The aim of this study was to analyze retrospectively the injuries of the male and female rowers at the Australian Institute of Sport (AIS) during the 10-yr period from 1985 to 1994 inclusive.
Despite the fact that rowing is a sport with a long history, studies of rowing injuries have been limited, perhaps partly because of its predominantly amateur status and the perceived low risk of major injury.
Rowing has been shown to carry a relatively low risk of injury(36). Although epidemiological studies of rowing injuries have been few, Hosea et al. (9) reported a series of 180 injuries in male and female university rowers, Wajswelner et al.(35) reported 222 injuries in domestic and international rowers, and Coburn and Wajswelner (3) presented a survey of 54 consecutive rowing injuries presenting to a Sports Medicine Clinic in a 12-month period. Redgrave (25) and Edgar(4) have provided overviews of injuries in rowers. Wajswelner et al. (34), Stallard,(30) and Howell (10) reported on the high incidence of low back injury in rowers, and stress fractures of the ribs have been reported in rowers by Holden and Jackson (8) and McKenzie (16).
To obtain a rowing scholarship at the AIS, rowers must be of elite standard, having already reached national squad level. AIS rowers train for an average of 25-30 h·wk over 10-16 rowing sessions per week (most often 12), which last approximately 2 h each. They also undertake two to three weight training sessions per week. The amount and type of sessions undertaken vary according to the phase of training (strength/endurance, taper, or competition). The rowers generally have 3-wk rest at the end of the northern hemisphere season (after World Championships in August/September).
This study benefits from the fact that all the rowers are based full-time at the AIS and all of their medical problems (illnesses and injuries) are managed by the staff of the Sports Medicine Department of the AIS.
The Sports Medicine Department of the AIS is staffed by medical practitioners, physiotherapists, masseurs, and nurses. All AIS rowers with injuries and illnesses present to the medical practitioners for diagnosis and may then be referred for further treatment (physiotherapy, massage, etc.) if required. Therefore, all significant injuries are recorded in the medical records of each rower. In this study the medical records of all rowers at the AIS from 1985 to 1994 inclusive were reviewed and all injuries included. An injury was defined as any injury presenting to the medical practitioners of the AIS Sports Medicine Department. The injuries were categorized according to time of injury, location of injury, cause of injury, and whether the injury was acute or chronic in nature. Acute injuries were those injuries that occurred from a specific event, were sudden in onset, and presented within several days of injury. The majority of injuries were treated by four doctors, with a small proportion of injuries treated by several other doctors. All the treating doctors were experienced sports medicine practitioners, either undertaking specialist sports medicine training (under supervision), or qualified sports physicians.
Written informed consent was obtained from the participants. The study was approved by the Ethics Committee of the AIS.
During the 10-yr period studied there were 84 female and 88 male rowers on scholarship at the AIS. The average duration of a scholarship was 18.5 months for the females and 18.7 months for the males.
The age at the commencement of their scholarships ranged from 14 yr 11 months to 36 yr for the females, and from 16 yr 5 months to 31 yr 3 months for the males. The average age at the start of scholarships was 20.1 yr for the females and 21.3 yr for the males.
The total numbers of acute and chronic injuries over the 10-yr period are recorded in Table 1.
Overall, 84 female rowers held scholarships for a total combined length of 1,552 months (129.3 yr) and sustained 204 injuries (57 acute and 147 chronic). This gave an incidence of one injury per 7.6 months or 1.58 injuries per 12 months on scholarship.
Overall, 88 male rowers held scholarships for a total combined length of 1,643 months (136.9 yr) and sustained 116 injuries (35 acute and 81 chronic). This gave an incidence of one injury per 14.2 months or 0.85 injuries per 12 months on scholarship.
When the timing of injury presentation was tabulated(Figs. 1 and 2), there appeared to be two peak times for injury presentation in both females and males. The period of May/June and the summer period of November/December/January/February had the highest incidence of injury. July was the month of lowest incidence, although this may have been because some rowers were away in competition in the northern hemisphere during this period.
ANATOMICAL DISTRIBUTION OF INJURIES
The anatomical distributions of acute and chronic injuries in females and males are presented in Tables 2 and 3, respectively.
Females. The total number of injuries to female rowers over the 10-yr period was 204. Fifty-seven injuries were acute (27.9%) and 147 chronic(72.1%). The regions most frequently injured were the chest (22.6%), lumbar spine (15.2%), forearm/wrist (14.7%), and knee (9.3%).
Of the chronic injuries in females 25.9% affected the chest, forearm/wrist(18.4%), lumbar spine (12.9%), and knee (10.9%).
The region most affected by acute injuries was the lumbar spine (21.1%), followed by chest (14.0%), hand (12.3%), andfoot/ankle (12.3%).
The most common specific injury in female rowers was tendinitis/tenosynovitis of the wrist/forearm (N = 20), which included De Quervain's tenosynovitis (6 cases), intersection syndrome(“rower's wrist”) (N = 3), and tendinitis/tenosynovitis involving other tendons of the wrist/forearm (N = 11). Stress fracture of the ribs was seen in 15 rowers, followed by “nonspecific chest wall pain” (N = 10)-so named because no firm diagnosis was made and in most cases (N = 8) a Tc99 bone scan had been performed and found to be negative. Intercostal muscle strain was diagnosed on nine occasions. The next three most common diagnoses all presented as low back pain, diagnosed as “disk-related” (N = 7),“muscular” (N = 6), and “mechanical”(N = 6). Tendinitis around the ankle (N = 6) included tendinitis of the achilles (N = 3), tibialis posterior (N= 1), flexor hallucis longus (N = 1), and extensor digitorum longus(N = 1) tendons (see Table 4).
Males. The total number of injuries seen in male rowers over the 10-yr period was 116. Thirty-five injuries (30.2%) were acute and 81 (69.8%) were chronic. The regions most frequenty injured were lumber spine (25.0%), forearm/wrist (15.5%), knee (12.9%), hip/pelvis/groin/buttock/thigh (10.3%), hand (8.6%), and foot/ankle (6.9%).
Of the chronic injuries in males lumbar spine accounted for 29.6%, followed by forearm/wrist (16.1%) and knee (11.1%), with chest injury making up 8.6%(compared with 25.9% of female chronic injuries).
The regions most affected by acute injury were knee (17.1%), hip/pelvis/groin/buttock/thigh (17.1%), lumbar spine (14.3%), forearm/wrist(14.3%) and hand (11.4%).
The most common specific injury (diagnosis) in males was ligament sprain of the lower back (N = 9) followed by hamstring tendinitis/bursitis at the knee (N = 8), “mechanical low back pain”(N = 7), “facet jointrelated” low back pain (N= 6), tendinitis/tenosynovitis of the hand (N = 5), and tendinitis/tenosynovitis of the wrist/forearm (N = 5) (seeTable 5).
Injuries to the chest in female rowers. In the female rowers the chest was the region most frequently injured, totalling 46 out of 204 injuries(22.6%). Chest injuries contributed 38 out of 147 chronic injuries (25.9%) and eight out of 57 acute injuries (14.0%).
The incidence of chest injuries in female rowers had two peak periods, coincident with injuries in total. The peak periods were June and the summer months (December to February).
With regard to specific diagnoses, stress fracture of the ribs was diagnosed on 15 occasions (see Table 6). These are discussed below. The next most common diagnosis was “nonspecific chest wall pain” (N = 10). This diagnosis was reserved for those rowers whose chest pain did not clinically appear to be an intercostal muscle strain and whose Tc99 bone scan was negative. Eight of the 10 rowers categorized as suffering “nonspecific chest wall pain” had Tc99 bone scan performed. Intercostal muscle strain was diagnosed on nine occasions, with four of these rowers also having had normal Tc99 bone scans. Other muscle strains included strains of pectoralis major (N = 2).
Rib stress fractures in rowers. Stress fracture of the ribs were diagnosed on 15 occasions in female rowers and on two occasions in males. The diagnosis was made after history, clinical examination, and (in all but one case) after Tc99 bone scan. Rib stress fractures therefore made up 17/320(5.3%) of all injuries in female and male rowers combined, 15/204 (7.4%) of the female injuries, and 39.5% (15/38) of chronic chest injuries in female rowers.
In the AIS rowers diagnosed with a rib stress fracture, presentation was usually within several days to 2 wk, with two rowers presenting later at 4 wk and 2 months of symptoms, respectively.
Management was generally symptomatic, with a reduction in training and modification of training to the limits of discomfort. Physiotherapy treatment(electrotherapeutic modalities and supportive taping) was given and technique reassessed. Full training was in most cases able to be resumed within 4 to 6 wk. Some rowers had managed to row through major championships with chest pain that was confirmed later to result from a rib stress fracture. In other cases rowers had been diagnosed with a rib stress fracture in the lead-up to an event and had managed to successfully compete at that event. There was no incidence of delayed union or nonunion of rib stress fracture in the AIS rowers, as have previously been reported in cases of stress fracture of the first rib (5,23).
The 15 cases of rib stress fracture in females occurred in 12 rowers. Three rowers presented with rib stress fractures on two separate occasions, with one of these rowers having involvement of three ribs. All but one of the fractures was confirmed with Tc99 bone scan. In this case stress fracture was diagnosed on clinical grounds because the rower had previously suffered a rib stress fracture. The average age of the female rowers with rib stress fractures at the time of presentation was 21.8 yr. Apart from one stress fracture involving the second rib, all the fractures occurred in the fourth to eighth ribs. Ten out of 15 occurred on the right side, 5/15 on the left side. Of the 15 rib stress fractures, seven occurred in the region of the anterior axillary line, two were located posterolaterally, and three were located laterally. In the other three cases there was insufficient information in the medical records to accurately localize the fracture site.
The two males who presented with rib stress fractures had an average age of 21.5 yr. Both stress fractures involved the left side, affecting the sixth rib and seventh rib, respectively.
Low back pain in rowers. This study confirmed, as has been previously shown (3,10,30,34), that low back pain is common in rowers.
Low back pain was the commonest complaint among the male rowers, comprising 29/116 (25.0%) of the total injuries. The incidence in the female rowers was somewhat lower at 31/204 (15.2%).
The majority of the low back injuries were chronic (24 out of 29 in males; 19 out of 31 in females).
Diagnostically it is known to be very difficult to accurately separate low back pain into specific causes. Five major categories of diagnosis were recorded for the rowers: 1) ligament sprain, 2) disk-related, 3) facet joint-related, 4) mechanical, 5) muscular. The diagnoses were spread fairly evenly across these five categories.
Most of the rowers improved with relative rest, modification of activities, physiotherapy treatment (electrotherapeutic modalities, manipulative therapy, flexibility and strengthening exercises), and were able to return to full activities within 1 to 2 wk. Several, however, developed longer term problems. Only one rower (male) abandoned his AIS scholarship because of ongoing back problems (in his case L4-5 disk prolapse required surgery).
It appeared that a significant proportion of the lower back injuries resulted from weight sessions rather than rowing. This was particularly apparent in the acute injuries.
Stress fracture of the ulna. In one 25-yr-old male rower a stress fracture of the left ulna was diagnosed. He presented with gradual onset of pain in the left midforearm but, surprisingly, had little pain with rowing. Tc99 bone scan showed a focus of increased isotope uptake in the mid-shaft region of the left ulna and computerized tomographic scan confirmed the presence of a fracture in the lateral cortex of the ulna. This improved quickly with relative rest, i.e., avoiding upper body weight work and reducing rowing workload, and he made a full recovery over 4 wk.
Acute injuries not sustained during specific rowing training. It is noteworthy that, in addition to the injuries reported in this study, there were also a large number of acute injuries sustained outside of specific training (rowing sessions and weights sessions).
In females 19 injuries occurred away from training. This included six in cycling accidents, two in motor vehicle accidents, four falls when running, and four other falls. The injuries included a fractured fibula, a fracture/dislocation of a proximal interphalangeal joint, a fractured distal phalanx, concussion, a broken nose, and many contusions and sprains.
In the male rowers 24 injuries occurred outside of specific training. Motor vehicle accidents caused injuries in four rowers, cycling injuries in three, three were allegedly caused by assaults, several caused by involvement in other sports (basketball (N = 2), cricket (N = 2), gymnastics (N = 1), and one rower was hit in the eye by a fishing line. The injuries included fractures of the talus, a metacarpal, and the nose, subconjunctival hemorrhage, and many soft tissue injuries.
There were no catastrophic (life threatening) injuries in the rowers in this study.
Only one rower (male) was forced to retire from rowing because of injury(chronic disk injury-lumbar spine). Surgery was required in one male rower(lower back surgery), and four female rowers (bilateral De Quervain's tenosynovitis release; unilateral De Quervain's tenosynovitis release; knee arthroscopy; repair of a large pretibial laceration sustained in the weights room).
Unfortunately, the authors were unable to quantify accurately the amount of time lost because of injury as medical records often lacked precise information in this respect. The results of this review are similar to the studies of Wajswelner et al. (35) and Coburn and Wajswelner (3). The study performed by Hosea et al.(9) on university rowers found a relatively higher incidence of knee injury (28.9% compared with our 9.3%). In the international rowers presented by Wajswelner (35), the incidence of cervical spine injury (12.9%) is higher than in other studies (the incidence in our series is much lower at 1.0%).
Stress fractures of the ribs have been reported in rowing(8,16), canoeing (14), golf(8,12,13,20,24), basketball(29), baseball (5,11), swimming(32), gymnastics (8,23), volleyball (18), tennis (8), squash(19), running (26), windsurfing(22), and dancing (2). A case has been reported in a bagpiper (personal communication, Dr. J. Canavan). Stress fractures have also been seen in weight-lifters, but these have generally involved the first rib. Studies of stress fractures in athletes have shown variations in the incidence of rib stress fractures. Matheson et al.(15) reported a study of 320 stress fractures in athletes. No rib stress fractures were identified in this group and no stress fractures at any site were seen in rowers.
Ha et al. (6), however, in their study of 169 stress fractures associated with sporting activities, found that the rib was the third most common bone injured (19 out of 169 cases). None of the 169 stress fractures studied occurred in rowers.
The postulated mechanism for rib stress fractures in rowers is a bending stress, caused by a combination of forces exerted on the ribs by serratus anterior, external oblique, and possibly the rhomboid muscles. Holden and Jackson (8) found that rowers' rib stress fractures occurred posterolaterally; however, in our group the site of fracture was more commonly anterolateral.
Female rowers seem to be more at risk of rib stress fracture. This may be because their upper body strength is relatively underdeveloped compared with that of male rowers. Hormonal factors such as athletic hypothalamic amenorrhea and associated bone mineral density reduction are theoretical risks for stress fracture, but the lack of relevant data in our study does not allow us to draw any conclusions in this area. Certainly, any prospective study of rib stress fracture in rowers should address this area. Similarly, our data prevented us from determining whether position in the boat led to increased or decreased risk of rib stress fracture.
The study confirms that stress fractures of the ribs are not uncommon in elite rowers and they appear to be particularly prevalent in elite female rowers. We identified 17 cases of rib stress fracture, but it is possible that in the earlier years of the study period rowers with chest pain were less likely to have been investigated with Tc99 bone scan. Also, in some of the rowers with chest pain, bone scans appeared to have been performed when symptoms had only been present for several days, which may have produced false negative results. The true incidence of rib stress fracture in rowers may thus be considerably higher than the figures indicate.
It is interesting to note that in the female rowers, a total of 31 Tc99 bone scans were performed to investigate chronic chest pain. Only 14 of those confirmed the presence of a rib stress fracture. This finding contrasts with the view of Strayer (31), who felt that chronic chest wall pain in rowers is nearly always caused by rib stress fracture.
Stress fractures of the ulna are uncommon in athletes but have previously been reported in a bodybuilder (7), a rower(28), tennis players(1,27,37), softball pitchers(17,33), and a volleyball player(17). One mechanism of injury is thought to be caused by repetitive heavy loading of the forearm flexors and has been called a“lifting fracture” (21). Tanabe et al.(33) postulated that stress fracture of the mid-shaft of the ulna is caused by torsional stress at the site of the smallest cross-sectional area.
This study documents the injuries sustained by a group of elite female and male rowers over a 10-yr period.
On average the females sustained 1.58 injuries per year, the males 0.85 injuries per year. Chronic injuries made up 72.1% of the female injuries and 69.8% of the male injuries.
The commonest sites of injury in females were chest (22.6%), lumbar spine(15.2%), and forearm/wrist (14.7%).
The commonest sites of injury in males were lumbar spine (25.0%), forearm/wrist (15.5%), and knee (12.9%).
Chronic chest injuries were much more common in the female rowers, with stress fractures of the ribs making up 15/147 chronic injuries in the females(10.2%).
This study also confirmed that low back injuries and injuries to the wrist and forearm are a significant problem in rowers.
Injuries were more prevalent in the (southern) summer months (December, January, February) and the months of May, June, and July. These periods coincide with times of more intense and prolonged training and/or competition.
A significant number of acute injuries occurred outside specific training. Many of these were major injuries, such as fractures.
This study shows that while there is a risk of injury in elite rowers, this risk is not great and the risk of major injury is very small.
Most injuries sustained in the course of rowing training are mild to moderate injuries, more often chronic; they usually do not require prolonged periods away from rowing, and most often result in complete recovery.
The authors wish to acknowledge the tireless work of Mrs. Shirley Steer and Ms. Jill Young in the preparation of this paper.
Address for correspondence: Dr. Greg Hickey, Sports Medicine Department, Australian Institute of Sport, P. O. Box 176, Belconnen ACT 2616, Australia, E-mail: firstname.lastname@example.org
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Keywords:©1997The American College of Sports Medicine
ROWERS; INJURIES; STRESS FRACTURES; RIBS; EPIDEMIOLOGY