HSS What's the Diagnosis Case 158

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Findings Edema is seen about the left 11th rib and costal cartilage as well as extending into the adjacent soft tissue. The internal oblique muscle extending to the left 11th rib demonstrates a prominent amount of edema and has been partially stripped from the cartilage of the left 11th rib.

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Diagnosis: Internal oblique muscle strain/partial disruption about the 11th rib Abdominal oblique injuries have garnered more publicity as a cause of loss of

days/games missed in professional baseball (both major and to an even greater degree minor league players) over the last decade. The pathology most commonly involves the internal oblique opposite the dominant side of a batter or pitcher. In other words, for a right handed batter the front side (left side) is the side of injury and for a right handed pitcher again the left side is the side of injury. Injuries sustained by position players in the field are much less common. Although external oblique injuries, intercostal muscle strains, abdominal wall strains, and diaphragmatic spasms have also been reported and can present with similar symptoms, internal oblique muscle strains are the most common. Although not described well in the literature, to my search, the internal oblique injury seems to involve the 11th rib attachment most commonly and begins at the attachment to the rib cartilage anteriorly and then with greater injury propagates posteriorly to the bony attachment. Again, I could not find documentation in the literature to support this but anecdotally this is my experience. Tremendous trunk acceleration is present in the swing (7200 deg/s²) and in pitching (11,600 deg/s²) imparting marked forces to the oblique musculature.

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Diagnosis: Internal oblique muscle strain/partial disruption about the 11th rib Studies have been performed analyzing return to play after oblique injuries with anywhere from 3 to 4 weeks quoted in the literature. The role of injectate (PRP, steroid, etc) is yet to be defined and a stratification about the degree of injury and return to play is likewise not well delineated in the literature. Particularly, knowing that the 11th rib seems to be the most likely area of pathology allows tailored imaging to more clearly delineate the pathology and add confidence to the diagnosis.

I would like to especially thank Steve Daniels, MD who helped bring this etiology to our attention and especially the unique 11th rib distribution.

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References Epidemiology and Impact of Abdominal Oblique Injuries in Major and Minor League Baseball. Christopher L. Camp, MD, Stan Conte, PT, DPT, ATC, Steven B. Cohen, MD, Matthew Thompson, MD, John D’Angelo, BS, Joseph T. Nguyen, MPH, and Joshua S. Dines, MD. Orthop J Sports Med. 2017 Mar; 5(3): 2325967117694025.

Abdominal Muscle Strains in Professional Baseball. Stan A. Conte, PT, DPT, ATC, Matthew M. Thompson, MD, Matthew A. Marks, BA. The American Journal of Sports Medicine. January 19, 2012.

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