Working Diagnosis:
Right upper quadrant rectus abdominis muscle strain.

Treatment:
We advised the patient to do heavy load strengthening of his rectus abdominis and obliques with manual treatments alongside a physical therapist comfortable working with high-level athletes. We reassured him that strengthening the rectus abdominis muscle should decrease running discomfort overtime. We recommended that he re-examine his running mechanics to prevent additional injuries in the future.

Outcome:
Patient started working with a running coach to improve his form, went to physical therapy, and completed a home-strengthening program. His pain decreased over the following 4 weeks and he ran his fastest time ever in the last meet of the season with minimal plan. He plans to graduate high school in the spring and plans to continue running in college. He will return to us as needed.

Author's Comments:
Rectus abdominis muscle strain fit the clinical history and was the most likely diagnosis given the patient's age, health status, and running mechanics. While other diagnoses were considered, patient had normal lab results and imaging which made cardiopulmonary, visceral, and gastrointestinal pathology less likely.

Muscle strains usually occur in larger joints, but can also occur along tendons near other bones including the rib cage. Effects are generally mild with normal activity and may only be apparent in high level athletes exercising at peak level. In this case, the patient only felt pain when running at top speed and did not feel it during practice or speeds slower than a 5:30 mile.

This case shed a light on several factors:
1-Muscle strains can occur along other bones and less common joints especially in certain patient populations like high-level athletes - keep them on the differential to avoid unnecessary tests and delay in treatment
2-Ultrasound can aid in the clinical analysis and management of rare complications - being skilled in diagnostic musculoskeletal ultrasound has benefits beyond injections and procedures
3-High-level athletes and runners may be at risk for musculoskeletal tendinopathies and muscle strains that are only symptomatic at peak performance which can make diagnosis challenging - not all muscle strains may be diagnosed via physical exam or provocative tests in clinic
4-Physical therapy should be the first option for treatment and rehab of suspected muscle strains, rest and time off from the sport may not help - physicians should feel comfortable advising high level athletes on management of exercise with muscle strains

Editor's Comments:
Interesting case and great example of how as you stated, some symptoms are difficult to recreate outside of high level performance, making diagnostic exams difficult. There was a great literature review on abdominal pain in runners from Germany, see reference 1. This included a great case report that was seemingly related to congenital visceral adhesions resolved after laparoscopy and adhesiolysis. There was another out of Australia in 2000, ref 2. Lastly, I think this is a great example of how much our core musculature is involved in all versions of exercise, even without a great deal of cut/pivot or dynamic movement.

References:
Dimeo FC, Peters J, Guderian HAbdominal pain in long distance runners: case report and analysis of the literature. British Journal of Sports Medicine 2004;38:e24


MORTON, DARREN P.; CALLISTER, ROBIN Characteristics and etiology of exercise-related transient abdominal pain, Medicine & Science in Sports & Exercise: February 2000 - Volume 32 - Issue 2 - p 432

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