Rib Bone Stress Injuries

Figure synthesized from McDonnell 2011; Warden 2002; Schowalter 2022; Coris 2005; Lord 2006; Frangakis 2003. 

Diagnosis

Medical staff of the Great Britain rowing team, in a two-part 2015 review, detailed that rib BSIs are often misdiagnosed as intercostal muscle strains, referred pain from the shoulder or rotator cuff, and thoracic disc or facet-related injury⁽⁶⁾. Their proposed diagnostic protocol provides a practical framework for clinicians to use, especially when imaging is not readily available⁽⁷⁾. They provide subjective and objective criteria when assessing athletes with suspected rib BSIs (see table 1).

Table 1: Common subjective and objective clinical findings associated with rib bone stress injuries⁽⁷⁾

The imaging gold standard for rib BSIs is MRI, although imaging can sometimes lag behind clinical symptoms. Thus, understanding identified clinical markers is important in diagnosing the severity of the injury. This will guide the rehabilitation plan and expectations for returning to sport⁽⁶⁾.

Mild BSIs are often tricky to identify as they can be quite vague, with low-level pain that the patient may be able to push through. Clinicians may initially suspect a soft-tissue injury and advise the athlete to continue training and competing. Therefore, they may diagnose BSIs only at more advanced stages. A patient may have tried to self-manage, thinking it was just a muscle strain. Moderate and severe rib BSIs have more clinical markers and are easier to identify. Moderate will start to impact training more, but once an athlete has started to experience pain at rest or during general day-to-day tasks, e.g., reaching up or out, they are likely to be dealing with a severe-level injury⁽⁶⁾. 

Extrinsic and Intrinsic Factors

A clinician’s subjective skills are instrumental in identifying BSIs, as the questions will determine whether this is even on their radar. Furthermore, investigating intrinsic and extrinsic factors is essential for managing all BSIs and preventing recurrence. The simplest trigger is an increase in load- the “too much, too soon” principle. However, BSIs are rarely simple, and a subjective assessment requires scrutiny of the athlete’s training pattern. Insight into the athlete’s training schedule and demands of sport will greatly influence the subjective assessment. But teasing through some extrinsic and intrinsic factors is essential (see figure 2)⁽¹⁾.  

Importantly for clinicians, they must consider Relative Energy Deficiency in Sport (RED-S) as an underlying predisposition and ensure they assess the athletes:

• Previous stress fracture history (vital),
• History of low bone mineral density,
• History of eating disorder/disordered eating,
• Recent illness,
• Persistent fatigue,
• Low energy availability,
• Previous diagnosis of RED-S⁽¹⁾.

Screening questionnaires, such as the IOC RED-S CAT2, will provide more accurate information.

Sport-specific Biomechanics

Many intrinsic factors, alongside extrinsic training factors, can increase the risk of rib BSI. Training load may be less of a contributing factor and more down to technique. For example, in rowing, clinicians must assess the athlete’s coordination of seat and handle movement, their sequencing of lower limb, trunk, and upper limb motion during the rowing stroke, relative dominance of elbow flexor strength compared with knee extensor strength, acceleration during the early drive phase, shoulder range of motion during the stroke, and gearing, which may increase mechanical loading through the rib cage^(3,5). 

In baseball, overhead pitchers are more prone to first rib BSI than sidearm pitchers, and starting pitchers are at higher risk as well. Biomechanical risk factors include: 

• High throwing volume and cumulative pitching workload,
• High pitching intensity and frequency,
• Altered pitching mechanics increasing rib loading,
• Kinetic chain dysfunction (including reduced thoracic mobility, poor lumbopelvic control, and scapular dyskinesis)⁽⁸⁾.

Management Principles

A BSI occurs when the load applied exceeds the capacity of the bone in question and exists on a continuum rather than defined stages (see figure 3). Early management is expected within 3-6 weeks and starts with offloading, as with all BSIs. Once all clinical markers have resolved, a gradual return to training may commence, but with the load kept under supervision. Clinicians can use a six-stage model to progress athletes through their recovery (see table 2). The stages overlap, and nutrition, strength, education, and correction of training errors should begin early and continue throughout the rehabilitation process⁽¹⁾.

Image taken from Kids Back 2 Sport, Angela Jackson article for Sports Injury Bulletin. 

“A BSI occurs when the load applied exceeds the capacity of the bone...”

Table 2: Six stages of return to rowing in rib BSIs in rowing.

Conclusion

Although rib BSIs are relatively uncommon and sport-specific, they should be considered in athletes who participate in repetitive overhead or rotational sports and present with persistent chest wall pain. Early identification, appropriate load modification, and thorough investigation of intrinsic and extrinsic risk factors are likely to improve outcomes and reduce recurrence. While much of the current evidence originates from rowing, the clinical principles are transferable across other overhead and rotational sports, highlighting the physiotherapist’s role not only in rehabilitation but also in identifying the underlying factors that contributed to injury.

References 

1.    Br J Sports Med. 2025 Jan;59(2):78-90.
2.    Curr Sports Med Rep. 2025 Jun;24(6):153-163.
3.    Sports Med. 2002;32(13):819-836.
4.    Br J Sports Med. 2020 Jul;54(16):991-996.
5.    Sports Med. 2011 Nov;41(11):883-901.
6.    Br J Sports Med. 2015;0:1-4. 
7.    Br J Sports Med. 2016;50:270-272.
8.    Open Access J Sports Med. 2022;13:89-105.