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Letters to the Editor |
Copenhagen, Denmark
Dear Editor:
This letter is regarding the article by Dr. Kristine Karlson that was entitled "Rib Stress Fractures in Elite Rowers. A Case Series and Proposed Mechanism" (July/August 1998, pages 516–519). She reported in this retrospective review, 14 cases in 10 patients among 61 national elite rowers over a 2-year period. Thirteen cases were documented by bone scan or radiograph; one case was documented only by clinical examination. The proposed mechanism was attributed to 1) new equipment (new blades), 2) repetitive bending forces of the fifth through ninth ribs in which the serratus anterior and external oblique muscles are the major muscles involved, and 3) the rowing technique.
None of this information nor the interpretations are new, but rather confirmatory of the increase in rib stress fractures in rowing. In 1997, six cases of rib fractures in elite rowers (among 50 national rowers) were documented by bone scan within a 14-month period.1 This report discussed exactly the same mechanisms as the causes of rib stress fractures but also pointed to another important fact, namely that highly specific training (in the rowing ergometer and in endurance training in the boat) is much more predominant in rowing today. The only difference between these almost-identical reports is that the interpretation of the biomechanics causing the injuries differ. In the report by Karlson, the interpretation of the injuries being precipitated at the end of the drive phase and the recovery phases is not new either,2,3 and seemingly does not take into account that, by introduction of the new oars’ blade, this rowing technique is already obsolete as the length of these oars are shorter than those used before 1992, which makes the strokes and movement of the rower’s upper body shorter.1 It is more likely that, because of the development of this highly efficient equipment used year-round, the injuries are caused by increased biomechanical stress on the thoracic skeleton in the catch and early part of the stroke.1
REFERENCES
Hanover, New Hampshire
The following is my response to the letter received from Dr. Christiansen.
1. The literature search for the paper in question was, I believe, complete. There were delays in publishing, which perhaps gave the perception the previous paper was ignored. My paper was submitted in April 1997 and a post-acceptance revision was submitted in July 1997, the same month as his paper was published. Even a thorough online search on the topic could not have found a paper that was not yet published while the revised version was already submitted.
2. Dr. Christiansen’s comments on the mechanism of stress fractures of the ribs involving stress transmitted to the thorax at the beginning of the stroke are interesting. He suggests that I have no real knowledge of the rowing technique or equipment involved; this is far from the truth, as I was one of the athletes in my case series. It was my, and my fellow athlete’s, pain at the end of the rowing stroke that led to my theories about the mechanism of stress fractures of the ribs. I suspect the new blade shape also holds onto the water more efficiently at the finish as well as at the catch, and both may contribute to rib stress fractures. This increased pain reported at the finish is best explained by my suggested mechanisms.
3. I agree that Dr. Christiansen’s paper was of interest. We do disagree somewhat concerning the mechanism of injury. As noted, we do believe there is an influence of the external oblique muscle, which inserts from the rib just adjacent to the serratus anterior muscle. I do not think that we have to apologize in the sense that none of this information or interpretations are new, as I do think there are some differences.
Dr. Christiansen also pointed out that his particular article had been sent in to the American Journal of Sports Medicine and was rejected. He wondered why the editorial process had led to his article being rejected when another article just a few years later on the same subject was accepted.
Editors depend on reviewers to help them in making a final decision. There are times when different reviewers may look at the same subject and one may say, "yes this is reasonable," and one may say, "I think not." The system is not perfect, but it is honestly performed. I will say at this juncture that I believe that Dr. Christiansen’s article published in the other journal is a good article on its topic, and I believe that the article we published by Dr. Karlson on the same topic is also a good article.
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