Rib Pain – that latest research with Dr. Anders Vinther

From the first twinge of pain that just won’t go away that develops to the unbearable pain that checks a rower mid stroke, rib stress pain that can lead to injury and fracture can be career ending. For some, sore ribs can feel like an unavoidable consequence of pulling on an oar or ergo handle. But there is nothing inevitable about rib stress injuries according to world expert, Dr. Anders Vinther. Vinther, a research physiotherapist at Herlev University Hospital, Copenhagen, Denmark, is widely regarded as a leading expert in the field of rowing rib stress fractures.

World Rowing reached out to Vinther for an update on the science since last speaking with him for a 2015 feature on rib pain. That article is well worth a read as what he covers here is in addition to the basic information discussed there.

WHAT’S CHANGED?

In some ways, not much has changed, says Vinther. It is important to note that it is best to call it “rib stress injury” since, as Vinther points out, “not all overuse injuries of the ribs progress to actual stress fractures.” Rib stress injury stems from repeated stress placed on the ribs that gradually develops into micro cracks. As these micro cracks continue to grow, one or more might lead to an actual fracture. The important thing is “reacting to the early signs and symptoms of rib stress injury.”

While few studies have looked specifically at rowers’ and rib pain, some in recent years point out clues that might help reduce the risk of experiencing rib stress injury. Two key findings include the potential benefits of calcium and vitamin D.

Calcium and Vitamin D

One significant finding from a study of university rowers in the United States is the potential protective role of calcium. “Calcium intake seemed to be one risk factor that really made a difference for the female rowers in this study,” says Vinther.

In support of potential benefits of calcium, this time taken in combination with vitamin D, Vinther points to a far larger study of female recruits conducted by the US Navy. “This is a totally different population,” he says, “but the similarity is that they are female and they have a lot of stress fractures. Significantly, they found that fractures can be reduced just by giving them supplements of calcium and vitamin D.”

Vitamin D helps the body to absorb and use calcium efficiently and, according to Vinther. They are often combined in these sorts of studies. “There is some pretty solid evidence that calcium and vitamin D could have a positive impact,” says Vinther, who thinks that this might hold true to some extent for men as well.

Big data revealing impacts of rib stress injury

“There is almost certainly a lot of data being collected,” says Vinther. “National teams probably know themselves what their injury rates are, but these data are not published.” One exception, points out Vinther, is a retrospective analysis of data from the Australian national team leading up to the Rio Olympics. “It clearly illustrates that rib stress injuries are common and that they have a detrimental effect on performance.”

One significant finding, says Vinther, was that “rib stress injury results in a longer absence from rowing than previously thought – stress fractures longer than stress injuries.” Also, “the highest number of rib stress fractures occurred in the year before the Olympics.”

REDUCE THE RISK

The best strategy for managing rib stress injury is of course prevention, which requires as clear an understanding of the risk factors as possible. Some of the major risk factors include:

Loading changes

As in 2015, Vinther is clear that “we still think that the largest risk factor for rib stress injury remains big changes in training. “Switching between sweep and sculling and changing side in sweep rowing are also typical changes in rowing. Increasing volume and/or intensity of training are also potentially problematic changes. If you combine changes, the risk increases.”

Nutrition

As the two studies above indicate, the role of nutrition is more significant than previously thought. This, says Vinther is possible a good thing from a prevention and management stand point since changing diet can sometimes be simpler than changing how someone trains. “Elite rowers may not want to change how they are training,” says Vinther. “But both female and male rowers might change how they are eating. We have seen previously in our research that lightweights seem to be more at risk, which suggests that nutrition might be a big risk factor and actually a modifiable factor.”

RED-S

Some of the risk stems from something called “Relative Energy Deficiency in Sports” (RED-S). RED-S is a condition that comes about essentially when an athlete’s nutrition is not adequately matched to the high energy expenditure related to endurance training.

RED-S is usually considered a condition that affects lightweights, but “RED-S is a risk for all athletes”, says Vinther. “You can be energy deficient even without trying to lose weight. Heavyweight rowers are also at risk. The body starts to shut down functions. The skeleton can be sacrificed for a period as the body goes into a safe energy mode.”

One disturbing phenomenon Vinther mentions come from anecdotal accounts of elite heavyweight athletes experiencing RED-S “because they wanted to look extremely lean and fit for things like sponsorships and social media,” he says. “This is speculative at this point but could be a factor.”

TAKE HOME MESSAGE

The message Vinther hopes rowers and coaches will walk away with is “that the most important thing is to be alert. When you start to feel a small amount of pain, just a little pain, that is when you need to see a physio or a doctor. See if this could be a rib over use injury. You can in this way catch stress injuries before a fracture occurs.”

“One of the best guidelines for identifying and managing rib stress injuries,” concludes Vinther, “is the British Rowing Guidelines prepared by Dr. Guy Evans and Dr. Ann Redgrave.”

LINKS

Find the British Rowing Guideline free to download here

Find the 2015 World Rowing feature interview about rib pain with Dr. Anders Vinther here