Article by John Miller
Side strains are an injury almost unique to cricket’s fast bowlers. Javelin throwers are the only other athletic participants who also regularly strain the side abdominal muscles.
In bowlers, side abdominal strains occur on the non-bowling side of the body and the majority is strains of abdominal muscle insertions on to the lower ribs. Side strain injury is caused by tearing of the internal oblique muscle from the under surface of one of the lower four ribs or costal cartilages. MRI scans can document the site of a muscle tear, characterise the severity of injury, and monitor healing. Bony stress lesions (such as stress fractures of the 10th or 11th ribs) can occur but are less common.
There is a traditional belief that a side strain is almost a ‘rite of passage’ for an elite fast bowler that is almost certain to occur once early in his playing career and is thereafter unlikely to return. However, there are cases of recurrent side strains that plague bowlers throughout their career.
What Causes Side Strain?
Side strains are strongly related to bowling speed, with the fastest bowlers much more likely to suffer this type of injury. It is postulated that the mechanism of injury for internal oblique muscle strain is sudden eccentric contracture with rupture of muscle fibres. An eccentric contraction is one that stops a muscle or joint from excessively lengthening.
Movements associated with bowling and throwing cause lengthening of the muscle, which is then subjected to superimposed eccentric contraction, making it vulnerable to rupture.
In research studies focusing on fast bowlers, the muscle tear occurs on the non–bowling arm side. For example, in a right-handed bowler, the left arm is initially hyperextended and then forcefully pulled through to allow the right arm to follow through and release the ball. In the hyperextended position, the internal oblique muscle on the left side can be assumed to be at maximum tension or eccentric contraction. The sudden vigorous motion from this eccentric contraction or pull through that allows the dominant shoulder to flex and release the ball is the probable point at which the internal oblique muscle is likely to rupture. A similar mechanism can be proposed for other throwing sports.
How is Side Strain Diagnosed?
MRI appears to be a sensitive test for evaluating side strain injury, showing an abnormality in all patients who had a clinical suspicion of a muscular tear. Stripping of the periosteum occurs as the muscular attachment is avulsed from the osseous or cartilaginous origin; this can result in excessive hemorrhage even though the muscle tear may be low grade.
How to Prevent Side Strain
Warming up and stretching the injury before spells of bowling is very important. Keeping the torso warm and performing a series of trunk rotation and side flexion exercises is recommended.
Side Strain Treatment
It is important to cease bowling and throwing immediately after injury and ice the painful area.For best results and a reduced recovery time, seek professional treatment for a side strain.
Costovertebral Joint Sprain
Costovertebral joint sprains typically occur during excessive bending, lifting, arching or twisting movements. They may occur traumatically or due to repetitive or prolonged forces.
Signs and symptoms of a costovertebral joint sprain
Patients with a costovertebral joint sprain may experience a sudden onset of upper back and rib pain during the causative activity. However, it is also common for patients to experience pain and stiffness after the provocative activity, particularly the next morning. Symptoms are typically felt on one side of the spine and rib cage and muscle spasm may be experienced around the affected joint. Occasionally pain may be referred along the rib, into the chest, into the shoulder blade or sometimes the upper limb. Symptoms may be exacerbated during coughing, sneezing or deep breathing or with activities that involve twisting, lifting, arching backwards, bending forwards or bending sideways.
Diagnosis of a costovertebral joint sprain
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a costovertebral joint sprain. Investigations such as an MRI or CT scan may be required to confirm diagnosis.
Treatment for a costovertebral joint sprain
Most patients with a costovertebral joint sprain heal quickly and have a full recovery with appropriate physiotherapy. One of the key components is that the patient rests sufficiently from ANY activity that increases their pain until they are symptom free. This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms. Maintaining optimal posture in daily activity is also essential to minimize stress on the costovertebral joint (a postural brace may be required).
Regular icing and anti-inflammatory medication may be beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). This can significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
It is important to perform early movement and strength exercises to prevent stiffness and weakness from developing and to ensure the back is functioning correctly. The treating physiotherapist can advise which exercises are most appropriate and when they should be commenced.
Prognosis of a costovertebral joint sprain
The recovery time for a costovertebral joint sprain may vary from patient to patient depending on compliance with physiotherapy. With ideal treatment, patients may be pain free in as little as several days, although typically this may take 2 – 3 weeks. It is important to note, however, that injured tissue takes approximately six weeks to restore the majority of its strength in ideal healing conditions. Care must therefore be taken when returning to activity during this period.
Physiotherapy for a costovertebral joint sprain
Physiotherapy for patients with this condition is essential to hasten the healing process, ensure an optimal outcome, and reduce the likelihood of future recurrence. Treatment may comprise of:
soft tissue massage
electrotherapy (e.g. ultrasound)
postural taping or bracing
activity modification advice
exercises to improve flexibility, strength, posture and core stability
Contributing factors to the development of a costovertebral joint sprain
There are several factors that may contribute to the development of a costovertebral joint sprain. These factors need to be assessed and corrected with direction from a physiotherapist and may include:
thoracic spine stiffness
a sedentary lifestyle
poor core stability
muscle weakness or tightness
inappropriate lifting technique
a lifestyle involving large amounts of sitting, bending or lifting
Other intervention for a costovertebral joint sprain
Despite appropriate physiotherapy management, a small percentage of patients with this condition fail to improve and may require other intervention. This may include pharmaceutical intervention, corticosteroid injection, investigations such as an X-ray, CT scan or MRI, or assessment from a specialist. The treating physiotherapist can advise on appropriate management and can refer to the appropriate medical authority if it is warranted clinically.
An intercostal strain can occur either suddenly (e.g. from a forceful bowl, particularly if not warmed up properly) or gradually over time from excessive or repetitive activity (e.g. overtraining). They most commonly occur due to a sudden contraction of the intercostal muscles when they are in a position of stretch (such as during the fast bowling action) or during other activities involving excessive side bending or twisting forces.
In athletes, intercostal strains are most commonly seen in (fast bowlers), javelin throwers, rowers and ice hockey players. Occasionally they may occur traumatically due to a direct impact to the ribs, forcing the ribs apart such as a collision in contact sports or due to a motor vehicle accident.Signs and symptoms of an intercostal strain
In c fast bowlers, intercostal strains tend to occur on the non-bowling arm side of the body. Patients typically experience a sudden, sharp pain or pulling sensation in the side of the chest (often in the region of the lower ribs) during the provocative activity. Pain typically occurs suddenly (e.g. during a forceful bowl), but can also occur gradually over time (e.g. over the course of a match or training session).
In minor cases, the patient may be able to continue the activity only to have an increase in symptoms upon cooling down. In more severe cases the patient may be unable to continue the activity and will often have to cease sports participation. Patients with an intercostal strain typically experience pain that increases with activities that place strain on the intercostal muscles. These activities may include: bowling, throwing, heavy lifting, rowing, side sit ups, twisting, turning or side bending. It is also common for patients to experience pain or stiffness after these activities with rest, especially upon waking in the morning (or at night).
Patients with this condition may also experience swelling, muscle spasm, weakness and bruising in the side of the chest. Symptoms typically increase on firmly touching the affected region of the muscle or ribs or when performing a side stretch. In more severe cases, deep breathing, laughing, coughing or sneezing may also provoke symptoms.
Diagnosis of an intercostal strain
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose an intercostal strain. Further investigations, such as an X-ray, MRI, CT Scan or ultrasound, are sometimes required to confirm diagnosis, rule out other conditions, determine the severity of injury and monitor healing.
Prognosis of an intercostal strain
With appropriate physiotherapy management, most patients with an intercostal strain can make a full recovery (i.e. return to sport or normal activities) in a period of 4-6 weeks. In more severe cases, recovery may take longer.
Contributing factors to the development of an intercostal strain
There are several factors which may contribute to the development of this condition. These need to be assessed and, where possible, corrected with direction from the treating physiotherapist. Some of these factors include:
- inappropriate warm up
- inappropriate or excessive training
- inadequate recovery periods from training or activity
- poor sporting technique (e.g. bowling technique, throwing technique)
- bowling speed (faster bowlers are more likely to develop an intercostal strain)
- poor core stability
- muscle weakness
- poor flexibility
- joint stiffness (particularly the upper back or lower back)
- poor posture
- a lack of fitness or conditioning
- inadequate rehabilitation from a previous abdominal or lower back injury
Physiotherapy for an intercostal strain
Physiotherapy treatment for patients with with condition is vital to hasten healing, prevent injury recurrence and ensure an optimal outcome. Treatment may comprise:
- soft tissue massage
- joint mobilization
- joint manipulation
- electrotherapy (e.g. ultrasound)
- ice or heat treatment
- anti-inflammatory advice
- dry needling
- activity modification advice
- technique correction
- protective taping or postural taping
- exercises to improve strength, flexibility, core stability and posture
- a gradual return to activity plan