Rib Injury

Anatomy of a rib injury

The human rib cage consists of 12 pairs of ribs that form a protective cage around vital organs such as the heart and lungs. Each rib articulates posteriorly with the thoracic spine at two joints—the costovertebral and costotransverse joints. Ribs 1–7 are known as true ribs because they attach directly to the sternum via their own costal cartilage. Ribs 8–10 are false ribs, connecting indirectly to the sternum via the cartilage of the rib above. Ribs 11 and 12 are floating ribs and do not attach anteriorly to the sternum at all.¹

The ribs are highly vascularized and richly innervated by the intercostal nerves, which explains why rib injuries are often extremely painful.₁

In addition to their protective role, ribs play a critical role in breathing. During inspiration:

• Ribs 1–6 elevate in a “pump handle” motion, expanding the anterior-posterior diameter and vertically.
• Ribs 7–10 move in a “bucket handle” motion, increasing the diameter of the rib cage in 360°.
• Ribs 11–12 move outward like a caliper, aiding in the expansion of the diaphragm muscle.

These motions are essential for breathing and are disrupted when a rib injury is present, often causing pain and mechanical restriction.

Ribs also move during trunk rotation, such as when throwing. For example:

• During rightward rotation (e.g., wind-up of a throw), the right ribs glide posteriorly and inferiorly, while the left ribs glide anteriorly and superiorly.
• During follow-through (leftward rotation), the opposite pattern occurs.
• This explains how rib injuries can negatively impact a quarterback’s throwing power.

Multiple muscles attach to the ribs and may be affected during injury:

• Pectoralis major and minor: Critical for throwing and ball security
• Latissimus dorsi: Critical for ball security and gets stretched when reaching overhead to make a catch.
• Obliques: Critical for torso rotation for throwing or rotating to make a catch, bracing for impact.
• Serratus anterior: Critical for scapular movement during throwing and reaching overhead.
• Intercostals: Critical for respiration and rib mobility.

Spasms or tension in these muscles following injury can restrict movement and prolong recovery.

Cause of rib injuries

Rib injuries occur from direct contact. There are two primary ways rib injuries occur in football_.²

• Compression Injuries: A defender lands on a player as they hit the ground, applying direct compressive forces to the ribs. This is a common mechanism seen in football.
• Direct Blows: Especially common for quarterbacks (e.g., hit while throwing) and receivers (e.g., exposed ribs during extension), these injuries result from unprotected impacts to the ribs.

Dangerous Complications of Rib Injuries

Several medical complications can occur in conjunction with a rib injury. The number of complications is numerous; we will highlight a few examples.^2,3,4

• Pneumothorax: Air enters the pleural space, causing partial or full lung collapse. Common in rib fractures, especially in the upper ribs. Can resolve spontaneously or require decompression depending on severity.
• Hemothorax: Blood enters the pleural cavity, typically from displaced rib fractures. Presents with shortness of breath and usually requires medical intervention.
• Commotio Cordis: A rare but fatal event where a blunt impact to the chest during a critical part of the cardiac cycle causes ventricular fibrillation. Most common in sports involving projectiles, but possible in football. This is what happened to Damar Hamlin.

Rib injury rehab process

Initial diagnosis typically includes a chest X-ray. However, X-rays miss up to 50% of rib fractures. Ultrasound has shown greater sensitivity in detecting fractures and costal cartilage injuries.₃

Most rib injuries in athletes heal without surgery. Return to play depends on pain tolerance and restoration of functional range of motion, especially trunk rotation. In some elite athletes, thoracic epidural injections or intercostal nerve blocks are used to manage pain and expedite return.

As healing progresses (typically 4–6 weeks), rehab focuses on:

• Stretching of the lats, pecs, and obliques to reestablish functional thoracic movement.
• Releasing protective muscle spasms (especially intercostals and obliques).
• Restoring rib mobility and torso rotation via manual therapy and mobility drills.
• Deep breathing exercises targeting lower rib expansion.

While the timeline for bone healing is 4-6 weeks, most athletes are able to return to play much sooner. Pain typically subsides after 2-3 weeks, and with the above-listed interventions, function should return in a similar time frame.

References

1: Thoracic Spine and Rib Cage Monograph
Osar E. Thoracic Spine and Rib Cage: Functional Anatomy, Assessment, and Clinical Integration. Integrative Movement Specialist; 2020.

2: Medical Sports Injuries in American Football Players
Rooks MD. Medical sports injuries in American football players. Clin Sports Med. 1990;9(2):435–458.

3: Treatment of Traumatic Rib Injuries
Franssen B, Brommeland T. Treatment of traumatic rib injuries. Tidsskr Nor Laegeforen. 2024;144(5). doi:10.4045/tidsskr.23.0424

4: Injury Patterns in Rugby Union
Quarrie KL, Hopkins WG. Injury patterns in rugby union. Sports Med. 2008;38(3):253–265. doi:10.2165/00007256-200838030-00005