Friday, June 22, 2012

Golfing and Rib Pain


Golfing injuries— could anything be worse for the avid golfer? Taking a sport you love, and making it painful. Injuries are typically of the upper extremity, and include tendonitis and hook of the hamate fractures. Injuries of the torso are less common, but can also occur.

In this case, a 27-year-old golfer presented to his physician with upper back pain. Conventional radiographs revealed no abnormalities, and the patient was sent for an MRI.
A coronal STIR image reveals bone marrow edema in two adjacent ribs in posterior left hemithorax:

Corresponding abnormal signal is seen on a coronal T1 weighted image:

The findings are diagnostic of rib stress fractures, secondary to overzealous golfing. Goyal et al. described several pertinent features of rib stress fractures in golfers:

--> injury usually occurs in beginners who golf frequently.

--> patients present with vague discomfort of the upper back, which is often mistaken for muscle strain.

--> conventional radiographs may show rib fractures, but they are often normal. Bone scintigraphy shows a characteristic pattern of abnormal focal uptake in the medial aspect of one or more posterior upper ribs (usually the 2nd-7th ribs).

--> affected ribs are typically contralateral to the patient's dominant hand (but these injuries can also occur on the dominant hand side).

--> proposed mechanism is that inexperienced golfers repetitively strike the ground when they swing their club. This causes a forceful traction of the serratus anterior muscle, which consequently places stress on the ribs.

Stress fractures can occur in golfers in other locations, including the tibial diaphysis, proximal phalanx, sternum, ulnar diaphysis, and acromion. The hook of the hamate and ribs remain the most common location of stress fractures, however.

Watch your form, and happy golfing!

Vic David MD