MSK case of the month October 2025 – Musculoskeletal Chest and Back Pain in Middle-Aged Women

Bone Health

As women approach menopause, the natural decline in oestrogen can have a significant impact on bone density and muscle strength, increasing the risk of osteoporosis and fractures.  

Maintaining musculoskeletal health during this stage of life is incredibly important, not only for long-term mobility and independence but also for overall wellbeing. 

Strength training and weight-bearing exercise are powerful tools in protecting bone density, improving posture, and supporting balance. 

This case study highlights how a personalised approach can make a lasting difference to bone health and quality of life.

Clinical History 

• A 56-year female presents with left side chest and back after a 5-day beginners golf trip
• Pain located in left side of chest, radiating to the upper back
• Did not have an acute injury, but became more aware of pain in the final 2 days of the trip
• On return home (after travelling by air) the pain intensified
• Pain on moving, deep breathing and coughing
• No shortness of breath at rest
• Unable to sleep comfortably when lying on the left side

Past Medical History 

• Total abdominal hysterectomy (TAH) at age 41 due to large fibroids

Drug History 

• Nil of note
• Not on HRT

Exercise History

• Participates in yoga training 3 times a week
• Enjoys running with no previous history of bone stress injuries 
• Does no formal strength and conditioning training

Clinical Examination 

• Patient is right hand dominant golf player
• Restriction in gait, and transitioning from chair to couch due to pain
• Apical breathing pattern due to diaphragmatic splinting
• Range of Motion: Marked restriction into thoracic rotation to the left due to pain
• Sharp focal pain localised to 7-9^th ribs left posterolateral area on palpation

Differential diagnosis and clinical reasoning

1. Muscle strain 

Strain of the serratus anterior muscle can occur in golfers of all ages. High torsional forces are required by serratus to rotate the rib cage and stabilise the scapular throughout the golf swing. Although serratus tears themselves are unusual, spasm and tension in the chest wall musculature is very common. Pectoralis minor and latissimus dorsi are also commonly injured in golf.  

2. Rib Injury

Clinicians may be put deterred from making this diagnosis due to the seemingly short period of time between the activity and symptom commencement.  

With lower limb injuries such as the tibia or femur, for example, it would be unusual to have a bone stress injury within 5 days of running. Ribs however are much thinner in structure and subject to a wide variety of forces such as compression, traction and rotation, making them much more susceptible to fracture. 

Bone health considerations also need to be taken into consideration. Given direct tenderness over the posterolateral left ribs and history of early menopause, this diagnosis is highly likely. 

3. Thoracic spine and costovertebral/costotransverse joint irritation 

Thoracic spine facet and costovertebral joint stiffness and/or inflammation can cause significant pain which can often radiate more anteriorly. Provocative movements include thoracic spine extension and rotation. If patients have diffuse chest symptoms radiating posteriorly it can be very difficult to differentiate between rib injury and thoracic spine relate.

4. Lung injury

It is important to rule out lung and pleural pathology in patients with chest pain. It may well be that this patient is suffering from pleural related pain, such as inflammation, pneumothorax or haemothorax as these conditions may be related to repetitive strain injuries in the chest wall. Often patients with pneumothorax and haemothorax do not have any shortness of breath or difficulty breathing at rest. Appropriate diagnostics should be performed to rule these pathologies out. 

5. Red flag symptoms

Pathologies that should be excluded in patients with severe chest pain and night symptoms, including malignancy or cardiac symptoms.  

Diagnostic Imaging

Ultrasound and MRI

In experienced hands, ultrasound can be a very effective tool for excluding rib stress injury and fractures at the bedside. Subtle cortical irregularities can be seen on ultrasound clearly and needs to be correlated with clinical examination e.g. palpation. 

Care needs to be taken to scan throughout the whole length of the rib from anterior to posterior and to not miss any single rib. Ultrasound scanning also can rule out pneumothorax particular at the lung apices. Haemothorax is usually more difficult to detect with ultrasound as fluid usually accumulates in the costophrenic angle (better detected with x-ray, MRI or CT)

MRI is usually the gold standard in ruling out rib stress fractures. Small field of view scans are usually more useful when trying to differentiate between rib stress and fracture, so it is important to provide as much clinical information as possible for the radiographers. 

A – shows an ultrasound view of a rib with a cortical break

B – shows MRI with rib bone stress injury

Above – shows ultrasound interpretation of the chest wall structures showing ribs and normal pleural surface ruling out pneumothorax

Detecting Rib injuries on x-ray can be challenging even for experience clinicians. Rib stress injuries before fracture are difficult or not possible to detect.

 X-rays however, rule out other red flag symptoms such as pneumothorax, haemothorax or masses. 

Above – shows a normal chest x-ray. 

To assess healing in ribs fractures, CT scan is often used to demonstrate bone sclerosis. Less frequently, nuclear medicine studies can be used to demonstrate rib injury and is particularly useful when assessing for metastasis. 

Image a – shows left 7^th rib fracture demonstrated on nuclear medicine studies. 

Image b – shows 7^th rib healing cortical fracture 8 weeks after initial injury

Discussion

Rib stress injuries in golf

• Most rib stress fractures in golf occur on the lead side (left side for a right-handed golfer), in the posterolateral aspect of the ribs, with the fourth to sixth ribs being the most frequently involved. These fractures are often associated with inexperienced golfers or experienced golfers who have significantly increased their practice time. 
• Location: The fractures most commonly develop in the upper posterior ribs, specifically ribs 4, 5, and 6.
• Side: The majority occur on the “lead” side of the body—the left side for a right-handed golfer.
• Mechanism: A proposed cause is a combination of poor technique and repetitive motion, which can put excessive stress on the ribs. For example, the repetitive forceful impact on the ground from a poor swing can strain the muscles attached to the ribs.

Golfers who presented with stress fracture of the ribs were almost exclusively novice golfers who participated in high-volume, high-frequency practice/training regimens. 

The site of occurrence was most often the lead-side posterolateral ribs with ribs four to six most frequently involved. 

Symptoms were typically reported as having presented with a gradual onset of vague posterolateral thorax pain that often prevented the golfer from further play. 

The diagnosis was often delayed as they were treated for a muscle strain or thoracic spine joint dysfunction with either a lack of therapeutic benefit or worsening of symptoms. Radiographic evidence of fracture was often unremarkable.

The diagram below shows the muscular attachments of the axillary triangle and the chest wall. The posterior axillary line is the most common place to incur rib stress injuries. 

Bone Health in Women

In this case study, strong suspicions should arise around this patient’s bone health and density, given her age and by the fact she underwent medical sterilisation at the age of 41 via TAH. 

A DEXA (dual-energy X-ray absorptiometry) scan is a quick and painless procedure that uses low-dose X-rays to measure bone mineral density (BMD). By measuring bone density, doctors can assess the strength of bones, diagnose osteoporosis, and evaluate your risk of future fractures. 

1. Dual-energy X-ray beams: A mechanical arm passes over the part of body being scanned, usually the hips and lower spine. The machine emits two distinct X-ray beams at different energy levels through bones.
   1. One beam is designed to be absorbed primarily by soft tissue.
   2. The other beam is absorbed mainly by bone.
2. Calculation of bone density: Detectors in the scanner measure how much of each X-ray beam passes through the body. By subtracting the soft tissu absorption from the total, the machine’s software can calculate the bone mineral density.
3. Image generation and analysis: The information is sent to a computer that creates an image of the scanned area and displays the bone density measurements. The results are reported as a “T-score,” which compares your bone density to that of a young, healthy adult.
   1. Normal: A T-score of -1 or higher.
   2. Osteopenia: A T-score between -1 and -2.5, indicating lower-than-normal bone density.
   3. Osteoporosis: A T-score of -2.5 or lower, indicating osteoporosis. 

What a DEXA scan can do

• Diagnose osteoporosis: A DEXA scan can identify tiny reductions in bone density, making it possible to diagnose osteoporosis in its early stages before a fracture occurs.
• Predict fracture risk: The results are used with a fracture risk assessment to determine your chances of breaking a bone.
• Monitor treatment: DEXA scans can help track the effectiveness of osteoporosis treatments.
• Assess body composition: In some cases, a DEXA scan can measure total body composition, including body fat, muscle mass, and bone. 

Key advantages of DEXA scan

• Non-invasive and low-risk: The procedure is painless and quick, and it uses a very small amount of radiation, much less than a standard chest X-ray.
• Safe and effective: DEXA is the established “gold standard” for measuring bone mineral density and assessing the risk of fractures.

In this case the patient had a T score at the hip of –2.1 and lumbar spine of –2.4.

A holistic management plan for this patient would include:

• Advice, information and encouragement should be given around the commencement HRT to aid bone density (please put in LBSM links to articles)
• Adequate of loading of the rib fracture for the first 6-8 weeks to allow for healing. Note that rib fractures can take many weeks to heal and can be symptomatic for many months. Taping strategies and analgesia can help to aid rib mechanics.
• Restoring normal breathing patterns and moving away from apical breathing to abdominal/diaphragmatic breathing requires specialist therapy cues and training
• As part of wider strategy to improve bone density, careful prescription of a strength and conditioning programme should be delivered to help improve bone lay down.
• Once tolerated, include exercises to improve T-spine and rib cage compliance to aid the biomechanical requirements of golf
• Nutritional review to ensure intake of bone minerals and substrates such as Vit D, calcium, phosphate and Magnesium. – Read more on Menopause and Nutrition
• Consider bone forming medications in 6-12months if no improvement in bone density from repeat DEXA OR further fractures.

Once ready slow return to golf with key safeguards including:

• Limited number balls hit per session (e.g. 50 max)
• Hitting of the tee at the driving range. This will avoid hard (fat) contacts reducing force through the rib cage. 
• Play on alternate days to allow rest and healing
• Ongoing strength and conditioning training

Strength and Conditioning

Strength and conditioning (S&C) training plays a vital role in supporting women’s health at every life stage, but it becomes especially important during and after menopause. As oestrogen levels decline, women naturally experience reductions in muscle mass, bone density, and metabolic rate. 

Regular, structured S&C training helps counteract these effects by stimulating muscle growth, strengthening bones through mechanical loading, and improving balance and coordination to reduce fall risk. Beyond physical health, resistance training can also enhance mood, cognitive function, and sleep quality – all areas that can be affected by hormonal changes.

Hormone Replacement Therapy (HRT)

Hormone Replacement Therapy (HRT) can complement these benefits by replenishing oestrogen and helping to slow bone loss, maintain lean muscle mass, and support recovery. However, HRT alone cannot replace the mechanical stimulus that resistance training provides to the musculoskeletal system. 

The most effective approach combines the two, using HRT to optimise the internal hormonal environment and S&C training to build external physical resilience. Together, they help women maintain strength, vitality, and confidence through menopause and into later life.

Conclusion

In conclusion, this case highlights an important clinical scenario in active midlife women – the presentation of chest or upper back pain without a clear traumatic event, which may in fact be related to an underlying stress fracture or low bone density. 

In this 56-year-old female, recent increased physical loading from a golf trip, combined with her surgical history of total abdominal hysterectomy at 41, should raise clinical suspicion for compromised bone health. Such patients may be at greater risk of osteoporosis or insufficiency fractures, particularly following prolonged oestrogen deficiency.

For GPs and referrers, key red flags include pain that worsens with movement or deep breathing, persists despite rest, or appears out of proportion to activity level – especially in peri or post-menopausal women or those with a history of early menopause or surgical sterilisation. Prompt investigation with imaging and bone density assessment can help identify fragility fractures early and guide appropriate management.

At London Bridge Sports Medicine, our multidisciplinary team combines expertise in sports and exercise medicine, diagnostic imaging, rehab specialists and nutritionists, to support patients with bone health concerns. We work closely with referring clinicians to ensure timely diagnosis, evidence-based treatment, and tailored strength and conditioning programmes to optimise recovery and long-term musculoskeletal resilience.

References

Lee, A.D., 2009. Golf-related stress fractures: a structured review of the literature. Journal of the Canadian Chiropractic Association, 53(4), pp.290–299.