Back pain is a common complaint among golfers. Symptoms of a rib stress fracture may be confused with back muscle strains. Differential diagnosis involves deep breathing and coughing. If either of these is painful, it is likely a stress fracture of one or more ribs. There are twelve ribs total comprised of fixed and floating ribs. Fixed ribs articulate to the sternum and vertebrae while floating ribs attach only to the vertebrae. Fractures of the first rib occur commonly in sports such as rugby, weightlifting, volleyball, and rowing. It is thought that the pulling of the scalene muscles produces a bending force at the thinnest portion of the rib. Fractures of the floating ribs (11 and 12) have been attributed to the opposing forces of the latissimus dorsi and external oblique muscles. Serratus anterior weakness has been cited as a causative factor associated with fixed rib fractures. Ribs four through six are the most commonly involved ribs injured in golfers. In a recent review of the literature, all fractures of the ribs in golfers occurred along the posterolateral aspect of the ribs. One study cited that multiple rib fractures were just as common as a single rib involvement in golfers. Of eighteen golfers with a rib injury, fifteen sustained the fracture on the leading side of the trunk. It is uncommon to see bilateral involvement. Diagnosis is generally based on x-rays including oblique views for rib detail with correlation to symptoms including deep breathing and coughing. Bone scintigraphy is sometimes necessary. A pathologic fracture should be ruled out before attributing the injury to mechanics or overuse. Healing usually proceeds with relative rest. There are belts and taping procedures to assist with rest and recovery. Most importantly, after the fracture is healed, SportExcel recommends strengthening and conditioning exercises specific to golf. Serratus anterior strengthening is indicated for prevention.
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