Sacroiliac pain is not unusual in rowers. There is no definite difference in the incidence of sacroiliac joint complaints among the different rowers und scullers (McNally et al. 2005; Timm 1999). Sacroiliac pain may be referred to the upper thigh but rarely below the knee. Whether the pain originates from the joint and/or the substantial and thick complex of sacroiliac and lumbosacral ligaments is a matter of debate. Some practitioners advocate anesthetic blocks, with a short-acting local anesthetic in one structure and longer-acting local anesthetic in the other. The duration of pain relief will help to determine the origin of pain and may guide the choice of treatment. Stress reaction and edema in bone may occur, especially in the older population.

Stress injuries are the result of overload of normal muscle, ligaments, entheses, or bone due to substantial load and repetitive activity. They may also occur with much less load when the bone or soft tissue is weak or previously injured. Rib stress fractures follow an imbalance between the rate of bone resorption and bone formation during bone remodeling (Figs. 17.5 and 17.6) (Christiansen and Kanstrup 1997; Dragoni et al. 2007). Early injuries may not show a fracture line, with only edema observed. Later partial fractures without displacement occur; if the load continues, they may progress to full fractures and potentially displacement. In general, stress fractures in athletes are the result of excessive, repetitive loads on normal bones that have not been adapted to these activities. They are exacerbated when the athlete elects or is encouraged to “train through the pain.” A series of rib stress fractures in elite female rowers was reported in 1985 (Holden and Jackson 1985; Vinther et al. 2005). Many of the diagnoses were made using nuclear medicine (bone scintigraphy), and it is not clear which of these injuries were intercostal muscle tears, which were periosteal avulsion injuries, and which were bone stress lesions. Bone scintigraphy will be positive for all these conditions. Stress injuries of the intercostal space and ribs are a known specific rowing-related injury and account for the most time lost from on-water training and competition (Wajswelner et al. 2000; Warden et al. 2002). They are one of the most common reasons for medical attention to rowing athletes in major championships. Therefore, early recognition is crucial for appropriate treatment and early return to rowing. Rates of occurrence of about 6–22 % have been reported (Dragoni et al. 2007; Wajswelner et al. 2000; Warden et al. 2002). Fractures generally occur during periods of intense training and usually lead to serious effects on rowing performance. Elite rowers are more likely to experience rib stress fractures than beginner or intermediate rowers. Rib stress fractures are more prevalent among rowers between 22 and 27 years of age, which is also the age range of most elite rowers. The etiology of stress fractures of the rib is probably multifactorial (McGregor et al. 2004; Wajswelner et al. 2000; Warden et al. 2002). The injuries may have little to do with age alone, but may be more influenced by level of performance and training loads (McDonnell et al. 2011). Equipment and technical factors including poor stroke mechanics, a lack of flexibility and/or strength, and a sharp increase in training loads contribute to stress phenomena (Christiansen and Kanstrup 1997). There is no difference in injury incidence between sweep rowers and scullers. Rib or intercostal stress injuries can occur in any location of any rib but most commonly occur in the anterolateral or dorsolateral aspect of the chest wall, typically in the region of the sixth to tenth ribs. Although rib stress fractures have been reported equally for sweep rowing and sculling, the locations of injuries are slightly different. In sweep rowing, 81 % of rib stress fractures occurred in the anterolateral/lateral aspects of the rib cage on the side away from the oar, while in sculling they tend to occur evenly along the anterolateral/lateral and posterolateral/posterior aspects of the rib cage (McDonnell et al. 2011). Intercostal stress injuries present with sharp intercostal pain, which is increased by coughing and even deep breathing. Localized complaints in the region of the affected rib radiating anteriorly as well as posteriorly to the axillary area are characteristic (Dragoni et al. 2007; Hosea and Hannafin 2012). Biomechanical studies suggest that the highest bending stresses occur at the posterolateral section of the rib. To transfer the force generated by the legs and trunk into the arms, and subsequently to the oar, the scapulothoracic muscles, especially the serratus anterior, contract maximally at the catch (Boland 1986). Rib fractures in rowers are caused by the repeated rowing stroke with contraction of the serratus anterior and external oblique muscles leading bending forces to the lateral segment of the rib (Karlson 1998). The risk may be increased also by low calcium, low vitamin D, eating disorders, low testosterone, or use of depot progesterone injections (McDonnell et al. 2011; Wajswelner et al. 2000; Warden et al. 2002). Treatment begins with a change to the training schedule to reduce the load on the affected area. This may be as simple as changing the side the swept oar athlete rows on. Many rowers will become more comfortable training on a single side of the boat and a change may be curative albeit disruptive to crew lineups. Cross-training will be the first choice for scullers who cannot select which side to row.

As rowing is a non-weight-bearing activity, rowers’ knees typically do not sustain traumatic ligamentous or meniscal injury. However, the knee of the competitive rower is at some risk for overuse injury due to the strain of repetitive maximal loading in the fully flexed position. Not surprisingly patellofemoral pain syndrome is a common complaint among rowers. The knee is subjected to large patellofemoral compression loads during training and especially competitions. In a survey of rowing-related injuries, the knee was the most commonly affected site (Boland 1986; Hosea and Hannafin 2012). Two typical overuse syndromes encountered in rowers are iliotibial band syndrome and patellar tendinitis (Figs. 17.7 and 17.8). However, chondromalacia patellae is not rare and can be exacerbated by maltracking. In case of patella alta, craniolateral impingement of Hoffa’s fat pad may also be observed and may cause complaints. Once these conditions become established, pain may be significant and rowing must be curtailed. Assessment of a rower presenting with generalized knee pain should include a history of previous injury such as patellofemoral dislocation or subluxation, locking, swelling, or giving way (Vinther et al. 2005).

Iliotibial band friction syndrome is discussed in the literature but seems to be very uncommon in the rowing population (Boland 1986). It may rather be caused or initiated by training outside the boat for increasing the condition generally or in winter. The iliotibial band originates as the tendinous extension of the fascia covering the gluteus maximus and tensor fascia latae muscles proximally and attaches to the Gerdy tubercle on the proximal aspect of the anterolateral tibial condyle. While sending fibers to the lateral intramuscular septum and the lateral aspect of the patella over the lateral femoral condyle, the iliotibial band is free to glide anteriorly and posteriorly. As the iliotibial tract moves frequently over the lateral condylar prominence of the knee in even mild varus deformity, inflammation and pain can result from friction, leading to complaints.

Patellar tendinitis is another overuse condition encountered in rowers and is characterized by anterior knee pain. The injury results from repetitive microtrauma to the patellar tendon just distal to the patellar attachment (Boland 1986).

With patella alta, repeated flexion and compression of the patella to the femur may lead to impingement of the uppermost part of Hoffa’s fat pad causing complaints (Fig. 17.9).

While rowing, repetitive knee flexion and extension generates large patellofemoral compression loads resulting in injury of the hyaline cartilage of the patella. Chondromalacia of the patella presents with complaints of anterior knee pain with rowing and quad-strengthening training activities (Fig. 17.10). Patients with chondromalacia, with recurrent knee effusions and pain, should be advised to discontinue rowing.