Question

2. After 3 days of increasing abdominal pain, a hockey player comes to see you. He does not recall any incidence of direct trauma but has been working on his slap shot more than normal (pain increases during the wind up phase). He notes moderate discomfort while at rest and increased difficulty removing his shirt. There is no swelling or discoloration but upon evaluation you notice a slight gap in the lower abdominal musculature (two inches to the left of the umbilicus) along with tenderness. He has difficulty performing a straight leg raise noting considerable weakness in the abdominal region. The patient has no blood in the urine and no referred pain to note.

1. What structures can be involved and in what region and quadrant are they located?
2. What pathologies should be ruled out?
3. What do you think is wrong with the hockey player and what type of exercises can correct the problem?

Answer 1

a. The structures involved would be rectus abdominous muscle separated in the umbilical region, the condition is called Diastasis Rectus abdominis.

Explanation: Diastasis rectus abdominis (DRA) is a condition in which the 2 sides of the abdominal muscle separate, as the tissue connecting them stretches.

• The primary abdominal muscle on the front side of the body is called the rectus abdominis.
• This muscle is divided into a left and right half by a thick band of connective tissue called the linea alba.
• In some cases, the weakening and stretching of the linea alba connective tissue creates a separation between the right and left sides of the muscle, or diastasis.
• Diastasis rectus looks like a ridge that runs down the middle of the abdominals. It stretches from the sternum to the navel and increases with abdominal muscle contraction.
• The most prominent symptom is "slight gap in the lower abdominal musculature (two inches to the left of the umbilicus) along with tenderness." as given for the patient.
• It does not happen as a result of an injury and the patient also does not recall any injury.
• Other symptoms include discomfort in body movements, a weakened core, constipation, lower back pain, urinary incontinence, difficulty breathing, and the patient is positive for two.
• And a differential diagnosis of umbilical or ventral hernia is ruled out as there is no swelling or discoloration but upon evaluation.
• While it’s usually caused by pregnancy in women but can also develop in men or athletes gradually over time.

b) Certain medical conditions increase the risk of diastasis in men and should be ruled out like:

• cirrhosis of the liver
• abdominal wall cancer
• Abdominal Aortic Aneurysms

c) Cause for diastasis rectus in athletes include:

• improper exercise and weight-lifting, especially when it comes to sit-ups, crunches, push-ups, and front planks.
• Undue dress on abdominal muscle without proper strengthening.
• It’s important to note that this can be caused by muscle or adipose tissue and that’s why it’s commonly seen in heavy-weight bodybuilders.
• excess weight and obesity can also place undue stress on abdominal muscles and cause them to separate and weaken.

Here as mentioned the patient has been practicing a shot which includes the work of abdominal muscles as well, this might have caused undue stress on otherwise weakly trained muscle, leading to the stretching of the linea alba connective tissue thus creating a separation between the right and left sides of the muscle, or diastasis.

The patient needs

Stretching. When certain muscles become weak and overstretched, other muscles may become overactive and tight. stretching of these muscles relieves the tightening.

Core strengthening: This is the major and most important part of the treatment protocol.

This will involve training your other core muscles, such as your transverse abdominis (a deep abdominal muscle), and pelvic floor muscles. This will include (core contraction, quadruped position, Seated squeeze, Head lift, Upright push-up).

Training these muscles will strengthen them and relieve the undue stress on the rectus abdominis.

Exercise correction: Incorrect exercises, including crunches, can increase the diastasis recti separation. All corrective exercises should be in the form of pulling in the abdominal muscles rather than pushing them outwards.

Also, correct manner of practising is taught with proper stretching and resting techniques to the muscle to avoid any injury.

(Note: Please let me know if the exercises are to be explained in detail)