to the chest wall or muscle trigger points in the erector spinae, rhomboids, levator scapulae or upper trapezius. Stiffness in the thoracic spine can also cause an extra load to be placed on other structures such as the lumbar spine and shoulders.
Case Study 1: the rower with right-sided upper-chest pain
Barbara is 50 years old and just loves to row. She rows five mornings a week for up to 90 minutes a time, as well doing a gym programme a couple of times a week that she designed herself. On top of that, she works full-time and looks after her family. Barbara presented to physiotherapy two months before she was due to compete at a major event with a three-week history of right-sided upper-chest pain when rowing, that was getting worse. She has twice had rib stress fractures anterolaterally on the left side and reports always feeling some pain around that area when she rows. Barbara was understandably concerned that she might have stress fractures on the right side. The area on the right where she was feeling pain was not the typical area for stress fractures and she was not tender on palpation through that area. Examination revealed marked tenderness through the right costovertebral joints from T3-7 and limited thoracic extension and rotation to the right.
The diagnosis was made a lot easier when mobilising the costovertebral joints reproduced the right-sided chest pain. Barbara breathed a sigh of relief when I explained to her that I didn't think she had stress fractures on the right. In fact, she was suffering from a referral of pain from her costo-vertebral joints that related to her limitation of movement in the thoracic spine.
Management from here was relatively simple. Barbara rested for two days while we got in and loosened up the area with trigger points to the overlying muscle and joint mobilisations to the costovertebral and facet joints. Barbara felt a significant decrease in pain the next time she rowed. She was convinced that she needed to get flexible in her thoracic spine, and keep it that way, if she was to continue to enjoy rowing.
We started her on regular stretches to improve her extension and rotation and self-trigger pointing over a tennis ball to decrease the muscle tension over the joints. Her new friend became the thoracic wedge, which is designed to increase extension range of movement. The wedge is a hard piece of moulded rubber that you place on the ground with a groove cut away for your spine to sit in. You lie on the ground with the wedge sitting between your shoulder blades and arch over it. The same can be done with two tennis balls taped together. It is a good idea to do this before stretching.
Barbara coincidently started to feel less pain in her ribs on the left side. We progressed her treatment to include mobilising all of the stiff areas in her thoracic spine and some remedial massage therapy to help speed up the process. Within three weeks, Barbara was not feeling pain anywhere in her thoracic spine or ribs when she rowed. This was for the first time in years. She was obviously determined to keep it that way. Her new training programme includes flexibility exercises for her thoracic spine, regular massage therapy and a new gym programme (from an experienced strength and conditioning specialist) that concentrates on her upper-back strength, scapula stability and core stability.
Case Study 2: the rower with right anterior shoulder pain
A week later, I was paid a visit by another extremely fit-looking middle-aged lady. 'I have been recommended by a good friend of mine whom you've just treated,' she said. Kathy was long-time friend and training partner of Barbara. She also worked full-time and squeezed into her busy week a similar training schedule. Kathy complained of right anterior shoulder pain that had been present for a couple of months when she rowed. It had also started to hurt when she performed any exercises that involved elevating her arm. Her left side was not painful at present, but it had been a problem from time to time.
On assessment, Kathy showed all the positive signs of subacromial impingement. Kathy's posture was poor. She was rounded through her thoracic spine and her humeral head position was well forward. Impingement tests were positive and her posterior rotator cuff was very tight. I postulated that the impingement related mostly to the posture of her shoulder, which was poor because of her stiff thoracic spine and tight posterior rotator cuff musculature. This was an example of stiffness in the thoracic spine causing excessive load to be placed on other structures We immediately began addressing these two areas. Trigger points through infraspinatus and teres minor were performed in physiotherapy and at home. This can be done quite easily at home with the use of a tennis ball.
How to do it
Place the tennis ball behind your shoulder blade and a wall. You can then just rest on any points that are tender. Remember not to roll over these points; maintain the pressure on them until the pain starts to ease, and then go to another point. Kathy had to stretch these muscles after the trigger points. This can be done by taking your arm across your body at shoulder height with a bent elbow and using your other hand to pull your elbow across. If you can't feel the stretch, try and hold your shoulder blade back as you pull your elbow across. We began to loosen her thoracic spine through joint mobilisations in physio, stretching and the trusty two tennis balls taped together. Kathy's shoulder posture became noticeably different, and after two weeks of working on those two areas, she was rowing without any shoulder pain. Kathy was convinced that she needed to start addressing these areas with some regular flexibility exercises. Ironically, she had suffered from rib stress fractures in the past and had some ongoing pain in this area. Just like Barbara, Kathy's rib symptoms also disappeared with the increase in thoracic spine flexibility. Kathy then went to the same strength and conditioning specialist to work on the same areas as Barbara, as well as specific exercises to strengthen through her posterior rotator cuff.
We now had two very happy ladies one week away from competing. Both were rowing without pain for the first time in years. Rowers, take note. Keep that thoracic spine flexible. Don't let all that hard training be ruined by an injury that could have been prevented.