In order to better understand the root cause of several common upper extremity injuries that occur among rowing athletes, this post will walk through a variety of case studies related to upper extremity injury. Regrettably there are too many injuries for this one post to cover! Thus the focus of these case studies will be on injuries to the shoulders, elbows, forearms, wrists, and hands. Keep your eyes peeled for more posts on injury and injury prevention among rowers.

• Case 1 – Rotator cuff syndrome
• Case 2 – Long Thoracic nerve palsy
• Case 3 – Bicep Tendonitis
• Case 4 – Epicondylitis
• Case 5 – Intersection Syndrome
• Case 6 – Acute exertional compartment syndrome
• Case 7 – Blisters and Calluses

Case 1

A 23-year-old national rower presents to your clinic for an evaluation of shoulder pain. The onset of the pain begin within the past 2 weeks. There is no injury mechanism. This athlete has been training regularly in preparation for several upcoming competitions. Recently there has been an increase in training intensity, frequency, and duration. The pain this athlete feels is sharp and worsens with abduction and overhead motion. This athlete also notes that occasional clicks and pops in the shoulder occur. Previously this athlete was given “bands” to use to address the complaint of shoulder pain.

Possible diagnosis:

• Rotator cuff tear
• Subacromial impingement
• Subacromial Bursitis
• Calcific tendinits
• Labral pathology
• Bony pathology (acromioclavicular, glenohumeral joint)
• Rotator cuff tendinosis
• Mechanical issue

This rower was diagnosed with a rotator cuff tear, subacromial impingement, subacromial bursitis, and a mechanical issue (potentially scapular dyskinesis, poor core control). The next steps for this rower was imaging and treatment.

The rotator cuff lies under the roof of the shoulder and is a collection of four myotendinous units that work in concert to raise and lower the arm. These four units are the supraspinatus (responsible for abduction), the infraspinatus and teres minor (external rotators), and the subscapularis (internal rotator). Several rotator cuff syndromes include tendinosis and bursitis. In tendonosis, a tear occurs in one of the four myotendinous units. Bursitis refers to inflammation of the bursa, a fluid-filled sac between the rotator cuff and the roof of the shoulder that allows for smooth overhead motions of the shoulder.

During rotator cuff injury testing a trained medical practitioner provides opposing pressure against a patient’s movement of his/her arms in specific motions while holding his/her arms in a particular position. Once the type of rotator cuff injury is identified, treatment can contain a battery of options: rotator cuff exercises, scapular control exercises, assessment and treatment of any instability/laxity, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid drugs, autologous growth factor therapy, or other miscellaneous treatments.

This athlete underwent a collection of the above treatments in tandem with rigorous optimization of rowing “stroke technique”. By improving posture within the boat, this athlete could recover from his/her injury while curtailing future injury. Specifically, by not over-reaching or “lunging” at the catch, this rower could reduce negative forces on the rotator cuff.

Case 2

A 31-year-old master’s rower presents with acute onset posterior and axillary right shoulder pain. This athlete recently joined a club rowing team after taking three years off from rowing. The pain is periscapular and axillary. With forward flexion, the right scapula demonstrates abnormal protrusion and deviates from the normal active position demonstrated by the left scapula.

Possible diagnosis:

• Scapular dyskinesis
• Long thoracic nerve palsy

This rower was diagnosed with long thoracic nerve palsy. The long thoracic nerve innervates the serratus anterior muscle that keeps the scapula adjacent to the chest wall and assists with forward arm motions. The long thoracic nerve is prone to injury due to its long length. Injury to this nerve can be caused by stretching or repetition of a strenuous movement of the arms, both of which are common activities among rowers.

Treatment for this patient lasted roughly 18 months and involved a variety of exercises that activated the serratus anterior, such as scapular depressions/adduction, protraction, and retractions. Any practical advice on considerations a rower should take to minimize risk of this injury?

Case 3

An 18-year-old rower presents with anterior shoulder pain. This athlete was training hard in order to catch up to more experienced peers. The pain radiates down the arm anteriorly and is made worse with supination, elbow flexion, and shoulder flexion. Additionally, this athlete presents with a remote history of a shoulder dislocation. This athlete has tried icing and ibuprofen.

Possible diagnosis:

• Biceps tendinitis
• Rotator cuff tear
• Subacromial impingement and bursitis
• Calcific tendinitis
• Labral pathology
• Bony pathology (acromioclavicular, glenohumeral joint)
• Mechanical issue (kinetic chain dysfunction, scapular dyskinesis)

During the physical exam this rower experienced tenderness over the bicipital groove, pain with resisted flexion of elbow flexion, and pain with Speed’s and Yergason’s tests. These tests are used to test for bicep muscle or tendon pathologies.

Based on these symptoms this rower was diagnosed with biceps tendonitis. Bicep tendonitis is characterized by inflammation of the long head of the biceps tendon, typically prompted by overuse or shoulder instability. The treatment involved focus biceps rehabilitation along with optimizing shoulder stability. Any tips on how to avoid this injury?

Case 4

A 27-year-old presents with lateral elbow pain. The onset of this pain was sudden after a particularly difficult erg piece that was performed on an unfamiliar machine with high resistance/drag factor. This rower now feels pain when trying to grip and extend the wrist.

These symptoms are typical of epicondylitis. There are two different types of epicondylitis known as medial and lateral epicondylitis. Medial epicondylitis (“golfer’s elbow”) affects the wrist flexors and pronators, muscles that contract to bend the wrist and allow the hands to turn from palms up to palms down, respectively. Premature elbow flexion, also known as “breaking the arms” early, increases the risk of medial epicondylitis. Lateral epicondylitis (“tennis elbow”) affects the wrist extensors and suppinators, muscles that contract to straighten the wrist and allow the hand to turn from palms down to palms up, respectively. Feathering the blade late, such that the bottom edge of the blade scrapes the water, increases the risk of lateral epicondylitis.

Prevention strategies for epicondylitis include strengthening the forearm musculature, reducing grip intensity, maintaining wrist and elbow motions within your natural range of motion, and avoiding excessive activity when fatigued. Additionally, active awareness of good rowing technique can help minimize breaking the arms early and feathering the blade late, also known as flip catching, which in turn reduces the risk of epicondylitis.

Case 5

A 19-year-old crew athlete presents with swelling and a sense of crunchiness or crackling in the dorsal forearm. This athlete recently began using oars with an increased handle diameter. While the condition has been intermittently painful, the pain is getting stronger as the swelling increases.

Upon examination, there is palpable crepitance (crackling sound) along the dorsal forearm. During the performance of the Finkelstein test the athlete reports pain on the thumb side of the wrist. The Finkelstein test requires the patient to bend a thumb onto the palm, wrap fingers around the thumb, and bend the wrist towards the smallest finger.

Possible diagnosis:

• Intersection syndrome
• DeQuervain’s tenosynovitis

This rower was diagnosed with intersection syndrome, also known as cross over tendinitis. This tendinitis is a result of friction between different overlapping muscles in the wrist, which causes pain where the muscles cross over, about 5-8 cm from the wrist. Symptoms are characterized by swelling along with crepitance during extension and flexion of the wrist.

Faulty feathering of the oar and an irritation of the wrist muscles connected to extensor tendons can cause intersection syndrome among rowers. This athlete was treated with a corticosteroid injection and was required to take time out of the boat while wearing a thumb spica splint. Although this athlete was not rowing during recovery, this athlete continued to cross train. Technique modification like using a smaller oar handle, taking strokes with the thumb on top of the handle, and switching sides can help reduce injury risk factors and prevent the injury from occurring again.

Case 6

A 36-year-old novice rower presents with left forearm swelling and tightness. The swelling is most notable in the feathering hand of this novice rower. Symptoms only began the day prior during several hard erg sessions when the athlete admits to pushing it to the limit. This athlete is also experiencing intermittent tingling in the hands. An examination reveals a moderately swollen left forearm, a palpable radial pulse, and a brisk capillary refill.

Possible diagnosis:

• Acute exertional compartment syndrome
• Rhabdomyolosis
• Allergic reaction

This rower was diagnosed with acute exertional compartment syndrome. This pathology can be a medical emergency and requires special caution. A trained health professional must evaluate for vascular compromise, indicated by no pulse or a sluggish capillary refill rate, while assessing the risk of causes that are not exercise related. The trained health professional may also consider compartment pressure testing.

Acute exertional compartment syndrome occurs when the tissue pressure within a muscle compartment exceeds the venous pressure, impairing blood flow. This can bring about pain and decreased peripheral sensation due to a lack of blood flow.

Mild cases of acute exertional compartment syndrome are treated with sufficient rest. More severe cases may require a fasciotomy that relieves the muscle pressure and returns blood flow to the affected area. Any recommendation on avoiding acute exertional compartment syndrome?

Case 7

A 22-year-old crew athlete present with pain in the hands. This athlete reports frequent blisters and callus formation. Several lesions appear to be draining.

Blisters and calluses are frequent among rowers. Blisters are susceptible to infection, which poses a risk for the spread of infectious agents, such as MRSA. This transmission risk is compounded by decreased hand-washing compliance among rowers with open lesions on their hands that are painful when exposed to certain soaps.

To manage calluses, thin or trim the calluses using a sharp, clean object. Cover and protect sensitive areas on the hand with athletic tape to minimize blistering. Designate each oar to a rower and clean handles with a sterilizing solution after each work out to minimize the spread of infectious agents. Additionally, avoid rupturing blisters because this increases the rower’s susceptibility to infection while also increasing the ease with which infectious agents are transmitted.

 

This ends our first series of 7 case studies on rowers with upper extremity injuries. Please check back in for more content at a later date.