Abdominal Muscle Tear in a Collegiate Volleyball Player Muscle Tear in a Collegiate Volleyball...
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Abdominal Muscle Tear in a Collegiate Volleyball Player Nathan Kleppe, Nicole German, Ph.D., ATC North Dakota State University Department of Health, Nutrition and Exercise Sciences, Fargo ND, USA Abstract Background Uniqueness FIGURE 1: MRI image revealing muscle tear in the left rectus abdominis and extending into the external oblique. Treatment Clinical Significance •Although abdominal muscle tears are uncommon, they must be considered as a possible diagnosis when working with athletes that experience a sudden increase in abdominal pain. With many abdominal organs lying beneath the musculature, it is also important to consider the possibility that the pain is coming from organ trauma or pathology. •Like with any other athletic injury, a thorough history and physical exam is key to an accurate diagnosis of the problem. In most cases, referral to a physician is required so that the proper imaging and testing can take place. From there, surgical decisions can be made. Following surgical repair of an abdominal tear, the return to play decision is one that must be made congruently between the entire sports medicine staff. •Fortunately, the patient discussed in this case review was able to return to activity just five weeks after surgery with no complications. A female collegiate volleyball player sustained a tear to her rectus abdominis and external oblique muscles while serving a ball. Two and a half weeks later she underwent laparoscopic posterior abdominal wall reinforcement surgery. No complications arose from the surgery. Rehabilitation activities were started one week post-op with return to full activity five weeks post-op. •The patient is a healthy 19-year-old (5’4”, 143 lb.) female collegiate volleyball player with no previous history of abdominal muscle injuries. •Her symptoms initially began at the beginning of the season while starting fall practice. At that time, the patient described the discomfort as just “soreness” that worsened as the season progressed. •A few weeks later the patient reported having an abrupt increase in pain that occurred during a serve attempt. She felt a tearing sensation in her left lower abdomen that made her previous symptoms significantly worsen. •No bruising was present but she did have minimal swelling. The patient was able to continue to play with limited movement due to pain. •She then saw a family medicine physician at a walk-in clinic who diagnosed the problem as an abdominal wall strain. At that time she was referred to the sports medicine clinic for further examination. Differential Diagnosis Conclusions •The patient initially saw a family medicine physician at a walk-in clinic who diagnosed the problem as an abdominal wall strain. At that time she was referred to the sports medicine clinic for further examination. Anti- inflammatories and ice were recommended in the meantime. •Three days later she met with a physician at the sports medicine clinic where she reported persistent soreness and pain with trunk extension, sit-ups, and any other time she engaged her abdominal muscles. She also reported having pain when running, jumping, or trying to set backwards. The pain was isolated to the left obliques and the hip flexor region without radiation. At that time an MRI was ordered to obtain further information (FIGURE 1). •Initial treatment consisted of ice and rest with ultrasound and heat later being used. After one week, the MRI was reviewed and showed a tear in the left rectus abdominis muscle that extended across the linea alba into the left external oblique muscle. There was a 3.1 cm separation along the lateral margin of the rectus abdominis and a 1.1 cm separation along the medial margin. There was also a 0.4 cm separation of the left external oblique. The patient was then referred to a surgeon with previous experience with this type of injury. • Approximately two and a half weeks after sustaining the injury, the patient underwent a bilateral laparoscopic posterior abdominal wall reinforcement surgery. After necessary resection was finished, a Progrip mesh was placed over the area within the preperitoneum (FIGURE 2). No complications occurred during or following surgery. •After one week of rest, the patient was able to begin rehabilitation exercises. Physical therapy initially evaluated and measured strength levels of lumbar extension, lumbar flexion, lower abdominals, hip extensors, hip abductors, and hip flexors. Exercises were then initiated and focused on strengthening of the anterior, posterior, and lateral core muscles. Hip complex muscles, including the gluteus maximus and gluteus medius, were also included for further support. Stabilization exercises such as birddogs, planks, and bridges, were implemented to enhance core stabilization, endurance, and strength. •As the patient progressed, more concentric and eccentric exercises involving the abdominal and hip muscles were included to further strengthen the core region. This included functional and rotational exercises that mimicked the movements of athletic activities. Throughout this time, stretching was implemented to maintain range of motion and flexibility. All rehab was completed at an orthopedic and sports physical therapy clinic. • Approximately five weeks post-op, the patient was able to play volleyball, run two miles, and weight lift all with minimal pain. •A review of the literature has shown that abdominal muscle tears, especially those involving the rectus abdominis, are uncommon. Typically, it is the oblique musculatures that are more prone to tears due to repetitive twisting forces of the trunk that occur in most sports. 1,2,3 •These injuries usually happen when an athlete quickly accelerates or changes direction. During these times of explosive movements, the athlete will have a closed glottis that increases the intra-abdominal pressure pushing outward. 1,2,3 The abdominal muscles will then contract to protect the abdominal viscera from coming out under pressure. 1,2,3 However, this still requires a very large contractive force to cause the muscle tissue to tear. Due to the anatomy of the rectus abdominis, it is less prone to a large tear as is seen in this case study. Fortunately, with surgical repair and rehab, approximately 95% of patients can return to full sporting activity in as little as four weeks. 3 1. Brown RA, Mascia A, Kinnear DG, et al. An 18-year review of sports groin injuries in the elite hockey player: clinical presentation, new diagnostic imaging, treatment, and results. Clin J Sport Med. 2008;18(3):221-226. 2. Hemingway AE, Herrington L, Blower AL. Changes in muscle strength and pain in response to surgical repair of posterior abdominal wall disruption followed by rehabilitation. Br J Sports Med. 2003;37:54-58. 3. Lloyd DM, Sutton CD, Altafa A, et al. Laparoscopic inguinal ligament tenotomy and mesh reinforcement of the anterior abdominal wall. Surg Laparosc Endosc Percutan Tech. 2008;18(4):363-368. •Muscle strain, femoral hernia, inguinal hernia, osteitis pubis, pelvic stress fracture, hip arthritis, hip adductor muscle strain. References •This case study is relevant because it demonstrates how an abdominal muscle tear can easily be misdiagnosed. Keeping the possibility of an abdominal muscle tear in mind is important for athletic trainers to remember, especially since athletes are more prone to this injury compared to the average population. 1 •Abdominal muscle tears should always be considered among the differential diagnosis of a patient presenting with abdominal pain, as well as the possibility of a muscle strain, femoral hernia, inguinal hernia, osteitis pubis, pelvic stress fracture, hip arthritis, hip adductor muscle strain, or abdominal organ pathology. FIGURE 2: Images from laparoscopic reinforcement surgery. Notice the Progrip mesh that was used to enclose the abdominal hernia.
Transcript of Abdominal Muscle Tear in a Collegiate Volleyball Player Muscle Tear in a Collegiate Volleyball...
Abdominal Muscle Tear in a Collegiate Volleyball Player
Nathan Kleppe, Nicole German, Ph.D., ATC
North Dakota State University
Department of Health, Nutrition and Exercise Sciences, Fargo ND, USA
Abstract
Background
Uniqueness
FIGURE 1: MRI image revealing muscle tear in the left rectus abdominis and extending into the external oblique.
Treatment
Clinical Significance
• Although abdominal muscle tears are uncommon, they must be considered as a possible diagnosis when working with athletes that experience a sudden increase in abdominal pain. With many abdominal organs lying beneath the musculature, it is also important to consider the possibility that the pain is coming from organ trauma or pathology.
• Like with any other athletic injury, a thorough history and physical exam is key to an accurate diagnosis of the problem. In most cases, referral to a physician is required so that the proper imaging and testing can take place. From there, surgical decisions can be made. Following surgical repair of an abdominal tear, the return to play decision is one that must be made congruently between the entire sports medicine staff. • Fortunately, the patient discussed in this case review was able to return to activity just five weeks after surgery with no complications.
A female collegiate volleyball player sustained a tear to her rectus abdominis and external oblique muscles while serving a ball. Two and a half weeks later she underwent laparoscopic posterior abdominal wall reinforcement surgery. No complications arose from the surgery. Rehabilitation activities were started one week post-op with return to full activity five weeks post-op.
• The patient is a healthy 19-year-old (5’4”, 143 lb.) female collegiate volleyball player with no previous history of abdominal muscle injuries.
• Her symptoms initially began at the beginning of the season while starting fall practice. At that time, the patient described the discomfort as just “soreness” that worsened as the season progressed.
• A few weeks later the patient reported having an abrupt increase in pain that occurred during a serve attempt. She felt a tearing sensation in her left lower abdomen that made her previous symptoms significantly worsen.
• No bruising was present but she did have minimal swelling. The patient was able to continue to play with limited movement due to pain.
• She then saw a family medicine physician at a walk-in clinic who diagnosed the problem as an abdominal wall strain. At that time she was referred to the sports medicine clinic for further examination.
Differential Diagnosis
Conclusions
• The patient initially saw a family medicine physician at a walk-in clinic who diagnosed the problem as an abdominal wall strain. At that time she was referred to the sports medicine clinic for further examination. Anti-inflammatories and ice were recommended in the meantime.
• Three days later she met with a physician at the sports medicine clinic where she reported persistent soreness and pain with trunk extension, sit-ups, and any other time she engaged her abdominal muscles. She also reported having pain when running, jumping, or trying to set backwards. The pain was isolated to the left obliques and the hip flexor region without radiation. At that time an MRI was ordered to obtain further information (FIGURE 1).
• Initial treatment consisted of ice and rest with ultrasound and heat later being used. After one week, the MRI was reviewed and showed a tear in the left rectus abdominis muscle that extended across the linea alba into the left external oblique muscle. There was a 3.1 cm separation along the lateral margin of the rectus abdominis and a 1.1 cm separation along the medial margin. There was also a 0.4 cm separation of the left external oblique. The patient was then referred to a surgeon with previous experience with this type of injury.
• Approximately two and a half weeks after sustaining the injury, the patient underwent a bilateral laparoscopic posterior abdominal wall reinforcement surgery. After necessary resection was finished, a Progrip mesh was placed over the area within the preperitoneum (FIGURE 2). No complications occurred during or following surgery.
• After one week of rest, the patient was able to begin rehabilitation exercises. Physical therapy initially evaluated and measured strength levels of lumbar extension, lumbar flexion, lower abdominals, hip extensors, hip abductors, and hip flexors. Exercises were then initiated and focused on strengthening of the anterior, posterior, and lateral core muscles. Hip complex muscles, including the gluteus maximus and gluteus medius, were also included for further support. Stabilization exercises such as birddogs, planks, and bridges, were implemented to enhance core stabilization, endurance, and strength.
• As the patient progressed, more concentric and eccentric exercises involving the abdominal and hip muscles were included to further strengthen the core region. This included functional and rotational exercises that mimicked the movements of athletic activities. Throughout this time, stretching was implemented to maintain range of motion and flexibility. All rehab was completed at an orthopedic and sports physical therapy clinic.
• Approximately five weeks post-op, the patient was able to play volleyball, run two miles, and weight lift all with minimal pain.
• A review of the literature has shown that abdominal muscle tears, especially those involving the rectus abdominis, are uncommon. Typically, it is the oblique musculatures that are more prone to tears due to repetitive twisting forces of the trunk that occur in most sports.1,2,3
• These injuries usually happen when an athlete quickly accelerates or changes direction. During these times of explosive movements, the athlete will have a closed glottis that increases the intra-abdominal pressure pushing outward.1,2,3 The abdominal muscles will then contract to protect the abdominal viscera from coming out under pressure.1,2,3 However, this still requires a very large contractive force to cause the muscle tissue to tear. Due to the anatomy of the rectus abdominis, it is less prone to a large tear as is seen in this case study. Fortunately, with surgical repair and rehab, approximately 95% of patients can return to full sporting activity in as little as four weeks.3
1. Brown RA, Mascia A, Kinnear DG, et al. An 18-year review of sports groin injuries in the elite hockey player: clinical presentation, new diagnostic imaging, treatment, and results. Clin J Sport Med. 2008;18(3):221-226. 2. Hemingway AE, Herrington L, Blower AL. Changes in muscle strength and pain in response to surgical repair of posterior abdominal wall disruption followed by rehabilitation. Br J Sports Med. 2003;37:54-58. 3. Lloyd DM, Sutton CD, Altafa A, et al. Laparoscopic inguinal ligament tenotomy and mesh reinforcement of the anterior abdominal wall. Surg Laparosc Endosc Percutan Tech. 2008;18(4):363-368.
• Muscle strain, femoral hernia, inguinal hernia, osteitis pubis, pelvic stress fracture, hip arthritis, hip adductor muscle strain.
References
• This case study is relevant because it demonstrates how an abdominal muscle tear can easily be misdiagnosed. Keeping the possibility of an abdominal muscle tear in mind is important for athletic trainers to remember, especially since athletes are more prone to this injury compared to the average population.1
• Abdominal muscle tears should always be considered among the differential diagnosis of a patient presenting with abdominal pain, as well as the possibility of a muscle strain, femoral hernia, inguinal hernia, osteitis pubis, pelvic stress fracture, hip arthritis, hip adductor muscle strain, or abdominal organ pathology.
FIGURE 2: Images from laparoscopic reinforcement surgery. Notice the Progrip mesh that was used to enclose the abdominal hernia.
