Working Diagnosis:
Rectus sheath hematoma, left lower quadrant, due to grade 2 left rectus abdominis tear

Treatment:
After initial evaluation by team physician, she was told to rest, apply compression to area for few days, avoid manual therapies such as scraping, electrical stim and cupping.

Outcome:
Patient reported marked improvement in pain and swelling after 1-2 weeks and was able to return to full play at 3 weeks post-diagnosis.

Author's Comments:
Rectus sheath hematoma (RSH) is a rare, and often missed diagnosis. However, it is more prevalent in athletes with overhead extension movements such as tennis and volleyball players. Given the risk for delay in healing and return to play with misdiagnosis, RSH should be considered in this population and evaluation with POC ultrasound should not be delayed. Treatment for this condition should not include manual mobility adjuncts such as scraping, electrical muscle stimulation, or cupping. Physicians should work closely with their athletic training staff to ensure adequate evaluation prior to targeted, safe, and effective therapies.

Editor's Comments:
Rectus sheath hematoma (RSH) is caused by either epigastric vessel rupture (spontaneous or due to trauma) or rectus abdominis muscle tear. In this case, rectus abdominis muscle injury occurred due to repeated overhead activity in a volleyball player. A key learning point from this case is that RSH can occur due to noncontact strenuous exercise.

As in this patient, RSH typically occurs in the sub-umbilical region due to the relative weakness of rectus abdominis posterior wall support in this location, formed by transversalis fascia and peritoneum. Patients with RSH may demonstrate a positive Carnett's sign (pain with sit-up) or a positive Fothergill's sign (abdominal mass does not cross midline and remains in fixed position with abdominal flexion).

The majority of rectus sheath hematomas will self-tamponade, with treatment consisting of pain management with analgesics and cryotherapy, as well as temporary avoidance of exacerbating activities. In some cases, blood loss can be massive or even fatal. Patients with unstable vital signs or an expanding hematoma may require angiographic embolization or surgical intervention.

References:
Costello J, Wright J. Rectus sheath haematoma: 'a diagnostic dilemma ?'. Emerg Med J. 2005 Jul;22(7):523-4. doi: 10.1136/emj.2004.015834. PMID: 15983097; PMCID: PMC1726840.

Johnson R. Abdominal wall injuries: rectus abdominis strains, oblique strains, rectus sheath hematoma. Curr Sports Med Rep. 2006 Apr;5(2):99-103. doi: 10.1007/s11932-006-0038-8. PMID: 16529681.

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