Atraumatic trunk injuries represent a considerable proportion of athletic injuries yet are largely underrepresented in sports medicine literature. Among Division I collegiate athletes, nearly 20% of all overuse injuries affect the torso with one quarter of these injuries resulting in greater than 3 wk away from sport (1). Trunk injuries account for 9% of rowing, 10% of Major League Baseball (MLB), and 22% of cricket injuries (2–4). While not well described in an athletic population, more than 60% of children and 30% of adults presenting for emergent chest pain evaluation are found to have a musculoskeletal etiology, often requiring evaluation of visceral pathology prior to definitive diagnosis (5).
Because of the lack of recognition among sports medicine providers, trunk injuries may contribute to significant performance limitation and time away from sport. Determining specific location of pain and mechanism of injury in the context of sport-specific biomechanics are essential for an accurate diagnosis. Sports at highest risk of atraumatic trunk injury typically involve repetitive thoracic rotation and/or overhead activity such as rowing or throwing. Pain generators include the thoracic spine, ribcage, and chest and abdominal wall musculature (Fig. 1). Evidence-driven management guidelines are limited for these injuries.
The primary objective of this article is to present a comprehensive review of atraumatic trunk injuries in athletes focusing on anatomy and biomechanics, clinical evaluation, treatment, and return to play. The goal is to enhance awareness, propose an approach to evaluation, and guide management for athletes at risk for trunk injuries.
Basic anatomy and biomechanics
The thoracic spine is comprised of 12 vertebrae with unique characteristics, including long, inferiorly sloping spinous processes, circular vertebral foramina, and costal facets. Thoracic intervertebral discs have reduced height and volume compared with cervical and lumbar discs, and the thoracic spinal cord occupies 40% of the spinal canal compared with only 25% in the cervical spine. Secondary to its articulation with the bony ribcage, the thoracic spine has limited range of motion. Primary movements include lateral bending and rotation with increasing flexion/extension at lower thoracic levels (T10 to T12) (6).
Thoracic disc herniation
Thoracic disc herniation (TDH) is very rare, representing less than 1% of symptomatic intervertebral disc herniations at all levels (7). While trauma is a risk factor noted in 26% to 50% of symptomatic patients, degeneration is the most common etiology (7). Incidence is equivalent between men and women (7), while prevalence is approximately 15% in men and 11% in women younger than 50 years (8). The T11 to T12 level is most commonly affected (26% to 50%) because of the increased motion and load at that level (7).
Presenting symptoms are variable. Pain can occur exclusively axially or in a radicular pattern to the midaxillary line and/or anterior chest wall and abdomen; unilateral or bilateral. Discomfort can be worse with straining or coughing. In throwing athletes, specifically pitchers, pain can worsen with side arm delivery, involving increased thoracic forward flexion compared with overhead delivery (9).
On examination, pain may be provoked with thoracic forward flexion and rotation. Motor and sensory disturbances are less common at the thoracic level and often present later in the course. Myelopathy is present in only 4% of TDH cases from T9 to T12 with the paraspinal, intercostal, and abdominal muscles most commonly affected (10). Magnetic resonance imaging (MRI) is the diagnostic imaging study of choice (Fig. 2A, B). Treatment includes relative rest and physical therapy (PT) focusing on postural and proprioceptive exercises, periscapular, lower trapezius, latissimus dorsi, and erector spinae muscle strengthening, and pectoral stretching (11,12). Pain management may include anti-inflammatory and neuropathic pain medications, topical lidocaine, ice, and/or heat. Spinal epidural injections, intercostal nerve blocks, or surgical intervention may be considered for severe or refractory cases (9,13,14). In general, TDH has a more favorable natural history than the cervical and lumbar spine with decreased recurrence. However, time to return to play is often longer, averaging 6 months compared with 2 to 4 months in the cervical and lumbar spine (9,15).
Scoliosis is a spinal deformity that involves lateral and rotational curvatures of the thoracolumbar spine. The majority of scoliosis is idiopathic (85%); less commonly congenital or neuromuscular. Adolescent idiopathic scoliosis (AIS) affects 2% to 4% of adolescents with a similar incidence in women and men (16). There is a genetic predisposition with a seven-fold risk in individuals with siblings with scoliosis and a three-fold risk in individuals with parents with scoliosis (17). There has been no association between exercise/athletic participation and AIS (18).
Patients often present with a visible spinal, chest wall, or shoulder deformity/asymmetry, pronounced with forward flexion. Back pain is present in only 25% of patients and is often axial, over the prominent ribs (17).
The Cobb angle is utilized to quantify the magnitude of scoliosis on thoracolumbar weight-bearing posteroanterior radiographs (16). An initial Cobb angle of ≥25 degrees is the strongest predictor of long-term curve progression. Serial radiographs are indicated in patients with symptomatic scoliosis (with associated back pain), Cobb angle above 10 degrees, or significant progression noted on physical exam. Progression to severe disease is 10 times more common in women, particularly during pubertal growth (16).
Treatment depends on the severity of the curvature and is focused on PT, bracing (angle above 25 degrees), and surgical correction (angle above 40 degrees) (16). Only 0.25% of cases progress to require a brace and 23% of those cases progress to surgery (19). Routine screening is controversial (16,17). There are no restrictions for athletes with AIS in exercise and sports participation unless symptomatic (16).
Scheuermann kyphosis (SK) is defined as >45 degrees of thoracic spine curvature with anterior wedging at three adjacent vertebrae. The apex of the curve is often between the T7 and T9 vertebrae. SK should be distinguished from benign postural kyphosis in that it does not correct in extension (20). The prevalence is 0.4% to 8% in the general population with a 2:1 male/female predominance at 10 to 15 years.
There is no clear etiology for SK, but hereditary and biomechanical factors may play a role. Athletes participating in waterskiing and swimming may be at greater risk (17). SK is typically identified incidentally on physical examination. While the cosmetic deformity may be the only complaint, pain can occur in the midback, periscapular region, and lumbar spine with repeated activity or prolonged sitting or standing. Radicular symptoms are rare. Concomitant scoliosis is present in 20% to 30% of patients, while others have excessive lumbar lordosis and tight hamstrings (20). Diagnosis is made with a standing, lateral thoracolumbar spine radiograph. In addition to the aforementioned curve and wedging, vertebral endplate irregularities, disc space narrowing, and Schmorl nodes may be present (20).
Treatment may include therapeutic exercise focused on thoracic extension, scapular retraction, postural optimization, and bracing if the curve is 50 to 70 degrees, especially in the presence of pain (20). Brace options include the Milwaukee brace (CTLSO) and the TLSO worn 16 to 18 h·d−1; shown to arrest progression in almost 98% of cases (21). Surgical correction is indicated if pain is persistent or if the deformity progresses above 75 degrees despite nonoperative management (20).
Postural thoracic hyperkyphosis (angle >45 to 55 degrees), unlike SK, does correct in extension (21). While often asymptomatic, it can cause back pain and contribute to other conditions. For example, Sakata et al. reported 2.5 times increased risk for developing a medial elbow injury with thoracic kyphosis angles at or above 30 degrees (22). Treatment and prevention efforts should focus on thoracolumbar spine extension, core strengthening, and evaluation of the kinetic chain.
Ribs and Costal Joints
Basic anatomy and biomechanics
The bony ribcage consists of 12 pairs of ribs. True ribs (1–7) have bony articulations posteriorly with the thoracic vertebrae via the costovertebral and costotransverse joints and anteriorly with the sternum via the costal cartilage. False ribs (8–10) have the same posterior articulations but attach indirectly to the sternum via insertion of the costal cartilage onto the cartilage of the rib just superior. Floating ribs (11,12) have a single posterior articulation with the body of the corresponding thoracic vertebrae only. Further, “atypical” ribs (1,2,10–12) each have unique structural characteristics compared to the bony morphology of “typical ribs.” The inferior margin of each rib has a costal grove for the neurovascular bundle (23). The main functions of the bony ribcage are to provide a semi-rigid, protective enclosure for vital organs and important attachment sites for muscles of respiration and structural support (23).
Rib bone stress injury
Rib bone stress injury (BSI) occurs infrequently outside of sport. Athletes commonly affected include rowers, golfers, throwers, swimmers, and runners (24,25). Among elite rowers, rib BSI is relatively common with incidence of 0.13 to 0.27 per 1000 athlete days and prevalence of 4% to 15% (26). BSIs most frequently involve ribs 4 to 8, accounting for >80% of cases (24–27), and can occur at any location with anterolateral most common, followed by midaxillary and posterior (26,27). As with other BSI, female athletes are at increased risk (24,26). Elite rowers with a history of rib BSI were found to have lower bone mineral density compared to those without BSI (28), supporting the contribution of female athlete triad and relative energy deficiency in sport factors. First rib BSIs are uncommon and primarily described in overhead and dominant-arm throwing athletes, particularly pitchers (25,29).
The etiology is likely multifactorial. Contributing biomechanical risk factors include repetitive loading due to forceful and often opposing muscular contractions, ribcage compression and ring deformation, and various other intrinsic and extrinsic factors. The serratus anterior muscle has been implicated in BSI given the anatomic correlation to sites frequently involved and highly repetitive use in rowers and throwers (24,27). Opposing contraction of the external oblique muscle, interdigitating with the serratus anterior superiorly and the latissimus dorsi inferiorly, may further increase bone stress (25). BSI of the floating ribs may result from similar opposing pulls of the external oblique and the latissimus dorsi (14). Additionally, repetitive movement of the scapula against ribs 2 to 8 may contribute to posterior BSI (24). Finally, the first rib is subject to opposing scalene and serratus anterior muscular contractions, typically at the thinned subclavian artery groove (25), although intrascalene and posterior stress fracture patterns have been described as well (29).
Presentation is often vague chest wall or even shoulder pain (first rib BSI), and examination may not reliably demonstrate bony tenderness (25,29). Thus, misdiagnosis is not uncommon. Therefore, a high index of suspicion may trigger imaging to assist with diagnosis. As plain radiographs are generally normal, advanced imaging may be necessary. MRI is the preferred diagnostic imaging modality for BSI (Fig. 2C, D). Ultrasonography may be utilized for the identification of stress fracture (30). Treatment is similar to BSI in other locations with a period of relative rest followed by gradual return to sport, addressing metabolic and/or biomechanical risk factors concurrently. Return to sport in elite rowers has been reported as 10 to 12 wk for stress fracture and 5 to 6 wk for lower-grade BSI (26,29). Recovery is generally uncomplicated with the exception of first rib stress fracture, which has increased risk for delayed union or nonunion with pseudarthrosis and potential for thoracic outlet syndrome (TOS) due to callus formation (25). In a retrospective cohort of 23 throwing athletes (primarily baseball players), nearly 30% developed nonunion of first rib stress fractures at 7.5 months, three opting for rib resection to alleviate TOS symptoms (29).
Costochondritis is a common cause of anterior chest wall pain, affecting women more than men (14) and accounting for approximately 14% to 30% of outpatient and emergency room visits for chest pain in adults and adolescents (31). It most often occurs in patients older than 40 and has not been well studied in athletes. Costochondritis is a benign, self-limiting inflammation of the costochondral junctions or the chondrosternal joints, most commonly in ribs 2 to 5 (14,25,31) with multisite involvement in most cases (31). Onset is typically insidious, but it has been described in those with repetitive arm and trunk movements, history of chest wall trauma, and preceding cough (14,31). It is a clinical diagnosis with examination notable for tenderness over the affected costal cartilage or chondrosternal joints without associated swelling.
Certainly, further evaluation for cardiopulmonary or neoplastic etiology based on history, age older than 35, and risk stratification should be considered, but routine imaging is not necessary and generally normal (31). Lab work is not warranted unless there is clinical suspicion for infection or rheumatologic condition (31). Treatment is supportive and often includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Athletes can continue sport participation as tolerated. Symptoms usually resolve over weeks to months, but can persist for up to a year or longer in refractory cases (14,31). In these rare cases, corticosteroid and/or local anesthetic injections can be considered (31).
Tietze syndrome (TS) is a rare condition, which has not been well studied in athletes. On average, it affects younger populations than costochondritis, ages 20 to 40 years (31). Similar to costochondritis, TS is a benign, self-limiting inflammation of the costochondral junction or the chondrosternal joint. In contrast, TS most commonly affects rib 2 or 3 at a single site with associated swelling (14,25,31), which is the hallmark of this condition. Presentation also is most commonly insidious, although possibly related to repetitive arm and trunk movements, chest wall trauma, or preceding viral illness and cough (14). Examination reveals tenderness over affected regions with associated overlying edema. Diagnosis, similar to costochondritis, is clinical. Plain chest radiographs can rule out fracture but are often normal. Musculoskeletal ultrasound evaluation can reveal thickened, hyperechoic costal cartilage with increased posterior acoustic shadowing compared with the contralateral side (32). In refractory cases, MRI is generally recommended over CT or bone scan given decreased radiation exposure and better visualization of soft tissue abnormalities, and can reveal focal cartilage thickening, cartilage or subchondral edema, and associated contrast enhancement of affected structures (33). Laboratory work is not indicated unless there is a clinical suspicion for infection or rheumatologic condition. Treatment, similar to costochondritis, is supportive with consideration of corticosteroid and/or local anesthetic injection for refractory symptoms (32).
Pain generally resolves or decreases with NSAIDs over a period of weeks, but swelling can be more persistent. Of note, in a retrospective case series of 121 patients originally diagnosed with TS, 28% had resolution of swelling in 2 wk and another 35% within 1 to 2 years, but 22% of patients experienced an increase in swelling over the first year. Of those 27 patients, biopsy revealed primary chest wall tumors in 13; benign in five and malignant in eight (34). Thus, consideration of advanced imaging and biopsy should be considered for those with an atypical course. In rare cases, surgical resection of the affected region also has been successful (35).
Slipping rib syndrome
Slipping rib syndrome (SRS) is a relatively uncommon condition affecting athletes, although may be significantly underdiagnosed due to lack of clinical familiarity (25,36,37). Inadequacy of the fibrous attachments between the costal cartilages of the false ribs may result in subluxation of the affected cartilage superiorly, causing pain and potentially intercostal nerve impingement (14,36,37). SRS is more common in women than men, possibly due to its association with hypermobility (36). In a retrospective cohort of 54 young athletes with SRS, 70% were women and nearly 20% were hypermobile (36).
Presentation is typically insidious in athletes with repetitive upper extremity and trunk movements, such as runners, swimmers, rowers, and lacrosse players (36,37), but onset also can follow chest wall trauma during contact or collision sport (14). Pain is commonly localized to the anterior lower rib cage or upper abdomen, sharp/shooting in nature, transient, associated with mechanical symptoms, and can be debilitating. Examination may reveal tenderness along the costal margin or pain provocation with the hooking maneuver, applying an upward pressure under the inferior margin of the rib (14,36,37). SRS is a clinical diagnosis; however, due to its relative obscurity, various imaging studies are often obtained to rule out other thoracic and intra-abdominal pathologies. More recently, dynamic sonographic examination has been used to visualize the subluxation and aid in diagnosis (37). Mean time to diagnosis can be over 15 months, requiring two or more specialist consultations (36). Treatment is generally conservative with consideration of manual therapy, including osteopathic manipulative techniques, in addition to PT and local corticosteroid injection or intercostal nerve block for persistent symptoms (36). Surgical excision is reserved for refractory cases with good reported outcomes (36,37).
Costovertebral or costotransverse joint dysfunction
Posterior rib joint “subluxation” is discussed anecdotally, particularly in rowers and swimmers (25). However, there is a paucity of literature describing true subluxation of the costovertebral and/or costotransverse joints. Additionally, there is no correlative imaging evidence to suggest true displacement, even in high velocity trauma. Despite this, athletes often experience posterior thoracic pain that improves with manual therapy techniques focused on these joints (14). As such, we suggest that costovertebral or costotransverse joint dysfunction is a more accurate term, potentially related to periligamentous pain and microinstability rather than true subluxation.
Basic anatomy and function of clinically relevant muscles of the trunk and abdominal wall are reviewed in the Table.
Functional anatomy of clinically relevant trunk and abdominal musculature.
||Athletic injury considerations
||Lateral inguinal ligament, anterior iliac crest, thoracolumbar fascia
||Inferior borders of ribs 10 to 12, linea alba, pubis via conjoint tendon
||Laterally flexes and rotates trunk to the ipsilateral side
||Repetitive trunk rotation sports, i.e., baseball, softball, cricket
Can be associated with EOM/TA injuries
||External surface of ribs 5 to 12
||Anterior iliac crest, pubic tubercle, linea alba
||Laterally flexes and rotates trunk to the contralateral side
||Repetitive trunk rotation sports, i.e., baseball, softball, cricket
Can be associated with IOM/TA injuries
||Crest of the pubis, pubic symphysis
||Cartilage of ribs 5 to 7, xiphoid process
||Forward flexes trunk, aids in forced expiration
||Direct trauma can result in a hematoma contained within the muscular sheath
||Inferior border of the rib above
||Superior border of the rib below
||External: draw rib upwards, stabilize rib cage, expand thoracic cavity during inspiration
Internal: draw rib downwards, stabilize rib cage, compress thoracic cavity during expiration
Innermost: act with internal intercostals
|Exercise-related transient abdominal pain (“side stitch”) Intercostal muscle spasm
||Lateral 1st through 8th ribs
||Anteromedial border of the scapula
||Scapular protraction and stabilization
||Strain in trunk rotation / overhead sports, i.e., rowing, weightlifting
TA, transverse abdominus. Reference (38
Serratus Anterior Muscle Strain
The incidence and prevalence of athletic serratus anterior muscle strain (SAMS) is unknown. It appears to occur most commonly in athletes that rely on repetitive, forceful contractions of the serratus anterior, namely rowers and overhead athletes (39). Muscle avulsion and fracture are very rare but have been noted in rowers, underhand/submarine pitchers, and golfers (39–41). Symptoms include pain along the lateral chest wall made worse with coughing, sneezing, rotational movement, and/or scapular activation. In the case of avulsion, there may be a painful mass along the lateral chest wall adjacent to the costal attachments, generally without scapular winging (39). MRI can confirm avulsion and evaluate for possible rib fracture or BSI. Treatment for SAMS starts with rest from aggravating activities and conservative management, followed by PT focusing on scapulothoracic and core strengthening and gradual return to sports-specific skills (39). Strengthening exercises that effectively target the serratus anterior include the dynamic hug, serratus punch, and push-up plus (42).
Intercostal Muscle Strain
Intercostal muscular strain is the most common cause of muscular chest wall pain, accounting for up to 50% of cases, followed by pectoralis muscle group strain (43). Athletes who participate in sports requiring repetitive upper body motion, such as rowing, cricket, and baseball, are at risk. Risk increases during intense training or resumption after a prolonged period of rest (off-season). Among MLB players, strains of the intercostal or external/internal oblique muscles accounted for 92% of trunk muscular strains (44).
Diagnosis is based on injury history and a dedicated physical examination. Pain may be worsened by stretching, deep inspiration, and/or coughing (43). Tenderness may be elicited at the intercostal space. Imaging is not required for diagnosis, but localized edema can be noted on ultrasound and MRI (44). Treatment is symptomatic with relative rest and conservative management. In MLB, the average return to game play after any abdominal muscle strain is 35 d for pitchers and 27 d for position players (44).
Exercise-Related Transient Abdominal Pain
Exercise-related transient abdominal pain, or side stitch, commonly affects young athletes in sports requiring repetitive torso movements such as swimming (75%), horseback riding (62%), and running (70%) (45,46). The pain is described as a lateral midabdominal cramping that may radiate to the shoulder and is associated with postprandial exercise (particularly with hypertonic beverages) (45,46). The etiology is unknown but believed to be associated with diaphragm ischemia, visceral ligament stress, peritoneal irritation, and/or cramping of abdominal musculature. Prevention involves avoiding consumption of large volumes of food and drink for 2 to 4 h prior to exercise and improving posture and core strength (45). Symptom management is centered on deep breathing techniques, stretching the affected side, and ultimately cessation of exercise (45).
Oblique Muscle Strain
Oblique muscle strain (OMS) is a common athletic injury, with the internal oblique (IOM) more commonly affected (47,48). OMS comprises 5% of MLB injuries; 44% in pitchers (44). It is caused by unilateral explosive rotational movements. Electromyography and muscle fiber alignment indicate that in pitchers the lead (nonthrowing) side IOM and trail (throwing) side external oblique (EOM) have the highest activity during axial twisting. Overall, the lead side oblique is most stressed in pitchers at maximal shoulder external rotation at the end of the cocking phase of the throwing motion. Swinging a baseball bat puts stress on both the lead and trail side oblique muscles (especially the EOM). Batters and position players more commonly injure the lead side oblique (44,48).
OMS typically presents as acute onset of pain at the anterolateral or posterolateral aspect of ribs 9 through 12. Pain may worsen with inspiration, coughing, sit to stand, direct palpation, and active trunk lateral flexion toward and stretching away from the side of injury. Resisted ipsilateral shoulder adduction from 90 degrees of abduction also can elicit pain. While diagnosis is clinical, imaging may be indicated to evaluate for avulsion injury or bone stress injury at the rib or iliac crest (47,48). MRI can show edema on T2 images at the muscle, rib, or costal cartilage interface, as well as potential avulsion (47) (Fig. 2E, F). MRI findings have not been reliably correlated with return to play (47,48). Ultrasound may be helpful for sideline evaluation and diagnosis, hematoma aspiration, and assessment of healing (49).
Athletes are managed with a period of relative rest and conservative treatment. Absence of pain with coughing or sneezing may indicate ability to initiate active treatment. Rehabilitation focuses on isometric strengthening, functional retraining, and trunk range of motion with progression to sports specific skill work. Average RTP after OMS is 4 to 5 wk in the MLB but can be longer for pitchers with trail (throwing) side injuries and position players with lead (nonthrowing) side injuries. There is a 12% recurrence rate, often within the same season (44).
Myofascial Pain/Trigger Points
A trigger point (TP) is a palpable, discrete, painful nodule within a taut band of skeletal muscle often related to repetitive microtrauma and/or relative deconditioning. It is considered “active” when spontaneously painful and latent when it is painful only with a mechanical stimulus. Sports-related risk factors include a history of ligamentous injury, tendinopathy, repetitive stress injuries, and suboptimal biomechanics (50).
Athletes may present with localized muscle pain and/or radiating pain. Diagnosis is clinical and largely based on localization of characteristic TPs and referral patterns on examination (50). Common trunk TPs in athletes include the rhomboid, levator scapulae, infraspinatus, pectoralis major and minor, trapezius, latissimus dorsi, thoracic paraspinal, and quadratus lumborum (51) (Fig. 1). Treatment is focused on correcting underlying biomechanical deficits and other risk factors. Additional options include manual therapy, ice, heat, acupuncture, and transcutaneous electrical nerve stimulation. Dry needling and TP injections also can be considered (50,51).
Visceral pain may contribute to trunk discomfort in the athlete. Sources of referred pain include hepatic, biliary, pancreatic, gastrointestinal, pulmonary, and cardiac pathology. A thorough medical history is critical, and examination of the heart, lungs, and abdomen may be necessary. Visceral pain is not reproduced with soft tissue or osseous palpation, muscle stretch, or activation (38,52). Depending on clinical suspicion, additional diagnostic studies may be warranted. Further discussion of visceral pain is beyond the scope of this article.
Trunk injuries are not well-studied in athletes. Sources of atraumatic trunk pain include the thoracic spine (disc herniation, scoliosis, kyphosis), ribcage (BSI, costochondritis, TS, slipping rib syndrome, costovertebral or costotransverse joint dysfunction), and torso musculature (serratus anterior, intercostal, oblique muscle strain, myofascial pain). Overall, an understanding of mechanism of overuse injury and sport-specific biomechanics alongside a focused clinical evaluation are essential for accurate diagnosis. Relative rest and targeted rehabilitation are the mainstay of treatment for safe and expedited return to sport. Further research is necessary to better understand these injuries and associated risk factors so that sports medicine providers can optimize management and prevention strategies.
The authors declare no conflict of interest and do not have any financial disclosures.
1. Yang J, Tibbetts AS, Covassin T, et al. Epidemiology of overuse and acute injuries among competitive collegiate athletes. J. Athl. Train
. 2012; 47:198–204.
2. Hosea TM, Hannafin JA. Rowing injuries. Sports Health
. 2012; 4:236–45.
3. Posner M, Cameron KL, Wolf JM, et al. Epidemiology of Major League Baseball injuries. Am. J. Sports Med
. 2011; 39:1676–80.
4. Stretch RA. Cricket injuries: a longitudinal study of the nature of injuries to south African cricketers. Br. J. Sports Med
. 2003; 37:250–3; discussion 3.
5. Moran B, Bryan S, Farrar T, et al. Diagnostic evaluation of nontraumatic chest pain in athletes. Curr. Sports Med. Reports
. 2017; 16:84–94.
6. O'Connor RC, Andary MT, Russo RB, DeLano M. Thoracic radiculopathy. Phys. Med. Rehabil. Clin. N. Am
. 2002; 13:623–44 viii.
7. Dietze DD Jr., Fessler RG. Thoracic disc herniations. Neurosurg. Clin. N. Am
. 1993; 4:75–90.
8. Teraguchi M, Yoshimura N, Hashizume H, et al. Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama spine study. Osteoarthr. Cartil
. 2014; 22:104–10.
9. Kato K, Yabuki S, Otani K, et al. Unusual chest wall pain caused by thoracic disc herniation in a professional baseball pitcher. Fukushima J. Med. Sci
. 2016; 62:64–7.
10. Cornips EM, Janssen ML, Beuls EA. Thoracic disc herniation and acute myelopathy: clinical presentation, neuroimaging findings, surgical considerations, and outcome. J. Neurosurg
. 2011; 14:520–8.
11. Heneghan NR, Gormley S, Hallam C, Rushton A. Management of thoracic spine pain and dysfunction: a survey of clinical practice in the UK. Musculoskelet. Sci. Pract
. 2019; 39:58–66.
12. Pesco MS, Chosa E, Tajima N. Comparative study of hands-on therapy with active exercises vs education with active exercises for the management of upper back pain. J. Manip. Physiol. Ther
. 2006; 29:228–35.
13. Wilke HJ, Herkommer A, Werner K, Liebsch C. In vitro analysis of the segmental flexibility of the thoracic spine. PLoS One
. 2017; 12:e0177823.
14. Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med
. 2002; 32:235–50.
15. Huang P, Anissipour A, McGee W, Lemak L. Return-to-play recommendations after cervical, thoracic, and lumbar spine injuries: a comprehensive review. Sports Health
. 2016; 8:19–25.
16. Horne JP, Flannery R, Usman S. Adolescent idiopathic scoliosis: diagnosis and management. Am. Fam. Physician
. 2014; 89:193–8.
17. Janicki JA, Alman B. Scoliosis: review of diagnosis and treatment. Paediatr. Child Health
. 2007; 12:771–6.
18. Kenanidis E, Potoupnis ME, Papavasiliou KA, et al. Adolescent idiopathic scoliosis and exercising: is there truly a liaison? Spine
. 2008; 33:2160–5.
19. Gielen JL, Van den Eede E. Scoliosis and sports participation: FIMS position statements. Int. J. Sports Med
. 2008; 9:131–40.
20. d'Hemecourt PA, Hresko MT. Spinal deformity in young athletes. Clin. Sports Med
. 2012; 31:441–51.
21. Ashton-Miller JA. Thoracic hyperkyphosis in the young athlete: a review of the biomechanical issues. Curr. Sports Med. Reports
. 2004; 3:47–52.
22. Sakata J, Nakamura E, Suzukawa M, et al. Physical risk factors for a medial elbow injury in junior baseball players: a prospective cohort study of 353 players. Am. J. Sports Med
. 2017; 45:135–43.
23. Graeber GM, Nazim M. The anatomy of the ribs and the sternum and their relationship to chest wall structure and function. Thorac. Surg. Clin
. 2007; 17:473–89, vi.
24. Warden SJ, Gutschlag FR, Wajswelner H, Crossley KM. Aetiology of rib stress fractures in rowers. Sports Med
. 2002; 32:819–36.
25. Karlson KA. Thoracic region pain in athletes. Curr. Sports Med. Reports
. 2004; 3:53–7.
26. Harris R, Trease L, Wilkie K, Drew M. Rib stress injuries in the 2012–2016 (Rio) Olympiad: a cohort study of 151 Australian Rowing Team athletes for 88 773 athlete days. Br. J. Sports Med
. 2020; 54:991.
27. McDonnell LK, Hume PA, Nolte V. Rib stress fractures among rowers: definition, epidemiology, mechanisms, risk factors and effectiveness of injury prevention strategies. Sports Med
. 2011; 41:883–901.
28. Vinther A, Kanstrup IL, Christiansen E, et al. Exercise-induced rib stress fractures: influence of reduced bone mineral density. Scand. J. Med. Sci. Sports
. 2005; 15:95–9.
29. Funakoshi T, Furushima K, Kusano H, et al. First-rib stress fracture in overhead throwing athletes. J. Bone Jt. Surg
. American volume. 2019; 101:896–903.
30. Roston AT, Wilkinson M, Forster BB. Imaging of rib stress fractures in elite rowers: the promise of ultrasound? Br. J. Sports Med
. 2017; 51:1093–7.
31. Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am. Fam. Physician
. 2009; 80:617–20.
32. Kamel M, Kotob H. Ultrasonographic assessment of local steroid injection in Tietze's syndrome. Br. J. Rheumatol
. 1997; 36:547–50.
33. Volterrani L, Mazzei MA, Giordano N, et al. Magnetic resonance imaging in Tietze's syndrome. Clin. Exp. Rheumatol
. 2008; 26:848–53.
34. Kaplan T, Gunal N, Gulbahar G, et al. Painful chest wall swellings: Tietze syndrome or chest wall tumor? J. Thorac. Cardiovasc. Surg
. 2016; 64:239–44.
35. Gologorsky R, Hornik B, Velotta J. Surgical Management of medically refractory Tietze syndrome. Ann. Thorac. Cardiovasc. Surg
. 2017; 104:e443–5.
36. Foley CM, Sugimoto D, Mooney DP, et al. Diagnosis and treatment of slipping rib syndrome. Clin. J. Sport Med
. 2019; 29:18–23.
37. McMahon LE. Slipping rib syndrome: a review of evaluation, diagnosis and treatment. Semin. Pediatr. Surg
. 2018; 27:183–8.
38. Hansen JT, Netter FH, Machado CAG. Netter’s Clinical Anatomy
. 4th ed. Philadelphia (PA): Elsevier; 2019.
39. Carr JB II, John QE, Rajadhyaksha E, et al. Traumatic avulsion of the serratus anterior muscle in a collegiate rower: a case report. Sports Health
. 2017; 9:80–3.
40. Otoshi K, Itoh Y, Tsujino A, et al. Avulsion injury of the serratus anterior muscle in a high-school underhand pitcher: a case report. J. Shoulder Elb. Surg
. 2007; 16:e45–7.
41. Winther AK, Ohlenschlaeger TF. Avulsion fracture of the serratus anterior muscle in a golfer. Ugeskr. Laeger
. 2015; 177(2A):56–7.
42. Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J. Orthop. Sports Phys. Ther
. 2009; 39:105–17.
43. Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim. Care
. 2013; 40:863–87, viii.
44. Conte SA, Thompson MM, Marks MA, Dines JS. Abdominal muscle strains in professional baseball: 1991-2010. Am. J. Sports Med
. 2012; 40:650–6.
45. Morton D, Callister R. Exercise-related transient abdominal pain (ETAP). Sports Med
. 2015; 45:23–35.
46. McCrory P. A stitch in time. Br. J. Sports Med
. 2007; 41:125.
47. Stensby JD, Baker JC, Fox MG. Athletic injuries of the lateral abdominal wall: review of anatomy and MR imaging appearance. Skelet. Radiol
. 2016; 45:155–62.
48. Nealon AR, Kountouris A, Cook JL. Side strain in sport: a narrative review of pathomechanics, diagnosis, imaging and management for the clinician. J. Sci. Med. Sport
. 2017; 20:261–6.
49. Obaid H, Nealon A, Connell D. Sonographic appearance of side strain injury. AJR Am. J. Roentgenol
. 2008; 191:W264–7.
50. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am. Fam. Physician
. 2002; 65:653–60.
51. Donnelly JM, Fernández-de-Las-Peñas C, Finnegan M, Freeman JL. Travell, Simons & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual
. 3rd ed. Wolters Kluwer: Philadelphia (PA); 2019.
52. Brukner P, Khan K. Brukner & Khan's Clinical Sports Medicine,
volume one: injuries. 5th ed. Sydney: McGraw-Hill; 2017.