by Rib stress injuries are an overuse injury affecting up to approximately 10% of rowers in a given year of training. While not as common as other injuries, the long recovery time of a bone injury makes it the costliest injury in terms of total missed training time per injury. Injury risk increases with training volume: Collegiate and elite rowers doing more total training volume experience more rib stress injuries than masters and junior rowers. This article is a practical guide to what rowers and coaches need to know about rowing rib stress injuries, focusing on preventing, managing, and returning from injury to full performance.
Key Points: Check out this summary graphic for a one-page flowchart of key points to rowing rib stress injury symptoms, management, and returning from injury. Also, read a partner guide here for the more detailed medical side of diagnosing and treating rowing low back pain, written by my friend and rowing physical therapist Dr. Lisa Lowe. I also have a reference section at the end of this article where you can read a lot more about rowing rib stress injury from the resources I have found most helpful. Finally, read my article, “Rowing Injuries: Understanding, Preventing, and Managing,” that sets up the basics of general injury understanding and prevention before the injury-specifics of this article and “Rowing Low Back Pain.”
Table of Contents:
- Defining the Rowing Rib Stress Injury
- Rowing Rib Stress Injury Symptoms and Red Flags
- RSI Risk Factors: Rowing and Individual
- Reducing Risk of Rowing Rib Stress Injury
- Care and Reducing Pain from Rib Stress Injury
- Returning to Training After Rib Stress Injury
Defining the Rowing Rib Stress Injury
Here is the obligatory disclaimer that I am just a strength coach with a library card, not a medical professional. I am relaying information from academic research on rowing injuries and rib stress injury in this article, plus my own opinions and experiences as a strength coach of rowers. I cannot diagnose injuries or prescribe rehabilitation programs, and do not attempt to do so here. Like everything, there are varying opinions about rib stress injuries and many different individual athlete, coach, and professional experiences. I have done my best to synthesize what I have found to be the most useful information for this guide, with thanks to everyone who has published on this so the rest of us can learn and work to apply that knowledge! Read my references at the end of this article for more information, and check all of this with a medical professional if you are personally working through rib stress injury.
Rib stress injury describes any pain in the bones of the chest wall. This is a catch-all term that includes the spectrum of bone injury from “stress reaction” to “fracture.” The goal of this reframing was to avoid the idea that a mild RSI is not serious or significant while it is “only a bone bruise.” This is important because there is not an inevitable progression of injury from bruising to full fracture or breaking. All RSI are significant injuries that benefit from early detection, prompt treatment, and short or long-term modification to training in order to restore and maintain full health and performance.
Rowing Rib Stress Injury Symptoms and Red Flags
Read Lisa’s guide for a detailed understanding of RSI symptoms and diagnosis from the physical therapist side. As a strength coach, I suspect an RSI when a rower experiences chest wall area pain from any of the following: coughing, sneezing, breathing deeply, pulling or pushing doors, side-sleeping, doing pushups or abdominal exercise such as sit ups, and of course erging and/or rowing (may not be both). Pain often begins insidiously and is ignored or minimized by the athlete or coach as being too minor to require modifying training. Early detection and rapid offloading of the chest wall is key to minimizing long-term impact from injury, so it’s important that athletes and coaches recognize common symptoms to get an accurate diagnosis and appropriate response.
RSI Risk Factors: Rowing and Individual
Rib stress injuries are multifactorial. There are usually many contributing causes to injury rather than one single, “smoking gun,” cause. These contributing causes include:
- High total training volume
- Rapid progression of training volume
- High per-stroke loading
- Change in equipment, such as from sweep to scull or on-water to erging
- Change in rigging, especially if this increases per-stroke load
- Challenging environmental conditions, such as cold water, against current, or up-wind
- Technique and change in technique, especially those that increase upper body force like very segmented drive phases and deep laybacks at the release
- Fatigue from non-rowing training, such as strength training and cross-training
- Low recovery from training, such as due to lack of sleep, insufficient calories, lack of micronutrients, or general stress
Does this sound familiar? Many of these factors also cause low back pain (LBP), another common overuse injury in rowing. In fact, RSI and LBP are related: One is a risk factor for another. Rowers with RSI often to row a more segmented stroke with greater emphasis on the mid-drive and late drive “swing” phases. Rowers with LBP tend to shift force away from the heavier front-end (catch side) of the stroke, when the back is in a more challenging position. Both of these technical changes increase torso and upper body force contribution in the rowing stroke, increasing stress and strain on the low back and ribcage.
Rowing researchers do not find support for the common opinion that sweep rowers are at greater risk for RSI than scullers. There is also no consistent connection between a sweep rower’s side of the boat and side of the body injured by RSI. Port-side rowers do not get either left-side (outside arm) or right-side (inside arm) RSI any more than starboard-side rowers get right-side (outside arm) or left-side (inside arm) RSI. This is important to note so that sweep rowers are not dismissive of RSI symptoms because the pain is coming from the “wrong side,” or that scullers are dismissive of RSI symptoms because they aren’t sweep rowers. There may be a trend for sweep rowers to get more RSI on the anterior ribcage, while scullers may get them more evenly on the anterior and posterior ribcage. Researchers noted these trends in early-2000s RSI research, but I haven’t seen this re-evaluated more recent research. One reason for a lack of difference in RSI rates between types and sides of rowers is likely the high volume of year-round erg training done by all modern rowers since the mid-1980s. This technological change has the effect of equaling-out much of rowing training, where prior to their popularization we may have seen larger differences in the types and volumes of training performed by different types of rowers at different times of the year. Training on static ergs tends to increase training volume, per-stroke load, and often progression of volume and load during the beginnings of seasons and transitions between seasons. These all connect with known RSI risk factors.
Reducing Risk of Rowing Rib Stress Injury
The best thing we can do to reduce risk of RSI is pay attention to the overlap of risk factors. Rib stress injuries most often occur during major changes in training volume and equipment. For example, the beginning of winter erg training after the fall rowing season, or the beginning of spring on-water rowing after the winter erging season. The athletes may be perfectly cardiovascular fit, but the ribs experience different stress between these different modes of training that increases risk of injury. Coaches should reduce training load during transitional times. When possible, try to make the change in equipment progressively. For example, rather than a wholesale shift from 100% on-water rowing to 100% erging, start two weeks earlier with 50% rowing and 50% erging for one week, then 25% rowing and 75% erging for the next week, then 100% erging. We can do the reverse when transitioning from winter erging to spring on-water rowing. We might not like giving up the water time, but we like RSIs even less!
In a 2020 study of Rowing Australia elite rowers over two Olympiads, six (32%) of the team RSIs occurred during training camps or the first week back to normal training following time away. Training camps and the return-to-train phase can rapidly increase training load. Again, the rower’s cardiovascular and muscular systems may be able to keep up with the increase, but the skeletal structures may not. Training camps also commonly involve a change in equipment, such as rowers during winter erging training getting a week of on-water rowing in a warmer climate. The increase in training load is combined with a sudden change in equipment, greatly increasing risk of RSI.
Rowers cannot “out-recover” anything that coaches throw at them in training. Reducing RSI begins first and foremost with coach awareness and attention to minimizing risk factor overlap in training, especially during transitional phases. Rower recovery is a critical secondary factor after training management. Adequate sleep (7-10 hours per 24 hours, ideally mostly overnight but supplemented with daytime naps as needed), good nutrition (quantity as calories, and quality as macro and micronutrients), and stress management (inside and outside of training) are all crucial to recovering from training. Coaches and rowing programs still have responsibility here to help rowers achieve good recovery through education and ongoing coaching to make this a priority.
A major goal of strength training is improving coordination of the legs, hips, trunk, and shoulders to generate and transmit force more effectively. Rowers need quadriceps strength from a deep knee angle to generate early drive force from the legs. In my strength coaching, I focus on front squats performed to thighs-parallel or just below, as well as rear-foot-elevated split squats to the same range-of-motion (ROM). Rowers with weaker legs and stronger hips tend to shoot the slide, shifting the stroke force away from the early drive phase and into the middle and late drive phases. The force curve on the erg can be a good way to teach and assess this, although admittedly in a non-specific environment to on-water rowing and sculling. If rowers generate good early drive force from the legs, the next challenge is connecting this early drive force to the handle through the long kinetic chain of the hips, back, and shoulders. Rowers must be able to hold the “body forward” position of anterior pelvic tilt through a solid hip hinge position throughout the drive. Much of my strength training focuses on good hip hinge technique to support this on the recovery and drive phases. The shoulders also must be strong as the final link in the kinetic chain before the handle. We work a lot on shoulder retraction and depression strength through full-ROM upper body pushing, pulling, and specific shoulder exercises. We do the pushup-plus exercise in our warmups to improve coordination and strength of the serratus anterior muscle, a shoulder stabilizer that rowing researchers suggest could be connected to RSI risk. Finally, the anterior core muscles (abdominals) must be strong and specifically coordinated to the demands of rowing. Read my full core training article here for why rowers need to do more than just planks and crunches, and for a detailed guide to the seated rockback exercise, my favorite core exercise for rowers. Use strength training to teach and provide practice opportunities for rowers to learn these movements and improve coordination on-land, working to connect them to the skills on-ergs and on-water.
Care and Reducing Pain from Rib Stress Injury
Rib stress injuries cause the greatest amount of missed training time per injury in rowers due to the long recovery timeline of a bone injury. Early detection and rapid offloading of the chest wall is key to reducing total time lost from training. An RSI with stress fracture can require 6-9 weeks of no mechanical loading to facilitate healing, followed by a 4-10-week gradual return to training. An RSI caught and addressed at an early stage may heal more quickly and have a significant decrease in overall time out due to injury.
There is a lot that we can do to reduce risk of RSI, but injuries may still occur. Because RSI is a bone injury, we can do little at the superficial level to accelerate healing or reduce pain. For example, stretches and exercises may make the muscular areas around the chest wall feel better, but this does not necessarily help the bone heal faster. Stretching, exercise, foam rolling, massage, and other direct interventions can make an RSI worse by adding stress to the bone in the early stages of healing. Gentle massage away from the site of fracture and focused on relieving associated muscle spasm is likely safe. Typically, the athlete just needs to focus on avoiding painful movements and reducing mechanical loading for long enough to allow the bone to heal itself. Modalities including heat and ice may be helpful, as determined by the individual athlete’s response.
Avoiding pain is key to RSI healing, so any training during RSI healing needs to be totally pain-free. Endurance athletes commonly have a high training pain tolerance, so coaches need to help athletes navigate this and find truly pain-free forms of training to allow healing to occur. A minor RSI caught early and offloaded quickly might be fine with any intensity of aerobic cross-training without mechanical loading. Stationary biking, possibly with the arms supported in front of the athlete, is often the most tolerable form of cross-training. The arm-swinging of walking, running, and skiing is often painful. Biking in the outdoor environment increases risk of a bump or other contact injury that sets back the rib healing process. A moderate or significant RSI can be painful when breathing above ventilatory threshold, ie. above a conversational level of aerobic exercise. This can restrict even stationary cycling to low intensity to avoid aggravation and a delay in healing. Begin with low heart rate training below approximately 50%HRmax and progress gradually from there with the healing timeline.
Strength training also varies depending on pain and level of injury. An athlete with a minor RSI may be able to make a few adjustments to avoid painful movements, but otherwise strength train fairly normally. An athlete with a moderate or significant RSI may need to avoid all torso loading. The abdominal bracing commonly used when strength training can also be painful and delay healing, so even heavy lower body movements with no torso loading may not work early in the healing process. Leg exercises including unloaded single-leg squats, belt squats, and short-range Nordic hamstring curls or glute-hamstring raises are often the first exercises tolerable due to the low chest wall impact and minimal torso loading. These exercises can be beneficial to improve lower body strength and reduce upper body reliance when returning to full sport training. Researchers note improved strength of the legs, serratus anterior, and other muscles of the mid-back and shoulders beneficial to reducing RSI. Abdominal muscle training and pushups may be among the last exercises that the athlete is able to do without pain. Rowers with RSI history or risk should avoid barbell bench press and bench pull (or “seal row”) to reduce direct stress on the rib cage.
Returning to Training After Rib Stress Injury
Rowers returning to training often experience reinjury or injury elsewhere due to a progression of training load that is too rapid for technical and physical remodeling to occur. History of RSI is a significant predictor of future RSI. In other words, an athlete who experiences one RSI is always at higher risk of a future RSI. An athlete with RSI history may never be able to fully return to exactly the kind of training that they did before the injury. They certainly can return to equal or greater levels of performance by increasing attention to nutrition or recovery, excluding certain forms of high-risk sport or strength training, and including specific sport or strength training practices to decrease risk of injury or reinjury. This process of long-term maintenance and adjustment may take a year or more depending on injury severity.
Rowers should maintain some elements of their rehab training while returning to training, and even while pain-free following a successful return-to-train phase. Rowers with a history of RSI may always need a little extra attention to shoulder mobility and strength in the pre-row or pre-erg warmup phase, for example. I advise athletes to pick the 3-5 movements that they feel have the most beneficial effect in helping them feel good and ready to perform, and keeping those in the warmup or elsewhere in their training. I continue to avoid barbell bench press and bench pull exercises to avoid overloading the rib cage with rowers with RSI history.
Any departure from normal training should be followed by a phase of gradual reloading approximately equal to the amount of time the athlete was away from normal training. For example, a rower who caught the RSI early, offloaded quickly, and is free of pain within two weeks of no mechanical loading could do a two-week gradual progression back to full training. A rower with a more significant RSI who did modified training for 4-6 weeks or more may need another 4-6 weeks or more to gradually progress to the pre-injury levels of training and performance. This is valuable rebuilding time to address technical factors that may have contributed to injury, as well as attention to nutrition to improve bone mineral density and reduce risk of future injury. Remember this for future return-to-train phases as well. Rowers with RSI history often experience reinjury during phases of rapidly increased training volume or load, such as training camps or returning from vacation.
My go-to approach to any return-to-train phase following time away from normal sport training is the National Strength and Conditioning Association’s “50/30/20/10 progression.” This is a four-week low-intensity progression beginning with 50% of the pre-injury workload (on the specific mode of training), then 70% (or, a 30% reduction), then 80%, then 90%, then 100% on the fifth week with reintroducing intensity training. I use variations on this system as well for shorter time away and different scenarios. Read my “Rowing Injuries: Understanding, Preventing, and Managing” article for more details on this system and additional notes on returning to training following injury.
References
- Caterisano, A., Decker, D., Snyder, B., et al. (2019). CSCCa and NSCA joint consensus guidelines for transition periods: safe return to training following inactivity. Strength and Conditioning Journal, 41, 1-23.
- Evans, G., & Redgrave, A. (2016). Great britain rowing team guideline for diagnosis and management of rib stress injury. British Journal of Sports Medicine, 50, 266-272.
- Harris, R., Trease, L., Wilkie, K., & Drew, M. (2020). Rib stress injuries in the 2012–2016 (Rio) Olympiad: a cohort study of 151 Australian Rowing Team athletes for 88 773 athlete days. British Journal of Sports Medicine, 54, 991-996.
- Lundy, B., Suni, V., Drew, M., et al. (2022). Nutrition factors associated with rib stress injury history in elite rowers. Journal of Science and Medicine in Sport, 25, 979-985.
- McDonnell, L., Hume, P, & Nolte, V. (2011). Rib stress fractures among rowers: definition, epidemiology, mechanisms, risk factors and effectiveness of injury prevention strategies. Sports Medicine, 41, 883-901.
- Thornton, J., Vinther, A., Wilson, F., et al. (2017). Rowing injuries: an updated review. Sports Medicine, 47, 641-661.
- Trease, L., Wilkie, K., Lovell, G., Drew, M., & Hooper, I. (2020). Epidemiology of injury and illness in 153 Australian international-level rowers over eight international seasons. British Journal of Sports Medicine, 54, 1288-1293.
- Wilson, F., Ackerman, K., Smoljanovic, T., et al. (2020). Return to full rowing training and avoiding risk of injury. World Rowing. https://d2wmdlq830ho5j.cloudfront.net/worldrowing/wp-content/uploads/2020/12/04181810/ReturntofullrowingtrainingandavoidanceofinjuryFINAL100620_Neutral.pdf
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