Rowing Injuries (The Physician and Sportsmedicine Article)

[igoeja]

The Physician and Sportsmedicine: Rowing Injuries

Rowing Injuries

Identifying and Treating Musculoskeletal and Nonmusculoskeletal
Conditions

Kristine A. Karlson, MD

THE PHYSICIAN AND SPORTSMEDICINE -VOL 28 -NO. 4 -APRIL 2000


In Brief: Rowing—whether on the water or with machines—is increasingly
popular, and, as with any strenuous exercise, the potential for injury
is high. Rowers may have common symptoms, such as low-back and knee
pain, or more sport-specific problems such as rib stress fractures,
nerve impingement, and blisters. Virtually all rowing injuries are due
to overuse, and many can be traced to training errors or equipment
problems. Understanding the mechanics of rowing, the equipment, and the
training procedures is essential for the physician caring for injured
rowers.

Rowing as a sport is growing at both the competitive and recreational
levels. There is also growing enthusiasm for recreational and
competitive use of rowing machines, which extend the rowing season and
make rowing available to those who have never set a boat on the water.
The popularity of rowing means that primary care physicians are
increasingly likely to see rowing- related injuries.

Demographics

Rowers have been competing at the collegiate and club level for over 100
years. It was one of the first sports added to the modern Olympics and
was a popular spectator sport, with significant wagering, in the late
1800s. Today, rowing continues at the club, elite, collegiate, and high
school levels. Recent changes in Title IX enforcement, requiring equal
opportunity for participation by women in collegiate sports, has spurred
the rapid growth of collegiate rowing for women, with a trickle-down
effect to the high school level. In the summer Olympics, rowing
represents the second largest sport next to track-and-field in number of
participants.

Equipment and Racing

Boat. The rowing boat, or shell, accommodates one to eight rowers, who
may have either one oar (sweep rowing), or two oars (sculling). Each
station has fixed shoes and a sliding seat (figure 1). Oars are held in
riggers, and multiple individual adjustments are possible to vary the
load per stroke, height of oarlocks, and position and angle of the
shoes.

The rowing stroke begins as the oar enters the water, in a position
called the "catch" (figure 2a). In this position, the legs and back are
maximally flexed and the arms extended. During the power phase of the
stroke, the "drive," the legs extend, followed by an opening of the back
to a less flexed position, and finishing with flexion of the arms, the
"finish" (figure 2b). The oar is removed from the water and the oar
blade is turned parallel to the water by rotating the oar in the fixed
oarlock, a maneuver called "feathering." In the "recovery" phase, the
body returns to the catch position, preparing to take another stroke.

Races typically are contested over 1,000-m to 2,000-m courses in the
spring and summer, and 3 miles in the autumn. The spring and summer
races are run parallel for up to six boats at once, beginning from a
stop, and are near-maximal aerobic efforts that begin with an anaerobic
start and conclude with an anaerobic sprint. Times for the 2,000-m races
vary depending on the boat size and weather conditions but are typically
in the 5.5-to 8-minute range. Autumn races are from a running start
against the clock and are virtually all aerobic effort, typically
lasting from 15 to 20 minutes.

Exercise machine. The most commonly used rowing machine, or ergometer,
has a flywheel for resistance connected to a handle by a chain, with a
retractable stretch cord aiding the return of the handle to the starting
position. The rower sits on a movable seat with fixed shoes and pulls
the handle away from the flywheel. The ergometer is used for winter
training, and winter "races" are held in which the times of each
participant are compared. It is increasingly common to see people use
the ergometer while training for another sport or for general
conditioning.

Training

Rowing has both high strength and high aerobic demands, ranking among
the most strenuous sports (1). Rowing athletes train virtually
year-round, with emphasis on distance training in the fall, weights and
distance in the winter, and increasing intensity and anaerobic work in
the spring and summer racing seasons. Rowing athletes are highly fit,
with recorded VO2max in the 65 to 70 mL/kg/min range for elite athletes
(2). Rowing favors the tall athlete with a long reach, who can cover
more distance per stroke.

Rowing is a repetitive-motion, nonimpact sport; thus, rowers are
unlikely to suffer sudden and unexpected injury, but more likely to
suffer overuse injuries. Like other athletes in repetitive sports, the
cause of these overuse injuries can usually be traced to a training
error in either volume or technique, or inappropriately sized or
configured equipment.

Musculoskeletal Injuries

Low-back pain. The rowing stroke puts extraordinary pressures on the low
back. The back begins the stroke flexed, and during the middle of the
stroke the back opens up, but remains flexed, in a motion similar to an
incomplete dead lift. Loading the back in flexion places large forces on
both the back muscles and the disks. In one review (3), low-back and
knee injuries were the two most common injuries found in collegiate
rowers. In sweep rowing, the back is also twisted slightly during the
stroke to achieve more reach in the catch position, which may increase
the incidence of back pain (4), though this does not appear to be the
case in my experience or that of several US national rowing team
physicians.

Back injuries from rowing vary from low-back muscle or ligamentous
strain to spondylolysis to lumbar disk herniation. Physicians evaluating
rowers with back pain should maintain suspicion for disk herniation, the
most serious of these problems. Rowers sometimes have disk herniation
without the typical radiation of symptoms to the legs, perhaps because
these herniations represent primarily central disk disease, which does
not press on the spinal nerve roots.

Low-back pain in rowers usually has an insidious onset, typical for an
overuse injury, but occasionally rowers may suffer acute disk
herniations. A careful history will often reveal training errors,
usually from increasing load or distance too rapidly, or attempting a
high-load drill. The physical examination is frequently unrevealing
because the rower may be only mildly symptomatic at rest, but a careful
search for signs of radiculopathy is warranted. Low-back pain,
especially with extension in a younger rower, is suggestive of
spondylolysis, and the mechanism of this injury is likely the load to
the pars interarticularis from the load to the back in rowing, rather
than the repetitive hyperextension mechanism seen in other sports.

Diagnostic tests are not always indicated at the initial presentation of
the rower with low-back pain, but the physician should suspect disk
herniation and consider proceeding to lumbar magnetic resonance imaging
(MRI) if conservative treatment is unsuccessful. Young people,
particularly those with pain in extension, need plain x-rays with
oblique views, followed by a bone scan if negative, to rule out
spondylolysis.

Treatment for low-back pain in rowers is often frustrating, and many
rowing careers have ended because of persistent low-back symptoms. A
typical treatment program of low-back strengthening, range-of-motion
exercise, rest as appropriate, and modalities such as ice and external
stimulation for pain control is commonly used (5). Rowing equipment can
be modified to decrease the load per stroke, and technique can be
altered to keep the low back straighter. Having sweep rowers change
rowing sides to lean and twist in the opposite direction, unfortunately,
rarely improves symptoms. Athletes with disk herniations who do not
respond to conservative treatment often have disk surgery, which also
can end careers. Rowers are cautioned to protect their low backs by not
making errors in training, encouraged to modify rowing technique and
volume, and reminded to seek care for persistent back symptoms.

Knee pain. The rowing stroke puts the knee through its full range of
motion, with a significant load exerted to the fully flexed knee at the
start of the stroke. There is, therefore, a fairly high incidence of
patellofemoral knee pain in rowers. Like patellofemoral pain in other
sports, this is more common in women, whose anatomy predisposes them to
patellar tracking problems that are further exacerbated by the fixed
position of the shoes in the rowing shell. If the shoes are spaced or
twisted incorrectly for the individual's anatomy, knee pain may persist
and worsen despite appropriate treatment. Knee pain may also be caused
or exacerbated by other activities used for cross training, such as
running and weight lifting.

Patellofemoral pain can be treated with specific strengthening of the
vastus medialis muscle to improve patellar tracking, and by use of
modalities, such as ice, in the acute phase. Bracing of the knee is
difficult due to the range of motion required for the rowing stroke and
thus is not recommended. Modifying the position of the shoes in the boat
can have a significant impact by encouraging better positioning of the
knee during the rowing stroke (figure 3).

Rowers may also complain of lateral knee pain, commonly due to friction
of the iliotibial band passing over the lateral femoral condyle, that is
exacerbated by the full knee compression required for the rowing stroke.
Individuals with varus knees are at increased risk for this problem.
Again, changing the position of the shoes in the boat can help alleviate
symptoms. Other treatments consist of ice, stretching, and other
modalities as appropriate. Gradual return to rowing is usually
successful.

Rib stress fracture. Stress fractures of the ribs were reported
infrequently in rowing prior to the introduction of a more efficient oar
design in 1992, which was rapidly and widely adopted (6,7). This new oar
holds its position in the water with less slippage, and thus transmits
greater forces to the muscles of the arm and chest wall. Since 1992,
stress fractures of the ribs have been seen at all levels, are regarded
by the rowing community as common, and have been reported more commonly
in the literature (8-10).

During the rowing stroke, the serratus anterior muscle holds the scapula
firmly against the chest wall while the scapula goes through its range
of motion, from protraction when the stroke begins, to retraction when
the blade exits the water. Researchers have proposed that overuse of the
serratus anterior muscle leads to bending forces at the ribs, which can
cause stress fracture, usually posterolaterally in ribs 5 through 9.
There is also a case report (11) of a serratus anterior avulsion from
rowing, attesting to the large forces exerted on and by this muscle.

The history of rib stress fracture is one of insidious onset of chest
wall pain, often associated with training volume increases or training
errors. Athletes often feel this initially as a strain of the
intercostal muscles in the chest wall, but over time the pain begins to
localize over a rib, where a palpable bony callus may develop. If a
callus is not palpable, diagnosis may be made by plain x- ray, but, in
most injuries, a bone scan is necessary for adequate and complete
diagnosis.

Unfortunately, once the diagnosis of rib stress fracture is made, rest
for 6 weeks is usually required for complete healing. There is little
else that can be done in terms of physical therapy once the injury
occurs; therefore, early recognition is necessary to save the rowing
season for injured athletes. Modifying technique, to decrease stress on
the serratus muscle, involves decreasing the reach at the beginning of
the stroke and the follow-through at the end of the stroke (figure 4).
It is also possible to modify the equipment to decrease the load per
stroke. Specific protraction strengthening exercises for the serratus
anterior may strengthen it enough to avoid rib stress fractures, but
there is no documentation of the success of such a program.


Forearm tendinitis. Maintaining the tight hand grip required to hold on
to the oar(s) for extended periods of time puts the forearms at risk for
overuse injuries. Each rowing stroke also involves twisting the oar
parallel to the water when feathering the oar in the recovery phase.
This motion is carried out by extension at the wrist, further stressing
the forearm.

Rowers with forearm tendinitis typically experience pain, tenderness,
and even crepitus of the dorsal wrist in the region of crossover between
the first and third dorsal wrist compartments (figure 5). On physical
exam, affected athletes have pain and swelling in this region of the
dorsal forearm. As with other overuse injuries, this problem is more
common early in the outdoor rowing season when feathering the oar is
still an unaccustomed activity. Feathering action at the wrist is not
necessary to use a rowing ergometer.

Treatment of forearm tendinitis involves appropriate rest and technique
modification. Affected athletes can try to row with their wrists as flat
as possible, which may or may not be possible, given their skill level.
Looser grip on the oar(s) is also very important. Medical treatment
involves ice, nonsteroidal anti-inflammatory drugs, and, occasionally,
local steroid injection into the tendon sheath. Tendinitis usually
resolves fairly quickly with appropriate management.

Dermatologic Problems

Hands of rowers are highly susceptible to blisters from friction with
the oar handle. Most rowers are reluctant to wear gloves, thinking that
this decreases the ability to feel the position of the oar in the water.
Rowers in northern climates do not practice outdoors year-round, which
can result in an increased incidence of hand problems when they return
to the water each spring.

Treatment and prevention of hand blisters is the object of much folklore
and tradition in rowing, but not all interventions have proven benefits.
Most rowers merely tolerate blisters as a necessary evil that will
resolve as the skin adapts. A few may get secondary infections, which
often require oral antibiotic treatment. More serious infection is rare.
Rowers should be cautioned to watch for secondary infection and taught
how to trim hand calluses to avoid the formation of new blisters under
large, thick calluses.

Oars are usually shared among members of rowing teams. Open blisters and
hand infections are therefore a potential source of blood or body-fluid
exposure. Oar handles need to be cleaned regularly, especially after use
by an athlete with hand wounds, to limit the spread of infection. One
study (12) found an increased incidence of hand warts among members of a
rowing team, suggesting that infection may spread even with intact
hands.

Some rowers are particularly susceptible to blister, callus, and
abrasion of the buttocks. This may be worsened by sitting on an
improperly fitted rowing seat, which allows chafing or pinching of the
buttocks, usually at the finish position of the stroke. Affected
individuals are usually uncomfortable but rarely seek medical attention.
This problem is usually improved by use of a different seat, a foam seat
pad, and petroleum jelly or another dressing to the affected area. These
abrasions can, though rarely, progress to serious infection, and
awareness of this problem needs to be increased among rowers to decrease
embarrassment in seeking appropriate care.

At the finish of the rowing stroke, the posterior lower leg contacts the
metal track in which the seat rolls back and forth as the legs bend and
extend. The extent of this contact is variable, depending on the width
of the tracks and the height of the tracks with respect to the shoes.
Athletes who tend to hyperextend their knees, whose shoes are
considerably lower than the tracks, or whose knee alignment also aligns
the calves with the seat tracks, can suffer a repetitive abrasion of the
posterior legs, known to rowers as "track bites" (figure 6: not shown).
These abrasions can be quite severe, frequently scarring and
occasionally infecting. Rowers should be encouraged to wear protective
long socks, cut-off portions of socks, or circumferential tape. Smaller
dressings usually do not stay in place. If possible, the equipment can
be altered to diminish contact of the legs with the tracks, but this is
often difficult or impossible.

Nerve Entrapment

Various nerve entrapments are seen in rowing. They range from carpal
tunnel syndrome caused by tight hand grip to numbness of the legs caused
by pressure on the sciatic nerve from a poorly fitted seat. A ridge on
the front of the seat can place direct pressure on the sciatic nerve.
Leg numbness may also occur if the seat holes designed to fit the
ischial tuberosities are improperly spaced for the individual,
especially when women use seats designed for men that do not accommodate
a wider pelvis.

Rowers with carpal tunnel syndrome often hold the handles too tightly
and should modify their technique in addition to the usual treatments.
Most other nerve entrapments are the result of poor equipment fit,
exacerbated by long rowing sessions. Rowers with nerve entrapment should
seek the assistance of an experienced rowing coach or trainer to aid
them in making equipment modifications.

Environmental Exposure

Rowing is an outdoor sport; thus, rowers should be aware of exposure and
safety issues, including sun exposure augmented by reflection from the
water and hypothermia augmented by wet clothing. Water exposure is not
intentional, but splash when the oars enter the water frequently reaches
rowers, making water quality a potential health problem as well.

Most rowing-associated deaths are preventable and due to drowning or
exposure. Storms causing high waves and lightning are dangerous for any
small boat and should be avoided. Collisions are possible, and strict
attention must be paid to traffic patterns and use of lights in low
light conditions. Rowing solo is not recommended. Rowers should be
cautioned to dress appropriately in noncotton layers (depending on the
anticipated weather conditions), avoid severe weather conditions that
could be life threatening, and carry and use safety equipment such as
lights, whistles, and personal flotation devices (PFDs). Coaches should
ensure that their launches are equipped with safety gear including PFDs,
paddles, lights, and a two-way radio or cellular phone.

Key Understanding

Rowing is a popular, strenuous sport with both unique and common
injuries caused by overuse. Acute, sudden injury is rare. An
understanding of the mechanics of the rowing stroke, the equipment, and
the training practices is key to making appropriate changes to prevent
and treat injuries.

References

1. Hagerman FC: Applied physiology of rowing. Sports Med
1984;1(4):303-326

2. Secher NH: Physiological and biomechanical aspects of rowing:
implications for training. Sports Med 1993;15(1):24-42

3. Boland AL, Hosea TM: Rowing and sculling and the older athlete. Clin
Sports Med 1991;10(2):245-256

4. Stallard MC: Backache in oarsmen. Brit J Sports Med
1980;14(2-3):105-108

5. Thomas P: Managing rowing backs. Practitioner 1989;233(1465):446-447

6. Holden DL, Jackson DW: Stress fracture of the ribs in female rowers.
Am J Sports Med 1985;13(5):342-348

7. McKenzie DC: Stress fracture of the rib in an elite oarsman. Int J
Sports Med 1989;10(3):220-222

8. Brukner P, Khan K: Stress fracture of the neck of the seventh and
eighth ribs: a case report. Clin J Sport Med 1996;6(3):204-206

9. Christiansen E, Kanstrup IL: Increased risk of stress fractures of
the ribs in elite rowers. Scand J Med Sci Sports 1997;7(1):49-52

10. Karlson KA: Rib stress fractures in elite rowers: a case series and
proposed mechanism. Am J Sports Med 1998;26(4):516-519

11. Gaffney KM: Avulsion injury of the serratus anterior: a case
history. Clin J Sport Med 1997;7(2):134-136

12. Roach MC, Chretien JH: Common hand warts in athletes: association
with trauma to the hand. J Am Coll Health 1995;44(3):125-126 Dr Karlson
is an assistant professor at NH-Dartmouth Family Practice Residency and
the Dartmouth Medical School in Lebanon, New Hampshire. Address
correspondence to Kristine A. Karlson, MD, Community Health Center, 1
Medical Center Dr, Lebanon, NH 03756; address e-mail correspondence to
Kristine.Karlson@Hitchcock.org.

[161km]

Hi-
I have a new injury not addressed in this article.

I have developed bursitis and neuritis in both feet. Apparently this is because of the way that my feet/shoes are cinched by the foot straps on my Concept II machine.

Any experience with this? Any guidance about alleviating the problem?

Thank you!

[Bob S.]

Hi-
I have a new injury not addressed in this article.

I have developed bursitis and neuritis in both feet. Apparently this is because of the way that my feet/shoes are cinched by the foot straps on my Concept II machine.

Any experience with this? Any guidance about alleviating the problem?

Thank you!

The straps are unnecessary. I haven't used them for the last 2-3 years except for intervals and sprints. With slides and on my new dynamic, I don't need them even for that.I just leave the strap out of the buckle and hanging to the side.

Bob S.

[kayakr]

A pretty good article. My main critique would be to include a little more information on trigger point therapy in the RICE section, as muscle spasms frequently cause referred symptoms like lumbar, hand and patellar pain. For instance, my recent achilles tendinis was solved by foam rollers to the calf.

[igoeja]

As Bob states, you can row without straps. It does make some difference in power output, lowering your speed slightly, as it takes a bit more control than rowing with feet strapped in. You should also check your strap usage, as many nonrowers misuse the erg, strapping in across the top of the arch. For myself, the strap comes across at the top of my foot where the ball flexes, closer to the base of my toes.

[bepah]

After reading the article, it seems like the author is trying to talk us out of rowing at all......what happened to the benfits of rowing? Is he going to follow up with them?

[161km]

Hi-
I have a new injury not addressed in this article.

I have developed bursitis and neuritis in both feet. Apparently this is because of the way that my feet/shoes are cinched by the foot straps on my Concept II machine.

Any experience with this? Any guidance about alleviating the problem?

Thank you!

The straps are unnecessary. I haven't used them for the last 2-3 years except for intervals and sprints. With slides and on my new dynamic, I don't need them even for that.I just leave the strap out of the buckle and hanging to the side.

Bob S.

Thank you for your quick reply.

I think that I ramped-up my total volume too quickly because our machine is only a few months old and as a runner and cyclist I have over-developed aerobic capacity so that I can row far longer than what my ligaments, tendons, and muscles should allow for a newb.

However, I'm glad to learn that the straps aren't necessary. I have not tried rowing without them b/c they give me a sense of stability and power, but when I get back on the rower after the inflammation subsides I will certainly try not using the foot straps.

Finally, one poster suggested that the straps should be placed further toward the toes (of course by adjusting the sliding foot guides). Is that where most people who row using the Concept II place their foot straps?

Thanks.

[Bob S.]

However, I'm glad to learn that the straps aren't necessary. I have not tried rowing without them b/c they give me a sense of stability and power, but when I get back on the rower after the inflammation subsides I will certainly try not using the foot straps.

Finally, one poster suggested that the straps should be placed further toward the toes (of course by adjusting the sliding foot guides). Is that where most people who row using the Concept II place their foot straps?

Thanks.

Across the ball of the foot is the generally accepted place for a strap.

Re rowing strapless: Try it carefully at first until you get the feel of it. Experienced OTW rowers generally have no problem, but many who have used machines only find that they have a tendency to fly off the back of the seat when there are no straps to hold them in place. The key here is that the powerful leg drive builds up a lot of momentum of the body moving back. That momentum has to be counteracted by the pull of the arms. For this reason, rowing strapless can be a good training tool to ensure that a rower is using a proper sequence of legs/back/arms. Strapless rowing is most easily done at low rate (15-25spm) where the rower can concentrate on form. After a period of getting used to strapless rowing, you can take the rate up and still have control. As I mentioned in my first response, it is easier on a regular erg on slides or on the new dynamic model than it is on a static rower. There is a lot less movement of the body, so there is no where near as much momentum build up. I was demonstrating my new dynamic to a friend recently and got up to 66spm strapless. During the demo I wasn't even thinking about the fact that I was not strapped in. With a grounded erg, I would hesitate to get up into the mid-30s without the straps, although I have done it a couple of time inadvertently.

Bob S.

[kayakr]

I don't really want to see the article on mountain biking, because I'm pretty sure you can hurt almost everything with that activity

[Atorrante]

Haven't seen nothing in the article about the shoulder. My right one is sore all the time for the last month.

[rowgirl]

Looks like I've had a decent number of the injuries described in this article! A new one for me, though, is ischiogluteal bursitis, which I've had in both legs for almost a year. This started with conjoint tendon tears, and apparently many develop the bursitis as a chronic problem. Does anyone have any experience with this?

[jhawk]

Great article....I was consulting it to try to diagnose a shoulder issue my rowing 15 year old daughter has. She is experiencing a 'popping' just below her left shoulder, during the rowing movement. She does not report pain during rowing movement, however is more tender to massage of that area on that arm than on the other arm. Also, she reports a numb patch of skin above the area. In researching, I'm thinking she has axillary nerve issue (fits w/the numbness to small patch above deltoid muscle), and the popping sounds like it might be related to Brachial tendon? I was hoping to have you add your thoughts. I notice the article is not written by you, but by Kristine Karlson....if you have any injury knowledge or could direct me to a really great source of info on rowing injury, I'd appreciate it. Looks like my daughter wants to be in this for the long haul....so I'd better get educated.

[rowgirl]

I have a similar problem with my feet on the C2 erg, and because of the straps, and the positioning of feet, have not been able to use an erg in over a year. I modified my erg, and it has worked out very well. I removed the plastic footplate, straps, etc. and mounted two pieces of wood to the footplate (using the existing screw holes) so that I could bolt my own tennis shoes to the new wood footplates. I no longer need the straps, and have been able to put the shoes in a position that is more similar to the positioning of my shoes in my 1x. Let me know if you want me to send pictures or any info. regarding how I did this.

[blue_heron]

Thanks for posting. I've been trying to find out more info on rowing and knees. Since it's low impact I figured it would be OK. Used to row a lot but have knees with patellofemoral syndrome. I've been trying to row again, but had problems with kneecap popping out on full extension on the drive. I ended up putting a bungie cord really tight around the rail to give me a reminder to not hit full extension. It's not perfect, but it helps. I also watch how far I let my knees bend on recovery. It does feel a little odd, but it does let me row. I also alternate with an exercise bike to not overexert it.

[grahamcawood]

Greetings, Watching many rowers with knees down at the finish, you can see the effort going into forcing and holding them down - overextending. Apart from doing nothing for the stroke, and using lots of energy, perhaps this is also bad for the knees.
The problem is partly caused by the coached technique of straightening the legs BEFORE moving the arms and torso. So we have to hold them down!
I would suggest the following:
1. Slow the leg straightening so that legs and arms finish TOGETHER. Hands go quickly away to clear the rebounding knees. No need to hold the knees down.
2. Use a 1:1 work:recovery ratio, always. This will encourage rebound and plyometric movement in a rhythmic, pause-free stroke.
3. Use 2 breaths per stroke - out at catch and release.
4. Leave arms comfortably bent in the recovery. Blade momentum (or the chain tension on the erg) will then pull the arm straight for the catch, followed by rebounding to a comfortable bend again.
5. When the arms finally work move the elbows away from the body to have about 90' between the forearms at the finish. This almost stops any movement of the shoulder blades, and in a boat will help hold the blades against the gates. Why do most people do press-ups with arms away from the body??
Visit "Youtube Rhecon sculling" for this technique.
Hope this helps. I use it 30 minutes daily on my B erg, at 2.07 split. I'm 70, and had 5* bypass surgery 15 months ago. Thank-you ERG!!!