Working Diagnosis:
Left lateral 4th rib stress fracture

Treatment:
Patient educated on relative rest
Acetaminophen, ice and heat were prescribed for the pain
Home exercise program given, including ROM exercises and gentle stretching
Strengthening focused on the serratus anterior and external oblique complex.
Educated that total energy balance and adequate caloric intake are essentaial in athletes, especially in the presence of oligomenorrhea. She agreed to decrease upper body activity, albeit reluctantly

Outcome:
On follow up at two months, improvement of symptoms.

Author's Comments:
What went wrong?
Stress fractures of the ribs are rare, but are reported in pitching, rowing, golf, swimming and even chronic cough. Anatomically, the lateral portion of the rib is the insertion for both the serratus anterior and external oblique muscles. The first rib is more often affected in weight-training and overhead throwing, while the middle ribs are more susceptible in rowing and golf swinging.
In this case, the patient did quite a bit of rowing, dips, and pull down exercises in her Cross-FitTM routine.
In our search of MedLine, Cross-FitTM related stress fractures to the rib have not been described.
Evaluation: Rule out complications such as pneumothorax, pulmonary contusion, or flail chest and insufficiency fracture.
For stress fractures, sport specific guidance and risk factors must be identified (errors in the mechanics of overhead athletes and in golf swings).
Risks for female athlete triad should be assessed via diet and menstrual history, if appropriate.
Our patient has a significant training load with mild oligomenorrhea, which may be a result of a negative energy balance.
Recommendations for rehabilitation and return to play:
Relative rest of the upper extremity, ice and acetaminophen for analgesia
Physical therapy exercises for the serratus anterior/external oblique complex
We recommended no return to upper body weight training until she had pain free range of motion, then gradual increase in training.

Editor's Comments:
-Provides solid differential to consider for an uncommon diagnosis
-Highlights the importance of assessing for female athlete triad in athletes participating in nontraditional sports.

These authors were fortunate that the diagnosis was obvious on plain film. Had this not been the case, the next test of choice is bone scan rather than MRI, because axial imaging can miss findings on ribs that do not have a strict axial orientation, while bone scan shows these nicely.

References:
Coris EE, Higgins HW. First rib stress fractures in throwing athletes. Am J Sports Med. 2005; 33(9):1400-4.
Provencher MT, Mazzocca AD, Romeo AA. Sternum and Rib Fractures in Adults and Children. In: DeLee JC, Drez D, Miller MD, ed. DeLee and Drez’s Orthopaedic Sports Medicine. 3rd ed. Philadelphia, PA: Elsevier, Inc; 2010: 893-896
Karlson KA. Rib stress fractures in elite rowers. A case series and proposed mechanism. Am J Sports Med. 1998; 26(4):516-9.

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