Working Diagnosis:
Primary levator ani tear and secondary pudendal neuralgia

Treatment:
Patient had 80% improvement in neuropathic pain after the pudendal nerve block. However, she still struggled to sit and felt pain localized to the left perineum. On repeat evaluation, ultrasound-guided, local steroid injection was performed with 1 ml 40mg/ml Kenalog and 3 ml 0.25% Bupivacaine near the left puborectalis/pubococcygeus. Pelvic rehab continued with pelvic floor stretching, manual therapy and transcutaneous electrical nerve stimulation.

Outcome:
Three days after the second injection, the athlete was able to perform her basic activities of daily living without pain. Within four weeks, she was able to resume Olympic weightlifting with slight modifications. At the 6-week mark, she was performing her normal activities, including weightlifting without any limitations or pain.

Author's Comments:
Levator ani tears are typically only seen in obstetrics after childbirth.1 Rare sports-related cases have been reported but solely due to blunt trauma to the pelvic floor in horseback riding.2 The kinematics of this specific exercise may be attributed to the mechanism of injury in this athlete; the catch phase of the full snatch mimics the lithotomy position in childbirth–deep knee flexion with deep hip flexion, external rotation, and abduction.3 This applies a stretch to the levator ani muscles. Adding a significant load via the overhead barbell likely placed undue stress on these muscles and resulted in the athlete’s injury. Injury to these core muscles can be extremely debilitating, affecting basic life functions such as urinating and defecating. Understanding the biomechanics of sport can help with diagnosis and prescription for rehabilitation. Early diagnosis and management are critical for helping individuals return to sport but more importantly, resume activities of daily living and improve function.

Editor's Comments:
Levator ani are important muscles in the pelvic floor that help support the bladder, prostate, uterus, vagina, and rectum. The levator ani is made up of puborectalis and pubococcygeus parts both with origins on the posterior pubis but insertions on the sacrococcygeal spine and rectum, respectively. The puborectailis part helps draw the distal rectum upwards and forwards with contributions to anal sphincter contraction. The pubococcygeus part aids in pelvic floor elevation. These muscles are commonly torn in pregnancy, specifically after vaginal delivery. While uncommon in sports it is a diagnosis to consider in a clinical scenario such as the one described in this case. When injured not only can this lead to debilitating pelvic pain but also lead to pelvic organ prolapse and possibly contribute to urinary or fecal incontinence. Prevention is key with pelvic floor strengthening and stabilization exercises.

References:
Volloyhaug I, Taithongchai A, Van Gruting I, Sultan A, Thakar R. Levator ani muscle morphology and function in women with obstetric anal sphincter injury. Ultrasound Obstet Gynecol. 2019;53(3):410-416. doi:10.1002/uog.20115
Epstein MD, Chew FS. Avulsion of the Levator Ani in a Young Adult Male by Blunt Trauma. Radiol Case Reports. 2008;3(4):248. doi:10.2484/rcr.v3i4.248
Korkmaz S, Harbili E. Biomechanical analysis of the snatch technique in junior elite female weightlifters. J Sports Sci. 2016;34(11):1088-1093. doi:10.1080/02640414.2015.1088661

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