season begins abruptly in Michigan. “In
Michigan, springtime is a day in May where the temperature goes from 37 degrees
to 98 degrees,” notes sports medicine specialist Sami Rifat, MD.
“That’s our springtime, and everybody hits the golf course.”
Many golfers go from complete inactivity to playing several rounds a
week. In addition, they often hit a
couple buckets of balls at the local driving range on intervening days.
The result is often a rash of musculoskeletal injuries, including back
recent annual meeting of the American Medical Society for sports medicine in
Orlando, Florida, Rifat described a case of mid-thoracic back pain that
wouldn’t go away. The patient was
an athletic 35-year-old woman who first developed symptoms two weeks after
enrolling in golf lessons. “She
tried to play through the pain,” said Rifat, “but after one week, worsening
symptoms forced her to stop.”
Non-Radiating Pain in the Thoracic Area
She had her back pain and tenderness in the
lower half of the left thoracic spine. She
had normal range of motion in the thoracic spine, lumbar spine, and the
back pain eventually localized to the posterior aspects of the ribs.
Results of radiographs of the thoracic spine and ribs were normal.
But when Rifat learned that the women had once been amenorrheic for seven
years, he ordered a bone scan. The
posterior aspects of ribs 6-10 lit up like a Christmas tree, suggesting several
rib stress fractures.
subsequent bone density evaluation revealed osteopenia in the spine and an
elevated spinal fracture risk. Rifat
ended up counseling the women about her exercise-associated amenorrhea and
offered her hormone therapy, and her bone density eventually returned to normal.
the connection to exercise-associated amenorrhea is unusual in a golfer, the
presentation of back related to a rib stress fracture in this case is fairly
typical. It would appear that these
are not unusual injuries, especially in the areas where golf is popular.
fractures of the ribs in golfers may be more common than previously realized and
may be incorrectly diagnosed as recalcitrant back strains,” note Michael J.
Lord, MD, and colleagues in a study of rib stress fractures in golfers. (See American
Journal of Sports Medicine, 1996; 24(1): 118-122.)
One study of athletic stress fractures found that the rib is the third
most commonly injured bone, and golf is the fifth most common sport involved in
stress fractures. (See Orthopedics, 1991; 14:1081-1095.)
et al. described stress fracture of the ribs in 19 golfers, including 13 men and
six women. Fifteen golfers
experienced their injuries on the leading arm side of the trunk, and one
experienced bilateral stress fractures.
reported a sudden increase in training levels before injury.
“Eighteen golfers were beginners, and the one experienced golfer had
dramatically increased his practice time on the driving range before injury,”
according to Lord et al. Ribs 4-6 were the most commonly injured bones.
rib injuries were visible on radiographs in 16 patients, whereas bone
scintigraphy was necessary in three patients.
In two patients, there was a delay in diagnosis of six to eight months
because the treating physicians misdiagnosed the injuries as stubborn back
et al. believe that the most likely mechanism of injury in rib stress fractures
is an imbalance in muscle forces created by fatigue of the serratus anterior
muscle. They suggest strengthening
this muscle during rehabilitation and as a preventive conditioning exercise.
many stress fractures of the ribs occur in beginners, poor golfing technique may
also be implicated. In a 1974
study, S. Rasad, MD, noted how often beginners strike the ground during their
swing, taking large divots, which no doubt puts the ribs of the leading side of
the trunk under tremendous stress. (See
Amer J of Roentgenology, Radium Therapy and Nuclear Medicine, 1974;
fractures of the ribs have been reported in a number of other sports as well,
including baseball (in batters), rowing, rugby, weightlifting, volleyball,
gymnastics, judo, tennis, table tennis, basketball, and surfing.
In other sports, unlike golf, the most commonly injured bone is the first
Lord et al. recommend that clinicians
thoroughly investigate rib fractures because of the frequency of metastatic
tumors in the ribs. In most
patients, however, relative rest and lay-off from golf usually result in an
however, might be reminded that the goal in golf is to hit the ball and not the