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Clinical Observations |
1 Department of Radiology, Royal National Orthopaedic Hospital, Brockley Hill,
Stanmore, London HA7 4LP, United Kingdom.
2 BUPA Wellness, Barbican, United Kingdom.
3 Centre for Sports Medicine, Queens Medical Center, Nottingham, United
Kingdom.
4 Football Union Rugby House, Twickenham, United Kingdom.
Received December 20, 2004;
accepted after revision July 10, 2005.
Address correspondence to D. Connell
(david.connell{at}rnoh.nhs.uk).
Abstract
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CONCLUSION. Asymmetrical hypertrophy of the recti is seen in elite tennis players. The muscle belly hypertrophies on the side opposite the dominant arm and is subject to muscle tears of its deep fibers below the umbilicus. Imaging can be used to show these injuries.
Keywords: MRI • muscle strain • rectus abdominis • sports medicine • sonography
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The length and cross-sectional area of muscle injury and the amount of hematoma are prognostic factors that have been implicated in convalescence and return to play after muscle injury [5]. Experimental data suggest that, after strain injury, muscle is weaker and at increased risk for further injury compared with normal muscle [6]. These considerations make the diagnosis of any potential strain or muscle tear important so that appropriate early rehabilitation and subsequent functional rehabilitation can be instituted promptly.
In this study, we describe the imaging findings of rectus abdominis muscle strain in a group of tennis players who presented with anterior abdominal wall injury. To the best of our knowledge, the imaging findings of rectus abdominis strain have not been previously reported.
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After clinical assessment, sonography was performed by a trained musculoskeletal radiologist (10 years of experience) with emphasis on the area of point tenderness and pain. The scanner used (HDI, ATL) had a 5-12 MHz linear probe. The presence or absence of a tear was noted as was the location within the muscle belly, and the craniocaudal length was measured. The patient lay supine and the recti were scanned separately by passing the transducer in a transverse sweep from the cranial-to-caudal direction, followed by longitudinally scanning in the left-to-right direction. The abdominal wall musculature was evaluated, and a comparison was made of rectus abdominis thickness on either side by measuring the distance from the posterior to the anterior margin at the level of the umbilicus. Any alteration in echotexture or fibril disruption was noted as was the length of any tear measured. The longitudinal length of the tear was measured because it was the greatest dimension in all cases. Color Doppler sonography was performed to assess for neovascularity. The presence or absence of echogenic foci characterizing scar tissue was noted.
On sonography, a muscle tear was diagnosed by disruption of the normal echogenic fibrillar pattern and the presence of anechoic clefts and irregular linear bands. Fluid collections were noted. Scar tissue was diagnosed by focal areas of fibril disruption replaced by echogenic foci with disorganization of adjacent normal muscle.
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In addition, 10 elite asymptomatic tennis players (five men and five women; mean age, 22.1 years) were recruited for sonographic examination. The recti thickness was measured and the muscle architecture evaluated for each player.
Statistical Analysis
The Kolmogorov-Smirnov test was used to assess the normality of the data.
Data that did not follow a normal distribution were analyzed using the
Mann-Whitney test. Data that satisfied the assumption of normality were
analyzed using a one-way analysis of variance. Comparisons were made between
the dominant and nondominant anteroposterior diameter measurements for the
symptomatic and asymptomatic tennis players. All statistical analyses were
performed using SPSS for Microsoft Windows, version 12.0 (Statistical Package
for the Social Sciences) and p values of < 0.05 were considered
statistically significant.
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At sonography, rectus abdominis muscle injuries were characterized by disruption of the normal echogenic fibrillar pattern with fluid-filled clefts traversing the disorganized muscle (Fig. 2A, 2B). The abnormality was thought to represent disrupted muscle fibrils, edema, and hemorrhage. Only in the presence of discrete anechoic collections of blood-fluid products was the musculoskeletal radiologist able to discriminate between the latter two. In nine of the 11 players, the injury was seen on the deep surface of the muscle belly. In one player the injury occurred on the superficial epimysial boundary and in another, it involved the lateral half of the muscle. The range of muscle tears ranged from 6-72 mm in craniocaudal length (mean, 32.2 mm). Pulsatile blood flow in the region of muscle injury was identified in six of the 11 patients on color Doppler sonography. The MRI findings were compatible with sonography and no additional information was provided by the former.
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There was no difference in the location of the muscle injury when comparing MRI and sonography. There was also no discernible difference in the size of the tears; however, a 6-mm slice thickness was used on MRI, and because many of the tears were small, the MR measurement was approximate.
We have limited data on the follow-up and return of players to the tennis circuit. Five players had returned to practice within 4 weeks and four of these were playing competitive tennis within 2 months.
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In our study, fibril disruption tended to occur on the deep epimysial surface of the muscle below the umbilicus. This part of the muscle is where the tendinous intersections do not extend, and the result may be a longer zone through which strain is transferred and a potential site of weakness. Hence, there may be an anatomic explanation for the site of injury, although this needs to be further evaluated with biomechanical testing.
The abdominal musculature plays a significant role in trunk and core stability for the tennis player, providing a mechanical link between the lower and upper extremities. During the tennis serve, a large amount of angular momentum is transferred to the racquet [8]. Trunk rotation and forward swing after lumbar extension are essential parts of generating the force needed to serve. The lower abdominal muscles function as both stabilizers and prime movers and consequently are vulnerable to injury.
Our study showed that hypertrophy of the contralateral rectus abdominis muscle (the nondominant arm side) is a common finding in tennis players who play at an elite level. High electromyographic activity is seen in the nondominant rectus during the throwing phase of the serving action [9, 10]. We postulate that this is the consequence of increased strain transferred through this muscle, possibly during the serving mechanism or during trunk rotation when hitting forehand ground strokes. Injury most often occurs in the distal rectus (below the umbilicus) on the hypertrophied side.
Sonography appears to be a sensitive and valuable technique in detecting rectus abdominis tears that can be performed courtside if necessary. Acute injuries are easier to diagnose in the presence of blood-fluid products and muscle edema. A high-resolution transducer (7-12 MHz) is necessary to appreciate small areas of fibril disruption and echogenic scar tissue. Color Doppler imaging is useful for depicting neovascularity, which may become apparent in the healing phase of muscle injury and hence a useful adjunct for the identification of muscle tears.
In our study, no additional information was obtained from MRI. However, seven of the 11 players went on to MRI at the request of the tournament medical director because many players would not be returning for further treatment or rehabilitation, and the treating physicians in other countries may not be comfortable with the sonography findings alone. It has been suggested in other muscle injuries that MRI provides better information in chronic injuries and also in documenting the healing process [5]. MRI may be useful in cases that need further evaluation or at institutions where sonographic expertise is not available.
Tears of the rectus abdominal muscles may have an impact on an elite player's career because of a slow recovery time. Professional athletes are under intense pressure to return to play as soon as possible, and rehabilitation programs may be curtailed prematurely. Continued inappropriate loading in the healing phases of this injury may lead to further injury while immature scar tissue is organizing. Our limited follow-up suggests that a return to full competitive play at the elite level after a strengthening rehabilitation program typically takes 4-6 weeks and is dependent on the extent of the muscle injury.
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