1 Introduction

Rib and upper extremity stress fractures account for fewer than 10 % of all stress fractures but can be troublesome injuries for athletes and manual laborers [1]. Historically, stress fractures have been predominantly regarded as overuse injuries occurring in the weight-bearing bones of the lower extremities. However, as awareness of overuse injuries of the thorax and upper extremities has increased, so has the rate of diagnosis of stress fractures of the ribs and upper extremities [2]. To prevent a delay in the diagnosis and treatment of these injuries, clinicians should be aware of the common precipitating mechanisms and locations of these injuries, as well as the indications for operative and nonoperative treatment.

Not all stress fractures are the same. They are diverse in their presentation, appearance, and healing potential. Stress injuries to bone are a continuum of mechanical failure ranging from simple bone marrow edema (stress reaction) to a small microcrack with minor cortical disruption to a complete fracture with or without displacement to nonunion. Most reported stress fractures of the ribs and upper extremities have been described in case reports and small case series. However, given the relative rarity of and the failure to report upper extremity stress fractures, the exact percentage or likelihood of their development is all but impossible to determine with certainty.

In this report, we will discuss the risk factors and clinical presentation for upper extremity stress fractures, based on a review of PubMed, Scopus, and Embase, using the terms “stress fracture,” “upper extremity,” “thorax,” “rib,” “scapula,” “shoulder,” “humerus,” “elbow,” “radius,” “ulna,” “scaphoid,” “metacarpal,” and “phalanx.” We will review the presentation, affected sites, physical and radiographic examination, and both operative and nonoperative treatment. We also will discuss return to activity and prevention, and suggest a classification that can be used to direct treatment.

2 Risk Factors

Many risk factors predispose both athletes and non-athletes to stress fractures [3]. Some of these are modifiable, but many are non-modifiable. Gender, age, race, hormonal status, nutrition, neuromuscular function, and genetic factors all influence the healing and remodeling potential of bone. Other predisposing factors include abnormal bony alignment, muscular imbalance, improper technique/biomechanics, and poor blood supply to specific bones. Two key modifiable risk factors are pre-participation conditioning and volume (frequency, duration, and intensity) of the causative activity. Neuromuscular conditioning plays a significant role in enhancing the shock-absorbing and energy-dissipating function of muscles and soft tissues [4]. Muscle function influences the amount of energy directly absorbed by the bones and joints, altering their susceptibility to stress injury. As muscles fatigue, they are less able to dissipate externally applied forces. This can result in more rapid accumulation of bone microtrauma.

3 Clinical Presentation

Any athlete or manual laborer with atraumatic chest wall or upper extremity pain associated with repetitive activity should be considered to have a possible stress fracture [1, 5]. Inciting mechanisms may involve repetitive upper extremity torsion (e.g., pitcher, javelin) or weight-bearing (e.g., gymnast floor exercise, pommel horse). Repeated forceful muscle contraction, which also occurs with throwing athletes, will also generate both compressive and tensile loads on the skeletal structures of the thorax and upper extremity and must be considered when evaluating these injuries [4]. As with lower extremity stress fractures, symptom onset is usually insidious. Typically, patients cannot recall a specific injury or trauma to the affected area. Patients with rib and upper extremity stress fractures present initially with pain that is present only during the inciting activity [1]. If the activity level is not decreased or modified, symptoms persist or worsen. Patients who continue to work or train without modification of activities may develop pain with activities of daily living and potentially progress to complete fracture [4]. The potential for other concomitant overuse injuries must be considered, diagnosed, and treated if present.

4 Physical Examination

A thorough physical examination, including evaluation of the chest, heart, lungs, and abdomen, should be performed to evaluate for non-musculoskeletal causes of upper extremity, rib, and thoracic pain. Examination should begin with a thorough inspection of the skin and soft tissues. Palpation, range of motion, and strength testing should be performed for all affected bones and joints of the neck, shoulder girdle, elbow, wrist, and hand. Unlike these other possible etiologies, a stress fracture often produces point tenderness at the affected site. Soft tissue or bony swelling also may be present. In the early stages of the injury, it may be necessary to have the patient perform or recreate the causative activity in order to reproduce the symptoms. Any biomechanical causes of injury, including muscle imbalance or abnormal mechanics of the throwing or rowing motion, should be noted at this time. Tuning fork testing may help identify occult fractures. For the long bones of the arm and forearm, a fulcrum test in which a three-point bend is applied to a long bone may be used to elicit symptoms. A thorough neurovascular exam is essential because vague exertional upper extremity pain may also be due to peripheral nerve entrapment and/or peripheral vascular disease, or other vascular etiologies such as deep vein thrombosis and thoracic outlet syndrome.

5 Causative Activities

Muscle contraction in the upper extremity and thorax produces tensile, compressive, and rotational stress on bone. Throwing and/or swinging motions are the two most common inciting activities to generate these forces [2]. A less common mechanism of creating bone stress in the upper extremity is repetitive axial loading [2]. Sinha and colleagues [6] reviewed 44 stress fractures of the ribs and upper extremity. In this study, all stress fractures in athletes performing weight-bearing activities of the upper extremity (e.g. gymnastics, cheerleading) developed distal to the elbow (8/8).

In the current authors’ practices, 73 cases of rib and upper extremity stress fractures in skeletally mature patients were evaluated over a ten-year period [2]. Analysis of the causative activities of these cases showed notable patterns, allowing division of the majority of the patients into one of five categories: (1) upper extremity weight bearers, (2) rowers, (3) axial rotators (repetitive torso rotators), (4) overhead throwers, and (5) weightlifters. The distribution of these injuries is detailed in Table 1.

Table 1 Anatomic distribution of rib and upper extremity stress fractures by causative activity [2]
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Upper extremity weight bearers showed a predilection for injuries occurring distal to the elbow joint (9/12 cases). A clear connection was observed in rowers. All eight of these patients developed stress fractures of the ribs, with seven developing them in the lower ribs. Three of the eight rowers developed stress fractures in multiple lower ribs. Like rowers, the axial rotator group showed a strong predilection for fractures of the ribs (6/9). Of the six rib fractures, five occurred in the lower ribs. Among overhead throwers, patients showed a tendency for injuries around the elbow (9/15).

Weightlifters showed the greatest variability in anatomical location of injury, with injuries occurring as far proximal as the sternum and as far distal as the scaphoid. This group also showed a significantly disproportionate number of shoulder girdle stress fractures. Notably, this group of patients sustained more injuries to both the first rib (7/22) and the scaphoid (4/22) than any other group. No clear explanation can be given for this injury pattern other than the variety of repeated bending, torsional and axial loading mechanisms applied to the upper extremity during weight training.

6 Common Locations

6.1 Ribs

Rib stress fractures have been reported in several sports, including rowing, rugby, golf, weightlifting, volleyball, gymnastics, judo, tennis, table tennis, baseball, basketball, soccer, javelin, backpacking, and wind surfing [1]. Tensile muscular forces (rather than axial compressive forces) are predominantly responsible for rib stress fractures, as this is a non-weight-bearing location [7]. The most common sites of fracture include the first rib anterolaterally, the fourth through ninth ribs posterolaterally, and the upper ribs posteromedially [5].

6.2 First Rib

The athletic activities most commonly associated with first-rib stress fractures involve repetitive overhead positioning of the arm, such as baseball pitching, basketball, lacrosse, weightlifting, ballet, javelin throwing, and tennis [8, 9]. Repetitive scalene muscle contractions elevate the first rib, while serratus anterior and intercostal muscles depress it [10]. Patients with first-rib fractures present with insidious-onset, dull, vague pain in the anterior cervical triangle and mid-clavicular region, with occasional radiation to the sternum and pectoral region [5]. Prisk et al. [11] reported on five cases of stress fractures of the first rib in ballet dancers, suggesting that the “trapezius squeeze test” in which pressure was applied to the anterior trapezius, causing involuntary contraction of the muscle and eliciting rib pain, was reliable for helping to make the diagnosis on physical examination.

6.3 Second Through Twelfth Ribs

Repetitive torso action is a cause of middle- and lower-rib stress fractures, and these are most commonly described in athletes involved in rowing, discus, and golf [6, 10, 12, 13]. Patients present with increasing lateral chest pain and are diagnosed most commonly by radionuclide scans [12]. Other athletic activities associated with these fractures include tennis, gymnastics, and throwing sports [1]. Among rowers, fractures are found most commonly between the fifth and ninth ribs, and pain generally is greatest at the finish of a stroke and may be exacerbated by coughing [10]. Among golfers, Lord [14] described 19 cases of rib stress fractures. Sixteen of the 19 golfers sustained injury on the leading arm side of the trunk. The posterolateral aspects of the fourth through sixth ribs were the most commonly injured sites [14]. The authors suggested that the ribs on the leading arm side are most commonly involved because of constant moderate activity of the serratus muscle through all phases of the golf swing on the leading side compared with the trailing side [14].

6.4 Shoulder Girdle

Stress fractures of the scapula in athletes are rare [16, 17]. Cases reported in the literature include a gymnast, a baseball pitcher, a jogger carrying weights, and a professional football player with a stress fracture at the base of the acromion [1, 16, 17]. They have been diagnosed in the coracoid, acromion, scapular spine, and scapular body, and represent a diagnostic challenge to clinicians [17]. The scapula has a complex array of muscle attachments and corresponding bone strain patterns. Depending on the motion, stress concentration occurs at different locations of the scapula. Authors have theorized that the likely cause was overuse and fatigue of one or more of the 17 muscles that control the scapula, leading to stress-related injury [1].

Reports of clavicular stress fractures have involved athletic activities such as rowing, diving, javelin, weightlifting, gymnastics, and baseball [1, 6, 18]. Abnormal bending, shear, and rotational forces can develop across the clavicle if there is any imbalance in muscular contraction between the pectoralis major, deltoid, and sternocleidomastoid muscles [1]. Repetitive bone strain by these forces may exceed the reparative capacity of the bone and lead to a stress fracture. Seyahi et al. [18] described a patient with a clavicular stress fracture presenting as atypical severe arm pain radiating throughout the upper extremity and hemithorax.

6.5 Humerus and Elbow

Stress fractures of the humerus are seen particularly in throwing athletes (baseball, javelin, softball, cricket) as well as among tennis players and weightlifters [1]. Complete humeral stress fractures in throwing athletes most commonly are spiral fractures involving the middle and distal third of the humerus (Fig. 1) [19]. It has been suggested that the compressive forces of the biceps and triceps brachii across the humeral shaft are protective of the bone against the rotational torque created during the throwing motion [20]. When the biceps and triceps brachii fatigue, their ability to dissipate energy diminishes, and a greater rotational strain occurs in the humerus, allowing for stress injuries to occur and propagate [20]. Patients with a humeral shaft stress fracture typically describe one of three clinical presentations: (1) acute pain following one specific incidence of overuse may occur; (2) a “crack” or “pop” may be heard or felt after a period of antecedent pain in the throwing arm [1] (Fig. 1); (3) most often, however, patients describe the insidious onset of increasing arm pain worsened by throwing or lifting activities [1, 21]. Unfortunately, given the wide distribution of stress fracture sites among weightlifters, we are unable to deduce the most common causative exercise/lift.

Fig. 1
figure 1

Completely displaced stress fracture of the humeral shaft (a) in the dominant arm of a 27-year-old baseball pitcher and football quarterback with increasing arm pain with activity for five months. This fracture required treatment with open reduction and internal fixation as shown (b)

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Baseball pitchers, javelin throwers, and weightlifters have been subjects of reports involving stress fractures of the olecranon [1, 22, 23]. Two types of olecranon stress fractures have been reported in skeletally mature patients. These include transverse fractures of the olecranon tip and oblique fractures through the midportion of the olecranon [22]. Ahmad and colleagues have suggested that osseous hypertrophy at the olecranon tip causes impingement of the olecranon in its fossa on the humerus, leading to a bone stress injury [24]. Repetitive tensile stresses exerted on the olecranon by the triceps may also lead to stress injury at this location [22, 24].

Fractures of the midportion of the olecranon (Fig. 2) result from the impaction of the medial olecranon on the medial wall of the olecranon fossa due to valgus extension overload in throwers [24]. With continued throwing, the repetitive valgus loads to the elbow produce repeated tensile strains in the olecranon, which may result in a stress fracture [23, 25, 26]. Patients with stress fractures in this location report posteromedial elbow pain during the acceleration and follow-through phases of throwing [24, 26]. Tenderness is often present over the posteromedial elbow, as is pain with valgus stress testing or forced hyperextension of the elbow [26]. Imaging is the most reliable method of differentiating VEO from a stress fracture.

Fig. 2
figure 2

Coronal (a) and sagittal (b) T2-weighted MRI images of a 19-year-old male collegiate baseball pitcher with chronic posterior elbow pain. Imaging demonstrates a transverse grade III stress (see Table 2) fracture of the olecranon process. Due to the chronicity and high-risk nature of the injury site, percutaneous fixation (c) with a 4.5-mm partially threaded screw was required to achieve healing of the fracture and resolution of pain

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6.6 Forearm (Radius and Ulna)

Stress fractures of the radius (Fig. 3) have been reported in cycling, gymnastics, crutch walking, and racket sports [1]. Ahluwalia et al. [27] described a skeletally mature female gymnast with bilateral radial shaft stress fractures diagnosed with bone scintigraphy. Sinha et al. [6] also reported two stress fractures of the distal radius that occurred in upper extremity weight-bearing athletes. Stress overload of the radius may occur in conjunction with ulnar stress fractures. Venkatanarasimha et al. [28] described a proximal radius stress injury diagnosed during a workup that also showed a stress fracture of the ulnar shaft in a patient using crutches.

Fig. 3
figure 3

T2 coronal (a) and sagittal (b) images of a left elbow demonstrating a grade II stress fracture (see Table 2) of the proximal radius in a 28-year-old weightlifter. This required four weeks of activity modification to resolve

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A wide variety of athletic activities have produced reports of stress fractures of the ulnar shaft: baseball, softball, tennis, volleyball, weightlifting, bowling, gymnastics, golf, baton twirling, crutch walking, and drumming [1, 6]. Patients typically describe pain in the ulnar shaft during and after inciting activities, particularly with upper extremity weight-bearing [28, 29]. Physical examination reveals tenderness at the subcutaneous border of the ulnar shaft.

6.7 Wrist and Hand (Scaphoid, Metacarpals, Phalanges)

As with traumatic scaphoid fractures, patients with scaphoid stress fractures present with radial-sided wrist pain and tenderness at the anatomical snuffbox [30–32]. Repetitive radial deviation and extension of the wrist in upper extremity weight-bearing athletes, as well as repetitive shearing force and rotational torque generated from a racket contacting a projectile, have been proposed as possible mechanisms [1, 6, 31]. Metacarpal stress fractures are rare but have been related to softball, tennis, rowing, and military recruits [1, 33]. Stress fractures of the index-finger metacarpal have been described most commonly. Increased training intensity combined with changes in stroke biomechanics and racket grip may predispose index metacarpals to fracture. Motion at the index carpometacarpal joint is relatively restricted compared with the ulnar carpometacarpal joints [34, 35]. This may result in increased stress transfer to the index metacarpal compared with the more mobile ulnar-sided metacarpals. Patients who presented with palmar and dorsal hand pain worsened with grip and weight-bearing through the hand. Grip strength may be decreased due to pain [34–36]. Phalangeal stress fractures have been described by Sinha et al. [6] and Waninger et al. [37] in rock climbers. Repetitive prolonged finger flexion at the interphalangeal joints while the metacarpophalangeal joint is maintained in extension has been described as the mechanism of the injury [37, 38].

7 Diagnostic Imaging

7.1 X-Ray

Plain radiographs are usually negative early in the course of rib and upper extremity stress fractures. Although two-thirds of initial X-rays are negative, one-half will be positive once healing has begun three or more weeks after symptom onset [39]. Even after healing has taken place, radiographic findings such as cortical thickening of bone edema can be subtle and easily overlooked if the images are not thoroughly scrutinized [39, 40]. For injuries of the radius and ulna, depending on the severity and chronicity of the injury, radiographs may be inconclusive and require bone scan or MRI for definitive diagnosis. In the wrist and hand, unless the fracture is displaced, X-rays are typically normal early in the course of the injury. MRI or bone scan is often necessary to make a diagnosis, with MRI being the authors’ preferred modality due to the superior specificity (>85 %).

7.2 CT

Computed tomography (CT) is useful when the diagnosis of a stress fracture is indeterminate based on plain X-rays (Fig. 4). CT scanning is useful for defining bony union and demonstrating evidence of healing by clearly showing the periosteal reaction. CT also delineates the presence or absence of a discrete lucency or sclerotic fracture line. This study can delineate a complete fracture from an incomplete fracture but is not as commonly used as MRI due to the increased amount of radiation exposure and poor ability to evaluate surrounding soft tissue structures.

Fig. 4
figure 4

Bone scan recovery sequence (a) demonstrating stress injury to the right first rib in a 20-year-old competitive weightlifter. The patient was treated with activity modification for six weeks and symptoms did not recur. A follow-up chest CT scan (b) (coronal sequence) performed eight weeks after bone scan demonstrates abundant fracture callus at the fracture site (arrow)

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7.3 Bone Scan

Bone scintigraphy has been shown to be 100 % sensitive for stress injuries of bone. The greatest value of bone scintigraphy is that it allows early diagnosis of stress injuries [40]. Bone scans will often demonstrate increased uptake and a focused area of increased osteoblastic activity in the affected bone one to two weeks before radiographic changes occur (Fig. 4) [40]. Uptake on bone scan requires 12–18 months to normalize, often lagging behind the resolution of clinical symptoms [40]. Thus, bone scans are less helpful for guiding return to activity and/or sports participation. In the case of first rib injuries, bone scintigraphy has demonstrated 100 % sensitivity for early detection and diagnosis, but with a lower specificity than MRI.

7.4 MRI

Magnetic resonance imaging (MRI) has the highest combined sensitivity and specificity of any imaging study for evaluating stress injuries of bone. This modality has demonstrated superior sensitivity and specificity over bone scan and CT for associated soft-tissue abnormalities, and may delineate bony injury 1–14 days earlier than bone scan [39]. MRI is used more frequently as the primary diagnostic tool for stress fractures [39, 40]. Although MRI sensitivity for detection of bone stress injury is similar to that of a bone scan, it is much more specific (>85 %) for delineating the anatomic location and extent of injury. Typical MRI findings on T2-weighted sequences include a band of low signal (corresponding to the fracture line) surrounded by diffuse high signal intensity (representing marrow edema). It has the additional benefit of identifying soft-tissue injuries [40].

7.5 Classification/Grading

Stress fractures are not a single consistent entity. They occur along a spectrum of severity that can impact treatment and prognosis. Not only does the severity of these injuries vary, but the clinical behavior of these injuries varies by location and causative activity. Lower extremity stress fractures are classified in multiple ways, but most commonly based upon the size of the fracture line seen on imaging, the severity of pain or disability, the biologic healing potential of the particular location, or a combination of these criteria [41]. The classification of lower extremity stress fractures as either “high risk” or “low risk” has been suggested by multiple authors [42, 43]. High-risk stress fractures have at least one of the following characteristics: risk of delayed union or nonunion, propensity for re-fracture, and long-term consequences if they progress to complete fracture [42]. This distinction allows clinicians to promptly decide if aggressive or conservative treatment is required. The majority of rib and upper extremity stress fractures are considered low-risk injuries. High-risk stress fractures of the upper extremity include those of the olecranon and the scaphoid because of their potential for nonunion due to high tensile stresses and poor healing potential, respectively.

In addition to risk stratification of stress fractures based largely upon anatomic site, the “grade” or amount of failure at a specific site is also used to describe the injury and make appropriate treatment plans. Stress injuries of bone occur on a continuum from simple bone-marrow edema (stress reaction) to a small unicortical disruption to a complete fracture with or without nonunion. The management of bony stress injuries should be based on the location and grade of the injury. A combined clinical and radiographic classification system developed by the authors of this manuscript is shown in Table 2 [44]. This system has shown high inter- and intraobserver reliability among sports medicine and orthopedic clinicians [44].

Table 2 Kaeding–Miller Stress Fracture Classification System [44]
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8 Management

8.1 Nonoperative Treatment

The treatment for stress fractures of the ribs and upper extremities should be individualized to the patient’s functional needs, causative activity, anatomical site, and fracture grade. Symptom severity also plays a major part in treatment decisions. Rehabilitation and training programs focused on proper mechanics and technique should be included in the treatment protocol after the fracture has been given sufficient time to heal [12, 14, 15]. If the fracture does not heal or symptoms persist beyond 4–6 weeks, the options for treatment are immobilization and restrictive bracing or potentially surgical fixation (Fig. 5). Patients who have a low-risk stress fracture and are without functional limitations may continue their activities as tolerated using symptoms as a guide.

Fig. 5
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Recommended treatment algorithm for stress injuries of bone

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The treatment of rib stress fractures is nearly always nonoperative, with the initial goal being to provide symptomatic relief. In general, rib stress fractures rarely fail to heal with modification or complete discontinuation of the causative activity for 4–6 weeks [1]. Treatment includes relative rest by avoiding overhead lifting, throwing, or rowing sports. Nonunion of the ribs has been described, but this is very rare and may be asymptomatic [1, 11]. In the case of clavicular stress fractures, activity modification until pain is resolved, postural training, and scapulothoracic stabilization exercises have yielded symptom resolution [1, 18]. Humeral, radial, ulnar, and phalangeal stress fractures are treated with rest and cessation of the offending activity. However, twelve months may be required for the patient to become asymptomatic [37].

The decision to continue, but titrate down, a causative activity in the presence of a stress fracture must be made in conjunction with the patient only after thorough understanding of possible progression is conveyed. The activity may then be continued at a tolerable pain level [4]. Close follow-up of these patients is necessary to ensure compliance with activity restrictions and prevent fracture progression to a higher-grade injury. This approach is acceptable if the risk and consequence of fracture completion are acceptable to the patient due to the importance of continuing their activity. Unless contraindicated, patients may be permitted to cross-train during this time to maintain fitness and supplement training as the fracture heals.

Low-grade stress injuries or those without a clear fracture line at a low-risk site have a shorter time to recovery than a higher-grade injury at the same low-risk site [4]. The major treatment differences between these two levels of severity of injury are duration of treatment, degree of activity modification, and need for immobilization. The goal of treatment is to decrease the repetitive stress at the fracture site, thereby restoring the dynamic balance between damage and repair [4]. This may include decreasing the volume of activity, equipment changes, technique changes, or cross-training. If pain persists or intensifies despite activity modification alone, treatment must be advanced to include complete rest, immobilization or surgical intervention (Fig. 5).

8.2 Operative Treatment

Few upper extremity stress fractures require surgical fixation for healing. As noted, one of the few sites considered to be high risk is the olecranon process, which may require surgical intervention because of the tensile nature of the forces at this area [23, 25]. Though this injury has the potential to heal with conservative management, when a stress fracture line (grade III injury, Table 2) is discovered in a throwing athlete’s olecranon, internal fixation is the preferred treatment [25]. This may be accomplished with single intramedullary screw fixation (Fig. 2c), posterior plating, or tension band fixation [22, 25]. However, the injury may fail to heal despite internal fixation due to tensile forces at the site [25]. This is treated with revision fixation with or without bone grafting.

As with nearly all displaced long-bone fractures in adults, displaced (grade IV, Table 2) stress fractures of the humeral, ulnar, and radial shafts require surgery to reduce, stabilize, and allow healing of the fracture. Furthermore, grade III stress fractures of the scaphoid and delayed unions or nonunions of the humerus, ulna, or radius (grade V) warrant surgical treatment. Both open and percutaneous screw fixation techniques are used for scaphoid stress fractures, while compression plating is used for long-bone stress fractures of the upper extremity. In the case of long-bone nonunion (Fig. 6), bone grafting with compression plating is often required to achieve union.

Fig. 6
figure 6

Elbow X-ray of a 40-year-old female who developed chronic atraumatic pain of the proximal forearm after using crutches for six weeks following hip surgery. The stress fracture (arrow) developed a nonunion and required open reduction and internal fixation with distal radius bone grafting

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9 Return to Sports Participation

Despite advances in the imaging and understanding of stress fracture behavior, the decision to return to activity is multifactorial and continues to challenge sports medicine practitioners. Critical to any return-to-play consideration is a thorough understanding by all parties (e.g., the physician, the player, the coaches, etc.) of the risk of possible disease progression. All patients, especially those with high-risk stress fractures, must understand the risk of noncompliance with the treatment plan. A treatment plan should be tailored to athletic and personal goals, and the risks and benefits of continued participation thoroughly discussed.

In the treatment of low-risk stress fractures, the point in the competitive season at which the injury is diagnosed is often a major consideration for return to play. Athletes at the end of a competitive season or in the “off-season” may desire to be healed from their stress fracture before the resumption of training. For these individuals, the treatment plan should include strict rest and activity modification to a pain-free level. In contrast, athletes in mid-season with low-risk stress fractures often desire to finish the season and pursue treatment for a cure at a later time, so the treatment will involve no or only slight rest. A gradual increase in activity can begin once the athlete is pain-free with activities of daily living and when the site is nontender.

10 Prevention of Stress Injuries

Prevention is the preferred management of stress fractures. An assessment of risk should be made at pre-participation evaluations, especially in individuals with a history of previous stress fractures. A history of prior stress fracture should alert the clinician to review that individual’s risk factors. In females, correction of amenorrhea is critical. Team physicians involved with female athletes must always keep an eye out for evidence of the classic triad of osteopenia, disordered eating, and menstrual cycle abnormality. Calcium and vitamin D supplementation is often recommended in addition to general nutritional optimization. If biomechanical abnormalities are encountered, video analysis with appropriate muscular strengthening and technique changes is helpful to prevent future injuries.

11 Conclusions

Stress fractures of the thorax and upper extremities can be a source of pain and missed time from sport or employment. Stress fractures, along with bony tumors and insufficiency fractures, should be included in the differential diagnosis (Table 3) of patients with pain of the ribs and upper extremities who perform repetitive tasks. They are common injuries in rowing and throwing athletes and in individuals performing repetitive weight-bearing activities through their upper extremity. The diagnosis may be made if a high index of suspicion is maintained and proper imaging studies are obtained. Treatment of these injuries, whether surgical or nonsurgical, should be individualized. Factors influencing treatment decisions include: location (low vs. high risk), fracture grade, the individual’s activity level, the competitive situation, and his or her risk tolerance.

Table 3 Differential diagnosis for rib stress fractures
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