Download Abdominal Muscle Tear in a Collegiate Volleyball Player

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
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.
Background
• 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.
Treatment
• 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. Antiinflammatories and ice were recommended in the meantime.
Uniqueness
• 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
• 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.
• 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
Conclusions
• 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.
Clinical Significance
• 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.
Differential Diagnosis
• Muscle strain, femoral hernia, inguinal hernia, osteitis
pubis, pelvic stress fracture, hip arthritis, hip adductor
muscle strain.
References
FIGURE 1: MRI image revealing muscle
tear in the left rectus abdominis and
extending into the external oblique.
FIGURE 2: Images from laparoscopic
reinforcement surgery. Notice the Progrip
mesh that was used to enclose the abdominal
hernia.
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.