Fight Doc – Rib Injuries

Fightland Blog

By Dr. Michael Kelly D.O. as told to Fightland Staff

Even with so many dollars spent and so many miles traveled to promote its main event, fate couldn’t keep its filthy hands away from UFC 189. By now, you know that Jose Aldo fell prey to the frailties of his own thoracic cavity, upstart Conor McGregor is facing top-ranked contender Chad Mendes, and the guys from Dublin and Sacramento are scrapping for an interim title and a future meeting with Aldo, the stoic king wearing the featherweight crown.

Aldo's journey to the sidelines, however, was a convoluted one. Initial reports said that he suffered a fractured rib in training. Then a revised diagnosis hinted that Aldo might be able to make it to fight night: it was a bone bruise and cartilage injury. Then it was, um, a fractured rib, and that was that. So we talked to our fight doctor, Dr. Michael Kelly—a sports-medicine specialist, part-time ringside doctor, and the author of the book Fight Medicine—about why rib injuries invariably suck, the grey areas that separate fractures and bone bruises, and why fighters with mononucleosis should stay in bed instead of getting punched in the chest. 

Dr. Michael Kelly: There are two main functions of the ribs. The first is to protect the internal organs encased up under the ribs—the heart, the lungs, the major part of the kidneys all slide up under the ribs. The second is that the ribs function as a splint for the intercostal muscles and as an opposing structure for the diaphragm to create a vacuum within the chest cavity so the lungs expand when you inhale. There's a very complex set of motions that occur in all the ribs when you take a deep breath, when you're breathing lightly, breathing rapidly—the motions of all the different parts of the rib cage will be affected. As you increase your respiratory rate and what's called your tidal volume, you'll start to forcefully exhale as those ribs move in the opposite direction and the diaphragm comes back up in the opposite direction.

Some people have [extra] ribs—usually up at the cervical area—and some people have missing ribs, I guess just from mutations in our DNA. But generally, you have 10 sets of stabilizing ribs, all attached to the sternal bone. There's a cartilage that's in between the rib and sternum—we call that the costochondral junction. The costo- is the bone, and the -chondral is the cartilage. They're intertwined: there is a very definitive line that you can actually feel, but some of what seems like cartilage might be bone and some of the bone might be cartilage—it's sort of a transition. When you transfer down to the floating ribs—the 11th and 12th ribs—they aren’t attached to the front of the sternum. Usually, it's a high-impact, very forceful blow like you see a motor vehicle accident that's going to affect the upper ribs in the upper anterior part. The lower sides and lower back parts of the ribs are what we usually see injured with combative sports.

Underneath each rib, you have an artery, a vein, and a nerve. Small muscles that connect one rib to the next surround those intercostal nerves. That nerve is actually pretty well exposed and it's very sensitive. If you've ever gotten punched in the ribs on an upward angle, it usually hurts, and you feel it right away.

Any irritation in the ribs can significantly affect and change the breathing pattern—one of the main treatment goals when you have a rib fracture is to control the pain so the patient doesn’t change their breathing too much. If they start doing what we call self-splinting, where they move all the ribs except for the injured rib, that part of the lung doesn’t expand. When you don't have free motion in the lung, your body tends to accumulate fluid in that area, and that stagnant fluid eventually can turn into pneumonia. 

A rib is like a curved stick, and [the consequences of a fracture] depend on which way it's fractured. If the fracture line runs parallel to the longitudinal line of the rib, that's gonna cause more pain and it won't be so worrisome if there's another trauma there—it's weakened, but it's not as likely to snap off or cause trouble. If the fracture goes perpendicular to the rib, now you have part of the rib that's disconnected from the rest of the rib cage and that becomes more vulnerable. And if the fracture completely transverses the actual rib bone, and the rib is not well connected, another blow can force the fragment into [the organs underneath]. Sometimes we see compound fractures where there's more than one bone that's fractured, and you actually have like a fragment that's not connected on either end, and that becomes even more risky. 

Jose Aldo's X-ray

As far as pain goes, the pain generated will be similar in all three [rib fractures, bone bruises, and cartilage injuries]. It's very hard to differentiate just by exam. And a lot of people aren’t aware that the whole term "bone bruise" evolved as readings from MRI machines started to become more common. What we were seeing on the MRI was that the bone was lighting up to indicate damage, but the periosteum—the outermost part of the bone—was still intact. So technically, a bone bruise is a microscopic fracture that's below the periosteum. Once you start breaking the integrity of the outer bone, then that's a fracture. 

The cartilage injuries sometimes cause more long-term trouble because cartilage doesn’t have very good blood supply, so it tends to heal very poorly. When a sports injury includes a cartilage injury, it often requires that piece to be removed because it's not healing or re-adhering to where it was originally located. With the ribs, sometimes on the lower anterior lateral part, you can break a piece of the cartilage and it never adheres back, then you get a floating piece of cartilage that gets stuck and causes trouble intermittently. We used to call it slipping rib syndrome—you'd see that commonly in the past in football players, from getting recurring blows to the same area. Every time it gets dislodged, it adheres less and becomes more of a problem. On a long-term basis the cartilage injuries can be just as troublesome, if not more.

Sometimes it's very difficult to diagnose a rib injury. X-rays are notorious for missing fractures of the ribs, especially if it's longitudinal and goes parallel to the rib's structure. If we don't see a transverse fracture line, a lot of times we'll treat it the same whether it turns out to be a bone bruise, a rib fracture, or a cartilage injury, and you might be a little more lenient in letting an athlete participate as opposed to something that shows up very distinctly on an X-ray. If you see it on the X-ray, then it's definitely troublesome.

The testing can sometimes be a little bit of a grey area and you'll need to get a CT scan to look at the bone from different angles. And even then, it can be difficult to tell what's really going on—it's fraught with trouble. A lot of it has to do with the anatomy of the rib: you have a tubular bone that you're trying to shine some sort of X-ray beam on from multiple directions, or interpret it from the change in the position of the protons going in the MRI. The bones have that tubular structure—all bones are kind of tubular, but the ribs are also thin, narrow, and curved—and that's going to diffuse sound waves, X-ray waves, or acoustic waves in different directions as opposed to a flat surface you can see very clear. 

Photo by Jeff Bottari/Zuffa LLC

We used to use a wrap [to treat rib injuries], but that's fallen out of favor because it actually increased the risk of pneumonia: It exaggerated the change in the breathing pattern. The main thing is to protect the area and provide adequate analgesic medicine to make sure you keep those normal breathing motions, then wait for the body to heal itself. If the athlete's in a great deal of pain, sometimes we'll do a nerve block in the intercostal nerve: using an ultrasound, you can guide a needle and squirt a long-acting anesthetic into the nerve and it'll block the pain for a number of hours, so the athlete is able to breathe normally until the healing process starts to kick in. Sometimes, depending on the pain threshold of the athlete, we'll do that twice in the first couple of days to get them through that initial pain.

Generally, you're looking at about six weeks healing time, give or take. Cartilage is probably going to take longer—it can take up to three months for the cartilage to finally heal. And the intercostal muscles are often injured in addition to the bone, and if they're very swollen or very inflamed, we may actually inject them to cool those down and make sure we maintain that normal breathing pattern. Other than that, it's really a waiting game.

I've seen a number of athletes go down instantly after a really hard blow to the ribs, more toward the anterior part—it's almost similar to a liver shot, where the legs go out and boom, they're on the ground. 

I haven't seen anything where there was blood and gore, but I have seen an individual who had taken a very hard shot to the ribs over the liver, and he wound up having a laceration in the liver along with the fracture. I've also seen an individual who took a blow over the spleen and had a laceration of the spleen. Interestingly, he was actually suffering from mononucleosis, so because of that, he had an enlarged spleen at the time. He probably shouldn’t have been doing any contact sports. 


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