Chest and Abdominal Injuries
David Perna, MD
Chest and abdominal injuries in athletes are relatively rare, but when they do occur, they can be severe and gravely dangerous. All adults involved in sport should be able to recognize the warning signs of potentially life-threatening injury to the liver, spleen, or hollow abdominal viscera. Coaches or even team physicians cannot provide definitive treatment or diagnosis for many of these conditions on the field. However, they should be familiar with the usual clinical signs and symptoms of chest and abdominal trauma, and any athlete showing these signs should be immediately transported to a medical facility for confirmation. Referral to a sports medicine physician to seek diagnostic details and treatment options is also appropriate but should be made expediently for all chest and abdominal injuries.
On the field, decision making is extremely important because some chest and abdominal injuries can be life threatening. Coaches and trainers being aware of the symptoms and signs and reacting to them with all due efficiency might be the difference between life and death for an athlete.
CHEST AND ABDOMINAL INJURIES
Hemothorax and Pneumothorax
Bladder, Kidney, or Ureter Injury
Pec Major Injuries
Hemothorax and pneumothorax should be considered together and should be on the radar of anyone evaluating blunt force trauma injuries to the chest wall with suspected rib fractures. A delayed hemothorax following blunt trauma is a rare but very serious, sometimes life-threatening injury. This injury is usually accompanied by displaced rib fractures and is most often seen in skiing, snowboarding, hockey, and baseball.
Pneumothorax is an injury that can occur spontaneously or with trauma. Spontaneous pneumothorax most often occurs in young, tall males in noncontact sports such as scuba diving, weightlifting, and running. Additionally, it can occur in older people with underlying pulmonary disease. Pneumothorax in trauma typically results from rib fracture that leads to direct injury of the pleura; however, sports-related traumatic pneumothorax in the absence of rib fracture has been reported. Simple pneumothorax itself is rarely life-threatening, but it can develop into and must be distinguished from tension pneumothorax, which can quickly lead to death.
A hemothorax is a collection of blood in the space between the chest wall and the lung (the pleural cavity). In blunt chest trauma, a rib might lacerate the lung tissue or artery, causing blood to collect in the pleural space. Hemothorax can also be associated with pneumothorax, which is air trapped in the pleural cavity. Depending on the amount of blood or air in the pleural cavity, a collapsed lung can lead to shock and cardiac arrest.
Hemothorax or pneumothorax is usually one-sided. The athlete with one of these conditions usually has pain in the chest; signs of respiratory distress, such as shortness of breath or an inability to take deep breaths; and a sense of impending doom or anxiety felt along with hyperventilation or an increased respiratory rate. If a stethoscope is available, listen for decreased or absent breath sounds on the affected side. The athlete might also have a very rapid heart rate and appear to be quite restless.
If you suspect hemothorax or pneumothorax, keep the athlete calm on the field and then move the athlete as quickly as possible to the nearest medical facility. An X-ray usually gives a quick diagnosis. Ultrasound evaluation may also provide for an expedient diagnosis of pneumothorax, and has been found to be extremely accurate. Studies have demonstrated better sensitivity and similar specificity (greater than 99 percent) (Ashrafian 2003) when comparing ultrasound to standard chest X-ray. Despite these promising findings with ultrasound, X-ray is still preferred because it provides a whole picture of the lung and evaluation of the size of the pneumothorax and bony injury. If pneumothorax versus hemothorax is in question, computed tomography (CT; CAT scan) is considered the gold standard for its identification.
The objective of treatment is to stabilize the athlete, stop the bleeding, and remove the blood or air from the pleural space. A chest tube is usually inserted through the chest wall to drain the blood and air. This tube is left in place for several days because it helps to reexpand the lung. The cause of the hemothorax, such as a broken rib, can then be treated. In most trauma patients, chest tube drainage is enough, and surgery is not required.
Return to Action
The athlete will probably not be able to return to action for six to eight weeks. It might be necessary to protect the affected area with a plastic shell, or flak jacket, to prevent further contact for several months following this type of traumatic event. Before the return to action, the athlete’s lungs will need to be reconditioned, using exercises such as long-distance running and wind sprints. Complications are rare if the athlete is treated appropriately. Occasionally, the pleural space will become fibrotic or scar between the pleural membranes. Watch for athletes complaining of chest wall pain as they begin to run. Athletes should see a physician to determine if they have developed pleuritis (or pleurisy), an inflammation of the pleura, the lining of the pleural cavity surrounding the lungs. This condition might require surgery.
Commotio cordis refers to a circulatory arrest caused by a nonpenetrating blow to the chest. This is an extremely rare scenario; however, because of its potentially fatal outcome, the clinician must be aware of its presentation. The condition can occur when an object, such as a baseball, hits the chest. It usually involves a high-speed (greater than 40 miles per hour [64 km/h]) impact, but it can occur with a low-speed impact. There is usually no fracture to the ribs or sternum in commotio cordis. Blows directly over the center of the chest are more likely to cause this injury.
Understanding the mechanism causing this injury allows one to realize the importance of the availability of devices known as automated external defibrillators (AEDs).Commotio cordis is initiated with a direct blow to the chest wall. Its consequences are dependent on location of impact directly over the cardiac silhouette, timing of the impact (when during the normal cardiac cycle the impact hits the chest wall), velocity of impact (with projectiles moving over 40 miles per hour [64 km/h] more likely to cause ventricular fibrillation), and hardness of the object and shape of the object. The smaller, more spherical, and denser the object, the more likely the cause of commotio cordis. Perhaps the most important of these factors is the timing of the impact. There is a very small window of vulnerability in the cardiac cycle where commotio cordis occurs. That is, a 20- to 40-millisecond window on the upslope of the T-wave (early ventricular repolarization) when the impact occurs will cause ventricular fibrillation (VF).
Ventricular fibrillation is a dysfunctional heart rhythm. Rather than beating normally and pumping blood to the organs, the heart just quivers and fails to adequately pump blood. The victim is in cardiac arrest. The most common activities during which this injury occurs include baseball, softball, hockey, and, to a lesser extent, karate, lacrosse, and American football. Rare cases have been reported in basketball, cricket, boxing, and martial arts other than boxing. In most instances (68 percent), the person is struck by a projectile—most commonly a pitched, thrown, or batted baseball or softball—estimated to be traveling 35 to 50 miles per hour (56 to 80 km/h). Other projectiles include hockey pucks and lacrosse balls. In 32 percent of instances, chest trauma resulted from bodily contact with another person or a stationary object. Examples include being hit by a player’s helmet during a football tackle, being hit by the heel of a hockey stick, being struck by a karate kick, or being involved in a body collision.
Individuals with commotio cordis are typically found to be unresponsive, apneic (not breathing), and without a pulse or audible heartbeat. Most are cyanotic (turning blue). Grand mal seizures occur with some cases of commotio cordis. Chest wall contusions and localized bruising that correspond to the site of chest impact are noted over the precordium (the front of the heart) in about a third of commotio cordis patients. Typically, the ribs or sternum are not broken or injured. Patients are often found in VF (with an irregular heartbeat).
Given the generally young age and excellent health of those afflicted, resuscitation is more difficult than expected. The earlier treatment commences, the better the chance for successful resuscitation. Use of a precordial thump (a single very carefully aimed blow with the fist to the center of the sternum) during cardiopulmonary resuscitation (CPR) is controversial, particularly in children. Expanded use of AEDs may save the lives of some people who receive blunt trauma to the precordium and go into cardiac arrest. In such cases, the application of electric current, as delivered by an AED, may be the only chance to “jump start” the heart back into normal rhythm. Even when an AED is used by someone with minimal training, this device can recognize and automatically terminate arrhythmias.
The use of AEDs is not without controversy. There are people who shy away from using them due to liability concerns. However, using an AED is simple because the device guides the operator through its use. More and more youth leagues, public places, and industries have AEDs available in case of emergency, and most basic CPR courses now include AED training. Many people now even have AEDs in their homes.
Until recently, AEDs were not approved for use in children younger than 8 years of age who weigh less than 55 pounds (25 kg). But the latest recommendations state that AEDs may be used in children from 1 to 8 who have no signs of circulation. Ideally, if available, the device should be outfitted with a special pediatric pad and cable set, which attenuates the charge, delivering a more appropriate pediatric dose. With more portable defibrillation units available, athletes who suffer commotio cordis can be revived and saved. More modern, small, inexpensive, and efficient defibrillators are appearing in trainers’ and sports physicians’ on-the-field medical bags.
Return to Action
Return to action is really a question that comes up only if the athlete makes it through this potentially fatal event. The National Commodio Cordis Registry has been in existence only since the mid-1990s.The initial 25 cases reported of commodio cordis had a 0 percent survival rate. Reports from 2006 to 2012 revealed a 58 percent survival. This is directly attributed to early recognition, early CPR, and early defibrillation with an AED.
Because of its potential life-threatening impact, the number one treatment is really prevention. Prevention measures with positive reduction in incidence of commodio cordis include coaching athletes to turn away from oncoming projectiles and to protect the chest at all costs from direct impact. Softer and less dense balls should be used whenever possible without changing the nature of the game. As an example, age-appropriate safety baseballs have been shown to decrease the risk of commotio cordis.
To date, there is no standard commercially available chest wall protector that has been shown to decrease the incidence of commotio cordis. In several reported fatal cases, the athlete had been wearing the current acceptable equipment. In 2017, the National Operating Committee on Standards for Athletic Equipment (NOCSAE) approved a mechanical surrogate for the evaluation of chest wall protectors to prevent or reduce the risk of commotio cordis. Mechanical surrogate is a model that can replicate the chest wall and the effects of impact on the chest wall so that chest wall protective equipment can be better evaluated.
Athletes who are treated successfully and survive will be out for at least two months. Athletes who suffer commotio cordis are not necessarily susceptible to a recurrence. Nonetheless, a thorough cardiologist evaluation is in order before return to play.
The most obvious cause of rib fracture is a direct impact, such as when two bodies collide. Athletes’ bodies might also be subjected to large indirect force from overuse. Rib fractures caused by overuse of remote portions of the body have been associated with golf and baseball pitching. Direct impact fractures can occur during collisions in hockey, American football, soccer, lacrosse, and baseball.
The athlete with a rib fracture usually has pain over the affected area, particularly when taking a deep breath. Palpation reveals local tenderness. The athlete’s breaths appear shallower. Mild compression placed over the fractured rib site while the athlete takes a deep breath may relieve pain to some extent. Bruising is usually evident at the site of injury. Definitive diagnosis is made by X-ray, CT scan, bone scan, or more than one of these.
Serious rib fractures occasionally occur; the signs of these are rapid and shallow breathing, elevated heart rate, increased difficulty breathing, and coughing up blood (hemoptysis). Place one hand on each side of the injured athlete’s chest and observe the excursion of the chest wall during respirations. If one side of the chest rises during inhalation while the other falls, it is likely that at least three ribs have been broken on the falling side of the chest in two or more places. This is called a “flail chest.” Flail chest is often referred to as paradoxical breathing, in that the ribs will be moving in with inspiration and out with expiration. This is the opposite of normal chest wall movement with breathing. Recognition of flail chest and paradoxical breathing on physical exam should raise major red flags for evaluation of more life-threatening underlying injuries such as hemothorax and pneumothorax (see p. 183).
When a rib fracture is suspected, the athlete should be taken immediately to a hospital. The injured athlete must be carried if there are any signs of respiratory distress, but will be able to walk if only simple fractures have occurred. If you suspect the athlete has a flail chest, lay the athlete on the injured side and place a rolled piece of clothing under the fractured area to support it; this will help control the pain with breathing. Keep the athlete on the same side and continue monitoring for difficulty breathing. The athlete might need to be rolled over to provide rescue breathing if breathing ceases.
Immediate treatment should be directed at alleviating pain. Ice packing the area will help. Until a definitive diagnosis is made and significant bleeding is ruled out, only acetaminophen should be administered for pain control; anti-inflammatories can promote bleeding. Once the athlete is stabilized either at the site (for mild rib injuries) or at the local emergency room (for more significant injuries), further treatment can ensue. A noninvasive and very effective method of treatment is the use of Lidoderm anesthetic patches, which help control pain by slightly numbing the area. A patch is applied for 12 hours at a time, followed by 12 hours off before another patch is used. These patches must be used with caution as prescribed by a physician. The use of these patches can lower the blood pressure of some people.
Rib fractures generally take three to eight weeks to heal. To speed the healing process, the athlete should avoid strenuous activities and take care not to bump the injured rib(s). The athlete should be encouraged to take deep breaths several times per day to keep the lungs free from infection. Rib belts or binders can be used for comfort but are not encouraged.
Return to Action
While typical healing is three to eight weeks, for displaced fractures, recovery may take longer, depending upon how the athlete responds and whether or not the fracture healing is delayed, as noted on X-ray. Return to sports should be adjusted accordingly. Some athletes may require three months or more for healing to be enough to permit a return to play. Athletes who participate in contact sports and had displaced fractures or significant pain at the fracture site(s) should wear a flak jacket for the remainder of the season. For athletes in noncontact sports, no binding or bracing is usually necessary unless local pain or breathing issues are present. Athletes who have been treated for a rib fracture should undergo a conditioning program to improve cardiorespiratory and pulmonary efficiency before returning to sports.
Most sternal fractures are caused by blunt trauma to the chest, although stress fractures have been noted in golfers, weightlifters, and other athletes engaged in noncontact sports. Direct impact sports such as hockey, American football, lacrosse, and soccer, as well as falls from bicycles, can also cause a sternal fracture. In the United States, motor vehicle collisions account for 60 to 90 percent of all sternal fractures.
Sternal fractures are more common in mature athletes because of the elasticity of the mature chest wall. The mortality rate from isolated sternal fracture is extremely low. Death and morbidity are related almost entirely to associated injuries such as aortic disruption, cardiac contusion, pulmonary contusion, or unrelated injuries to the abdomen or head sustained in the incident. Children under 18 rarely have sternal fractures, but when they occur, they are often more severe.
Sternal fractures cause pain and tenderness over the area. A definitive diagnosis is made by bone scan or CT scan. Additionally, differentiating sternal fractures and rib fractures from sternocostal separation is difficult without an X-ray, because both injuries produce significant pain.
After a sternal fracture, the athlete should rest and avoid physical activity for four to six weeks. No specific rehabilitation program is required. The treatment for sternocostal separations is self-limited, although taping with elastic tape is used occasionally. Athletes may be left with a cosmetic deformity, but no residual deficit, other than mild discomfort, is likely.
Return to Action
Prognosis is excellent for isolated sternal fractures. Most athletes recover completely over a period of four to six weeks and require no special treatment. The recovery timeline is similar for sternocostal separations. The athlete should be cleared by a physician prior to returning to athletic participation. A protective sternal pad may be used as a precaution but is usually not required once the fracture heals.
Costochondritis is an inflammation of the junctions where the upper ribs join with the cartilage tubing that attaches them to the breastbone or sternum. The rib inserts into a cylindrical tube on the sternum. Usually this fit is very snug. However, direct trauma or unusual activity during sports such as weightlifting or swimming can loosen the fit, allowing the rib to rub against the sternal tubing, causing inflammation and discomfort. This injury occurs more often than is obvious and is usually disregarded as mild tendinitis.
This condition is often misdiagnosed or undiagnosed. The athlete might have costochondritis for weeks or months before it is diagnosed. Athletes often note intermittent sharp, stabbing pain followed by a dull achy sensation that lasts for hours or days. Slipping and popping sensations are common in activities such as bending, coughing, deep breathing, lifting, reaching, or rising from a chair; stretching, turning, or twisting often exacerbates symptoms.
Costochondritis arises from hypermobility of the anterior ends of false rib costal cartilages. Hypermobility of the rib usually results from sports that require significant flailing motions of the upper extremities or from direct contact injuries. Hypermobility often causes the affected rib to slip under the superior adjacent rib. Slippage or movement can lead to irritation of the intercostal nerve, strain of the intercostal muscles, sprain of the lower costal cartilage, or general inflammation in the affected area. Costochondritis is also called Tietze’s syndrome, clicking rib syndrome, displaced ribs, interchondral subluxation, nerve nipping, painful rib syndrome, rib tip syndrome, slipping rib cartilage syndrome, traumatic intercostal neuritis, and 12th rib syndrome.
Treatment might include physical therapy and injection of the damaged cartilage with cortisone. Most often, costochondritis is treated conservatively with warm soaks and mild anti-inflammatory medications (if appropriate). If the cause of the pain is in question, consider calling 911 (or the local emergency telephone number in your area) and transporting the athlete to the local emergency room to rule out possible cardiac causes for the pain.
Return to Action
Return time depends on how long it takes for symptoms to subside. Surgical intervention is extremely rare. In most instances, the athlete may return to sports when relatively asymptomatic; but recovery may be protracted, and the decision should be based upon discussions between the athlete and physician. There is usually no need for special protective equipment upon returning to sport participation.
In adolescents and children, the most common cause of abdominal injury is direct trauma. One study in the pediatric population reporting the incidence of recreational genitourinary and abdominal injuries found that kidney injuries were the most common at 44 percent, followed by spleen injuries at 36 percent, and liver injuries at 20 percent. Hockey, American football, snowboarding, sledding, and bicycling account for many incidents of abdominal trauma. Such injuries are quite rare in basketball or soccer. Kidneys are most at risk in American football. Spleen injuries can occur in all recreational sports.
Abdominal trauma injuries frequently occur in bicycling, often when very young cyclists collide with handlebars, which can cause serious injury. Retractable bicycle handlebars, which consist of a spring-loaded damper system designed to retract and absorb most of the energy at impact, reduces the risk of severe injury in young cyclists.
Look for abdominal pain in athletes after direct trauma. It may be vague or localized. In most cases of abdominal pain, the athlete should be immediately transported to an emergency facility that has the equipment required for ultrasounds and CT and magnetic resonance imaging (MRI) scans for diagnosis by a medical professional.
In mild cases, when no organ damage is identified, treatment consists of rest until the athlete is pain free. Typically, this will take four to six weeks with ongoing close medical observation. General conditioning exercises are permissible so long as abdominal discomfort is not increased. Occasionally, blunt abdominal trauma requires laparoscopic surgery for diagnosis or treatment. Surgery can be avoided in many cases if MRI rules out significant abdominal trauma or injury. On the other hand, if MRI reveals injured organs, internal bleeding, or other suspicious areas, surgery may be required.
Return to Action
Athletes may return to action after four to six weeks or when they are symptom free. Clearance to participate must be obtained from a physician. If surgery is done, clearance from the surgeon is required prior to participation, and recovery may take 12 weeks or more, depending upon the injury.
Despite the vulnerable position of the testicles, testicular trauma is relatively uncommon, perhaps partly because of the mobility of the scrotum. Still, traumatic injuries to the testicles deserve careful attention given the importance of preserving fertility.
Testicular injuries are divided into three broad categories based on whether cause of injury is blunt trauma, penetrating trauma, or degloving trauma, which involves shearing forces acting on the skin and is typically seen in males from 15 to 40.
Blunt injuries account for 85 percent of testicular injuries, and penetrating injuries make up many of the rest. Most injuries are unilateral. In most cases, blunt trauma to the testicles is minor and requires only conservative treatment. Such injuries are reported in kickboxing, baseball, paintball, mountain biking, rugby, and hockey (usually when players are hit with a stick). Penetrating injuries are extremely rare in sports and are more common in auto accidents and work-related situations. In athletics, testicular degloving injuries are rare due to the use of protective gear (such as a cup), but they can occur. In soccer, for example, a slide tackle gone wrong can catch the scrotum between the athlete’s body and the turf, causing part of the scrotum to separate and tear.
The athlete typically has extreme pain in the scrotum, frequently associated with nausea and vomiting. Imaging tests such as MRI are required for specific diagnosis. Imaging determines the specific area of scrotal trauma, and evaluation by a urologist is essential.
Treatment is either self-limited or surgical, with little range in between, meaning that treatment is either self-limiting, allowing the injury to heal on its own or, a surgical repair is required. Currently there exists no medication options or interventional procedure options for relief.
Return to Action
If there is mild trauma without tissue tearing or functional loss, the athlete will be cleared to return to play by the urologist when symptom free. Following surgery, the athlete will be cleared by the surgeon for return to play after appropriate healing, which usually takes at least six weeks. Most players who sustain testicular injury are more susceptible to such injuries in the future. Use of an athletic protective cup is recommended.
BLADDER, KIDNEY, OR URETER INJURY
The most common cause of this type of injury is direct trauma during contact sports. Contact or collision sports are the usual culprits. However, falling from a bike, horseback riding, and simple jogging all can cause bladder or kidney damage.
Symptoms for these injuries include severe pain in the flank or lower back, nausea, vomiting, swelling of the abdomen, blood in the urine, fever, and shock. The kidney is the most commonly injured organ, followed by the bladder, urethra, and ureter (tiny tubes that connect the kidneys to the bladder).
History is important in diagnosing this problem. Has the athlete previously experienced such problems? Did the athlete fall from a distance? Was there a direct blow to the flank region? These injuries may cause bleeding, either internally or in the urine. Specific diagnosis requires blood and urine tests, X-rays, CT scans, MRI, and other tests.
Bladder injuries involve contusions and a small amount of blood in the urine, requiring no treatment. Most minor bladder and kidney injuries simply require healing time, usually a period of four to six weeks. No particular treatment is required other than repeat blood and urine tests to ensure medical stability. If the injury caused an internal laceration or tear, immediate surgery is required. Internal injury is diagnosed by imaging studies such as MRI or use of a cystoscope (a camera tube inserted through the urethra and into the bladder).
The severity of injury to the bladder, kidney, or urethra will be graded primarily on the findings of diagnostic tests. Most commonly, these injuries are low grade and include contusion, hematoma (collection of blood under the capsule of the kidney), or small laceration of the kidney, bladder, or ureteral wall. Athletes with a low-grade injury usually manage with rest and observation. Athletes with more severe and less common injuries might require close observation in a hospital and surgery.
Return to Action
Due to the nature of these injuries, a prolonged healing time, typically a few months, is prudent. Return-to-play time is at least three months. No special rehabilitation program is required.
Oblique injuries are among the more common causes of injury and time out-of-play in multiple sports, but perhaps the very widely publicized and common sport for such injuries is baseball. A summative report on all major and minor league baseball injuries from 2011 to 2016 revealed oblique injuries to be the fifth most common (1,249 total) of all injuries. To put this in perspective, that is more common than ulnar collateral ligament strain in the most popular throwing sport. The core muscles (thoracolumbar, internal and external oblique, and rectus and transverse abdominis) are the primary muscles that transfer force along the kinetic chain from lower to upper body in throwing and swinging motions.
The most common mechanism of injury is batting, which accounts for 46 percent of all injuries; pitching is responsible for 35 percent of all oblique injuries. The other 20 percent of oblique injuries were found to occur in regular athletic activities of baseball running, jumping, diving, and so on. While baseball has been the most often studied and recognized sport for oblique injuries, they can occur in any sport with high-velocity rotation. Golf, tennis, cricket, and Olympic throwing sports all require high-level skill, kinetic chain transfer, and high-velocity rotation of the core.
Understanding the anatomic location and function of the abdominal muscles is helpful for thorough evaluation of these injuries. The external and internal oblique muscles are perpendicular to each other. They are responsible for flexion and rotation of the trunk, as well as providing trunk stabilization during complex movements. The external oblique muscle is the more superficial of the two, originating from the lower eight ribs near the insertion of the serratus anterior muscle laterally. Its fibers travel anteriorly and inferiorly, inserting into the iliac crest and linea alba. Its direct actions are trunk flexion and bending, as well as opposite-side trunk rotation. The internal oblique muscle lies deep to the external oblique, originating from the inguinal ligament, iliac crest, and thoracolumbar fascia. Its fibers pass superiorly and anteriorly to insert into the costal cartilages of the 9th through 12th ribs and the linea alba. Its direct actions are trunk flexion and bending, as well as same-side rotation.
The patient is likely to present with acute onset of sharp pain over the lateral abdomen. This pain is usually brought on by forceful rotational activity. On physical exam, the patient may describe point tenderness, pain to passive stretch, and pain with coughing. Because there is no specific testing for the obliques, understanding the mechanism of injury and incidence with specific athletic maneuvers becomes key before one orders any diagnostic test.
One of the more vital aspects of oblique injuries is understanding the mechanism of rotation and laterality of injury with batting and throwing. When describing oblique injuries, we often refer to the “lead side” and “trail side,” and this can get confusing with “ipsilateral” and “contralateral.” When analyzing the data on laterality of injury and understanding the patient’s history and presentation, these terms become vital. Let’s consider a right-handed batter. His left-side oblique is his contralateral side; this is also considered the lead side—leading the movement, leading toward the action of play. The right-side obliques are the ipsilateral side, also viewed as the trail side. Considering this description, when evaluating athletes, it is more important to know whether they bat or throw “righty” or “lefty” than whether or not they are simply right-handed or left-handed. This is an important consideration in other rotational sports such as tennis. Did pain start on a forehand stroke or a backhand stroke? Identifying the lead and trail side is important in understanding oblique injuries because the lead side has a higher propensity for injury.
Electromyographic studies of abdominal muscles have shown that the leading-side internal oblique and trailing-side external oblique have the highest activity with maximal-exertion axial twisting. The lead-side internal oblique muscle is more active, is a same-side rotator, and is more susceptible to lead-side injuries. The external oblique muscle is more active as an opposite-side rotator, and more susceptible to trail-side injuries. The respective opposite-side oblique muscles also register significant electromyographic activity, indicating that they also have a stabilizing role during trunk rotation.
The contralateral lead side is responsible for 78 percent of oblique injuries in pitchers and 70 percent of oblique injuries in batters. Switch hitters, although a much smaller population, show similar statistics, with 68 percent of oblique injuries contralateral to their dominant batting side.
The imaging of choice for these injury types is MRI. Coronal and axial imaging by MRI can reveal edema pattern and avulsions in the internal and external oblique muscles.
Once the diagnosis has been made, the most essential treatment is to let things rest. If doing something hurts, don’t do it. Physical therapy including modalities, core stability training, evaluation of the kinetic chain mechanics, and identification of another weak link are all part of the rehab protocol. The most common mechanism of injury in position players is from swinging, and this will be the last movement to recover. Sport-specific activities for position players, such as running, jumping, fielding, and throwing pain free may all preclude swinging pain free. Corticosteroid or platelet-rich plasma (PRP) injections have not been shown to be an effective treatment for oblique injuries. In a comparison involving athletes who had received an injection, those who did receive the injections were on the disabled list for an average of 10 days longer than those in the noninjected group. Oblique injuries often do not require surgery.
Return to Action
The average time missed from oblique injuries ranges from three to four weeks. No protective equipment is required for oblique injuries. Perhaps the most important outcome is monitoring for pain reoccurrence. Primary oblique injuries had a reoccurrence rate of only about 8 percent; however, reoccurrence of injury led to another 20 days missed.
PEC MAJOR INJURIES
Any professional who intends to evaluate patients with sports injuries should have knowledge of the pectoralis muscles. A review of published pectoralis major injuries from 1822 to 2010 revealed that 75 percent of injuries occurred in the most recent 20 years, with greater than 80 percent of injuries being nontraumatic and almost half directly related to weightlifting incidents. While weightlifting is the most heavily reported cause of pec major injuries, they can result from any activity whereby the arm muscles are maximally contracted in an extended and externally rotated position.
Athletes, commonly in their 30s or 40s, typically present with acute onset of pain in the medial aspect of the upper arm. Patients may describe an audible “pop” at the time of injury. Injury is often reported to have occurred in the eccentric phase of muscle contraction of a pressing exercise. On physical exam, there may be ecchymosis in the chest, axilla, and upper arm. Tenderness can be noted over the humeral head. Examination of the axillary fold and direct comparison with the contralateral limb is performed as the patient isometrically contracts the pec major in attempted adduction while resting the palms on the iliac crests. The fold is then visualized. Frequently there will be thinning, hollowing, or complete loss of the fold. The muscle belly itself should be palpated directly in a lateral to medial direction to identify muscle belly or origin defects. Finally, subjective strength examination in adduction, forward flexion, and internal rotation is performed with assessment for concomitant discomfort (Butt et al. 2015).
Use of plain radiographs is of limited value. Loss of the pec major shadow is an inconsistent finding, and bony avulsions present in only 2 to 5 percent of cases (Butt et al. 2015). Ultrasound evaluation can yield quick results in the clinical setting; however, it is very operator-dependent in relation to evaluation. Magnetic resonance imaging is the gold standard for evaluation of suspected pectoralis major injuries. Standard shoulder MRI is not enough to fully identify or to characterize a pec major tear. Most standard shoulder sequences do extend caudal enough to include the tendinous insertion. A dedicated sequence that extends from the quadrilateral space to the deltoid tuberosity should be obtained.
Several factors must be considered in determining appropriate treatment for pec major injuries. Timing of injury is important to consider. Injuries occurring within a six-week time frame are classified as acute. The more chronic the injury, the higher the likelihood of a more extensive intervention including surgery, because dissection of adhesions, possible need for tissue grafts, and a longer healing time are likely. Nonoperative treatment is generally recommended for contusions, partial tears, muscle belly ruptures, and complete tears for lower-demand or sedentary individuals.
Depending on the severity of the injury, the patient may be left with cosmetic defect and potential strength deficits that may prevent return to preinjury athletic levels. Initial nonoperative treatment involves rest, ice, control of hematoma, analgesics, and sling immobilization in the adducted and internally rotated position. Passive and active range of motion exercises should begin within the first two weeks, with a gradual increase to full motion over the next six weeks. Light resistive exercises can start at six to eight weeks, with gradual increases over the next four to six weeks.
The biggest contributing factor to surgical treatment is tear location. Involvement of the muscle–tendon junction, intratendinous tear, and humeral insertion tears with and without avulsion are all indications for surgery. For postsurgery rehabilitation after repair, patients are immobilized in a sling for six weeks. Pendulum exercises are begun in the first week, avoiding abduction and external rotation. At six weeks, gentle passive motion can begin in all planes of motion, and periscapular and isometric strengthening exercises can be added over the next few weeks. At three months, the patient should have near-full range of motion and can begin light resistance exercises (Butt et al. 2015).
Return to Action
The athlete will probably be able to return to action in six months. Nonoperative cases predominately in the muscle belly may see a quicker return to full preinjury progressive resistance exercises as early as three to four months. Return to contact sports should be delayed for five to six months until full motion and strength return. If nonoperative patients are not making progress after three to four months, surgical evaluation should be considered.
Surgical cases also have an expected return to sport-specific action at six months. However, the timeline is different. The first three months postsurgery concentrate on a period of rest followed by restoration of full active and passive range of motion. Progressive resistance exercise begins three months postsurgery. It is recommended that postsurgical cases and some selective nonsurgical cases avoid the high-weight, low-repetition bench press and other pec major–dominant pressing exercises permanently.
*The author would like to acknowledge the contribution of Daniel A. Brzusek to this chapter.