• Manuel Delgado Gaona, MD

Case Closed?

Updated: Jan 16


A few days ago, during one of my travels, I was asked by a surgeon, with whom I share office in that city, to collaborate in the diagnosis for a 15 year old patient. It was an acute abdominal condition, which is not my main area of medical specialty, but the surgeon was frankly confused about this case. He had ruled out acute appendicitis and Meckel diverticulitis and other abdominal pathologies as etiology of the peritoneal irritation. The patient had been diagnosed the week prior by other doctors as having colitis and urinary track infection, and had received treatment for those without improvement of the abdominal pain or fever.

Two facts of the clinical history caused the surgeon to ask for my collaboration:

  1. the patient is a swimmer and

  2. the abdominal pain began after a workout

I heard the medical clinical history and reviewed the routine labs that showed urea, creatinine and uric acid near the upper limits or normal values and a urine lab that showed hemoglobin and protein without inflammatory cells or other elements present in urine. These labs were showing an injury of the muscular system in this specific patient, so I questioned the patient about his sport background and I found:

  • 2 continuous years of intense workouts with improvements in swimming times until the last few months

  • Lack of appropriate rest days - active rest or easy days

  • Feelings of “being tired” most of the day -Sleep problems such as insomnia during the night and sleepiness during day

  • Mood alterations (reported by his mother)

  • Desire to quit swimming.

  • The day he began to feel pain he'd had as main set a series of best effort 10 x 100m free-style with crunches until failure between each 100. (the time he spent on crunches was considered as “rest” for the 100´s.

  • He had not received information about how to perform a crunch. He was inhaling air when he contracted the abdominal muscles

  • The pain was exacerbated with respiration and movement

I performed a physical examination that showed a 1.5 cm. tear of the medial line of the rectus abdominis muscle. The ultrasound revealed a hematoma on the site of the tear. The child received information on how to breathe, was prescribed physical therapy, and received an anti-inflammatory prescription. In 24 hours he was improved, and referring pain was minimal.

He will be out of exercise for at least one month with the recommendation for a supervised and progressive return to workouts.

The medical diagnosis was “peritoneal irritation secondary to hematoma of the abdominal wall” (pseudoacute abdomen syndrome). Case Closed.

My main diagnoses/positions were Overtraining Syndrome and Overuse/Bad technique Injury. It will be a long path to overcome his overtraining and injury, and he will need to gain the skills to exercise in a safe and efficient way.

This case reminds us importance of several factors around exercise:

  • Hire a certified coach who can prescribed individualized workouts in a safety and efficient way. The most “innovative” and “showy” workouts may not be appropriate for you.

  • Appropriate REST is an important part of your training. Wonder why? See the Team MPI Coaches Corner, Complete your Puzzle by Coach Chris Palmquist.

  • Look for information on how to perform strength exercises with correct technique and in a safe way. It is important to know that when you contract a muscle, push or pull a weight, you should exhale and inhale when returning to the initial point. In crunches this has more importance because if you inhale when contracting the abdominal muscles, there is a greater increase of the abdominal pressure that impacts the abdominal wall and makes it prone to injuries -tears of the tendons or muscles, hernias, etc.

  • Routine labs can reveal information about our exercise status. Sports medicine professionals, exercise physiologists, and coaches use them as a method to evaluate the impact of workload on muscles and other systems. Remember there are no “normal values” - there are values adapted to gender, age, environmental and other factors.

  • Overuse injuries are situations that are sometimes under-evaluated. Talk with your coach about what part(s) of your exercise routine could tend to produce an overuse injury and take measures to avoid them.

  • Overtraining is a common situation in sport that affects us not only physically but mentally, but it is a main reason for quitting exercise. Talk with with your coach about the initial signs of overtraining to avoid it and enjoy life long the benefits of sport.

#ManuelDelgadoGaonaMD

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