{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T09:56:10Z","timestamp":1790934970165,"version":"4.1.0"},"reference-count":30,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"10","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["The Journal of Bone and Joint Surgery"],"published-print":{"date-parts":[[2019,5,15]]},"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>First-rib stress fracture is considered a potential cause of nonspecific atraumatic chronic shoulder pain in adolescent athletes. However, the etiology in throwing athletes with first-rib fracture is still unknown. The purpose of this retrospective study was to investigate the characteristic clinical features and radiographic findings of overhead throwing athletes with first-rib fracture.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>Twenty-four first-rib stress fractures in 23 players were studied retrospectively. Clinical features, including age, initial symptom, sports, pain-related activity, diagnostic method, treatment method, and final follow-up, were reviewed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>The following characteristic clinical features were identified: mean age of 16.8 years (range, 13 to 25 years), 19 dominant arm injuries and 5 non-dominant arm injuries, and an acute increase in pain while swinging the bat or pitching the ball. Sixteen fractures presented with posterior shoulder or upper thoracic back pain. At a mean time of 7.5 months after the initiation of conservative treatment, 17 healing fractures (71%) and 7 nonunion fractures (29%) among throwing athletes with first-rib stress fracture were identified. On image analysis, first-rib stress fractures were classified into 3 types depending on the direction and location of fracture lines: groove, intrascalene, and posterior types. Three symptomatic patients underwent first-rib resection due to thoracic outlet syndrome. On average, 46% of the first rib was visible on the shoulder radiographs and 97% was visible on the cervical spine radiographs. The Cohen kappa coefficient for the above percentages was 0.87 and the percent agreement was 89.4% for the shoulder, and the Cohen kappa coefficient was 0.80 and the percent agreement was 99.0% for the cervical spine.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>First-rib stress fracture should be considered when adolescent overhead throwing athletes have acute-onset posterior shoulder pain while swinging the bat or pitching the ball. Anteroposterior radiography of the cervical spine is available for initial diagnosis. Although 71% of the patients healed at a mean follow-up of 7.5 months with conservative treatment, some patients may have symptoms consistent with thoracic outlet syndrome.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence:<\/jats:title>\n                    <jats:p>\n                      Therapeutic\n                      <jats:underline>Level IV<\/jats:underline>\n                      . See Instructions for Authors for a complete description of levels of evidence.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.2106\/jbjs.18.01375","type":"journal-article","created":{"date-parts":[[2019,5,16]],"date-time":"2019-05-16T07:28:43Z","timestamp":1557991723000},"page":"896-903","source":"Crossref","is-referenced-by-count":41,"title":["First-Rib Stress Fracture in Overhead Throwing Athletes"],"prefix":"10.2106","volume":"101","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2905-0293","authenticated-orcid":false,"given":"Tadanao","family":"Funakoshi","sequence":"first","affiliation":[{"name":"Keiyu Orthopaedic Hospital, Tatebayashi, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1919-4170","authenticated-orcid":false,"given":"Kozo","family":"Furushima","sequence":"additional","affiliation":[{"name":"Keiyu Orthopaedic Hospital, Tatebayashi, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2164-2195","authenticated-orcid":false,"given":"Hiroshi","family":"Kusano","sequence":"additional","affiliation":[{"name":"Keiyu Orthopaedic Hospital, Tatebayashi, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3874-3040","authenticated-orcid":false,"given":"Yuya","family":"Itoh","sequence":"additional","affiliation":[{"name":"Keiyu Orthopaedic Hospital, Tatebayashi, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0158-6870","authenticated-orcid":false,"given":"Azusa","family":"Miyamoto","sequence":"additional","affiliation":[{"name":"Keiyu Orthopaedic Hospital, Tatebayashi, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5212-6383","authenticated-orcid":false,"given":"Yukio","family":"Horiuchi","sequence":"additional","affiliation":[{"name":"Keiyu Orthopaedic Hospital, Tatebayashi, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4984-2682","authenticated-orcid":false,"given":"Makoto","family":"Sugawara","sequence":"additional","affiliation":[{"name":"Matsuda Orthopaedic Memorial Hospital, Sapporo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8338-6425","authenticated-orcid":false,"given":"Yoshiyasu","family":"Itoh","sequence":"additional","affiliation":[{"name":"Keiyu Orthopaedic Hospital, Tatebayashi, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"issue":"237","key":"bib1-20230810","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1259\/0007-1285-20-237-345","article-title":"Further observations on fracture of the first rib","volume":"20","author":"Alderson","year":"1947","journal-title":"Br J Radiol."},{"issue":"3","key":"bib2-20230810","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1097\/00000658-197503000-00001","article-title":"First rib fracture: a hallmark of severe trauma","volume":"181","author":"Richardson","year":"1975","journal-title":"Ann Surg."},{"issue":"4","key":"bib3-20230810","doi-asserted-by":"crossref","first-page":"887","DOI":"10.1007\/s11845-011-0700-x","article-title":"Isolated first rib fracture with minimal trauma","volume":"180","author":"Breen","year":"2011","journal-title":"Ir J Med Sci."},{"issue":"1","key":"bib4-20230810","doi-asserted-by":"crossref","first-page":"159","DOI":"10.2106\/00004623-198567010-00022","article-title":"Stress fracture of the first rib. 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