Rib Stress Fracture Rehabilitation Protocol (Thoracic Spine)

Pathophysiology

Rib stress fractures are overuse injuries that occur when repetitive forces are applied to the ribs, exceeding their ability to withstand the load. In the thoracic spine region, these fractures commonly occur in athletes involved in rowing, baseball, golf, or other activities involving repetitive trunk rotation and/or forceful breathing. The rib's periosteum undergoes microtrauma due to this cyclical loading, leading to pain and eventually a stress fracture. Contributing factors include muscle imbalances, poor posture, inadequate warm-up, sudden increases in training intensity or volume, nutritional deficiencies (e.g., Vitamin D, calcium), and biomechanical abnormalities.

Understanding the biomechanics is crucial. The rib cage protects vital organs and provides stability for the trunk. Ribs typically fracture at their weakest points, often the posterolateral aspect where they angle sharply or at the costochondral junctions. Repetitive muscle contractions (e.g., serratus anterior, external obliques, intercostals) create tensile and compressive forces on the ribs, leading to fatigue and eventual fracture.

Phase I: Protection (Week 1-3, Pain Control & Tissue Healing)

Goals: Pain reduction, inflammation control, promote initial bone healing, prevent muscle atrophy.

• Rest: Cease aggravating activities. Complete relative rest. Avoid movements that reproduce pain. Consider using a rib belt or brace for pain management, especially during activities of daily living.
• Pain Management:
  • Modalities: Cryotherapy (ice packs 15-20 minutes every 2-3 hours), electrical stimulation (TENS), ultrasound (with caution).
  • Pharmacological: Over-the-counter analgesics (acetaminophen, ibuprofen) as directed by a physician. Discuss stronger pain medication options with the patient’s physician if needed.
• Breathing Exercises: Diaphragmatic breathing exercises to promote lung expansion and rib cage mobility without stressing the fracture site. Focus on slow, controlled breaths. Avoid forceful coughing or sneezing if possible; splint the chest with a pillow if necessary.
• Gentle Range of Motion (ROM):
  • Scapular Retraction/Protraction: Promote upper thoracic mobility.
  • Cervical ROM: Maintain neck mobility.
  • Gentle Shoulder ROM: Pendulum exercises, gentle shoulder flexion/abduction within pain-free range. Avoid aggressive overhead movements.
• Isometric Exercises: Gentle isometric exercises for shoulder and core muscles, avoiding movements that directly stress the ribs. Focus on low-intensity contractions (e.g., isometric shoulder abduction, isometric abdominal holds).

Phase II: Loading (Week 4-8, Gradual Return to Activity)

Goals: Pain-free ROM, improved muscle strength and endurance, gradual return to functional activities.

• Progressive ROM Exercises:
  • Thoracic Extension/Rotation: Gentle stretching and mobilization exercises to improve thoracic spine mobility. Consider using a foam roller for gentle thoracic extension.
  • Rib Mobilizations: If appropriate and pain-free, begin gentle rib mobilizations (e.g., muscle energy techniques) to address joint restrictions.
• Strengthening Exercises:
  • Core Strengthening: Progress from isometric to dynamic core exercises, focusing on stability and control. Examples include: pelvic tilts, bridging, planks (modified initially), side planks.
  • Shoulder Girdle Strengthening: Progressive resistance exercises for scapular stabilizers (e.g., rows, scapular squeezes), rotator cuff muscles (e.g., external rotation, internal rotation), and shoulder abductors/flexors (e.g., lateral raises, front raises). Use light resistance initially and gradually increase the weight as tolerated.
  • Back Strengthening: Rhomboid and trapezius strengthening with theraband or light weights. Focus on proper form and avoid shrugging.
• Cardiovascular Training:
  • Low-Impact Activities: Begin with low-impact activities such as walking, cycling, or elliptical training. Gradually increase the intensity and duration as tolerated. Monitor for any pain exacerbation.
• Activity Modification: Continue to modify activities to avoid aggravating the fracture site. Gradually reintroduce activities that were previously limited, starting with low-intensity versions.

Phase III: Return to Function (Week 9+, Sport-Specific Training)

Goals: Return to pre-injury level of activity, full pain-free ROM, optimal strength and endurance, prevention of re-injury.

• Sport-Specific Training:
  • Gradual Reintroduction: Begin with light sport-specific drills and gradually increase the intensity and duration as tolerated. Examples for different sports: Rowing – gradually increase rowing time and intensity; Baseball – gradually increase throwing volume and velocity; Golf – gradually increase swing repetitions and club speed.
  • Plyometrics: If appropriate for the sport, introduce plyometric exercises (e.g., jumping, bounding) to improve power and explosiveness.
• Advanced Strengthening:
  • High-Intensity Exercises: Progress to more challenging strengthening exercises, such as weighted core exercises (e.g., Russian twists, cable rotations), and heavier resistance exercises for the shoulder and back muscles.
  • Functional Training: Incorporate functional training exercises that mimic sport-specific movements to improve coordination and power.
• Maintenance Program: Develop a maintenance program that includes regular stretching, strengthening, and cardiovascular exercise to prevent future injuries.
• Return to Sport Criteria:
  • Full, pain-free ROM
  • Symmetrical strength and endurance compared to the non-injured side
  • Successful completion of sport-specific drills without pain
  • Physician clearance

Common Special Tests

These tests are used to help diagnose a rib fracture and rule out other conditions. They should be performed with caution and consideration for the patient's pain level.

• Rib Compression Test: Apply gentle, firm pressure to the anterior and posterior aspects of the rib cage. A positive test elicits pain at the fracture site.
• Sternal Compression Test: Apply gentle, firm pressure to the sternum. A positive test elicits pain at the fracture site, especially with more laterally located rib fractures.
• Tuning Fork Test: Place a vibrating tuning fork on the sternum or directly on the rib suspected of fracture. A positive test elicits pain at the fracture site. (Less reliable, but potentially helpful).
• Rule out other conditions: Carefully assess and rule out other conditions that can cause thoracic pain, such as muscle strains, intercostal neuralgia, or visceral pathology.