Working Diagnosis:
1. Rectus abdominis muscle strain of of the side contralateral to the dominant striking arm
2. Rectus sheath hematoma

Treatment:
Such injuries are treated conservatively, focusing on symptoms control, rest from aggravating activity, icing, and oral analgesics. The athletes found abdominal binding to provide support and compression of the affected area. They performed light abdominal rehabilitation, which was gradually intensified as tolerated.

On one athlete, evacuation of the hematomma was attempted for pain control, but it was too coagulated for successful aspiration.

Outcome:
Return to play is determined by resolution of functional limitation due to pain, decreased range of motion, or strength. Once asymptomatic sport-specific activity can be performed, return to play is appropriate.

Of the three athletes, the first athlete was not able to return to play for about 6 weeks due to persistent discomfort at rest and worsened by volleyball activity. However, she was able to return to play by the end of the volleyball season.

The second athlete was sidelined for about 1 week, but was able to return to play without concern for the remainder of the season.

The third athlete was least severely affected. She did not undergo ultrasound or MRI, but was able to continue playing after only a few days of rest.

Author's Comments:
Rectus abdominis strains are more commonly associated with other sports involving overhead activity, such as tennis or throwing sports. Tennis players, for example, usually suffer the strain during serving on the contralateral side of the serving arm. This occurs during a forced concentric contraction of the abdominal muscles with the spine hyperextended and rotated contralateral to the injury site. The same mechanism likely occurs in volleyball hitters during a spike shot.

A rectus sheath hematoma may occur due to bleeding from a high-grade muscle strain or rupture of the inferior epigastric vessels (most frequently). These vessels are particularly prone to shearing forces at the arcuate line, just inferior to the umbilicus, where they pierce the rectus abdominis muscle. This is an uncommon athletic injury. It is usually self-limited, as the bleeding will tamponade. It can rarely cause life-threatening hemorrhage, but this is usually in cases of significant anti-coagulation or higher grade trauma.

Very unusually, these issues occured in 3 athletes of the same sport within a short period of time. There had been no changes in off-season or in-season drills or activity of the athletes from previous seasons. However, there is no specific off-season conditioning regimen other than optional summer workouts, and the athletic trainer did mention that these athletes in particular had spent more time away from the team during off-season workouts than other team members, suggesting deconditioning with an aggressive return to high-level activity early in the season.

References:
None

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