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  • Unusual Abdominal Injury

    Posted by seekadvice on May 7, 2015 at 5:35 am

    I suffered an unusual abdominal injury in late October 2014, and, after seeing a few providers, have not talked with anyone who has come across an injury of a similar nature. I was following a gentle exercise program, and, for one of the exercises, I was coming up from a forward bend. My feet were hip width apart with toes forward and the knees bent deeply to the end of the toes and pushing out to the little toes. While coming up from the forward bend in this position, I was tucking the tailbone and roiling up one vertebrae at a time to a standing position. While completing this movement, I noticed a weird feeling in my abdomen. I picked up my shirt and noticed something sticking out about 2/3 of the length of my pinky finger slightly above and to the left of my belly button. It looked like/had curvature like the Space Needle in Seattle, and I believed it wiggled, not in height but in moving slightly across the surface of my abdomen. Almost as soon as I noticed it, my abdominal muscles flattened back out and whatever popped out popped back into place. I have since looked at pictures of hernias on the Internet, and it did not look like what was shown in those pictures. My abdomen and skin in that area were sore for a few days, with a slight burning sensation at the skin level in the lower left portion of the rectus abdominis/six pack area, with that particular soreness disappearing after a couple of weeks. The lower left portion of the six pack to the left and above the belly button also appeared and still appear more noticeable, leaving more of a valley between the two segments of that part of the six pack. Essentially, the left side portion of the six pack is more defined than the right side portion. This suggests to me that the area where the injury initially occurred is still somewhat contracted, although it does not necessarily feel more contracted. This might have been true even before the injury. I was able to finish the exercise program that day, although I have not completed it sense, and continued an elliptical routine at the gym. I also continued to stretch after my elliptical workout but had to be more careful to avoid aggravating my abdominal muscles, particularly when doing a side-lying twist.

    I had a physical therapist dry needle some trigger points in my abdominal muscles six days after the injury, which happened to be in the relative vicinity of my belly button, but not where the left lower portion of the six pack appeared more noticeable. I had tried dry needling for my abdominal muscles in the past to help with a back injury, but my abdominal muscles were so rigid that the needles bent into the shape of an L. This time, the needles penetrated easily, but felt strange going into the muscle, leaving soreness and weird twitching sensations. The soreness at the sites of insertion of the needles lasted for a few months, which was strange as at most, soreness from dry needling typically only lasts for a couple of days. The day after the dry needling, after getting off the elliptical, my abdominal muscles at the belly button and lower started hanging to form a pooch. I continued my exercise and stretching routine even after these symptoms and noticed I had to be even more careful when stretching. About a week later, I had to give up my elliptical routine and stretching, as my right groin felt extremely strained to the point of having difficult walking and raising the leg. I am guessing this happened through my body compensating. The pooch, over the past six months, has gotten significantly smaller. It essentially feels like an expansion in that portion of the abdomen, creating a stretching sensation in the skin. It also seems to move up and down involuntarily, with the area bellow my belly button becoming firm while the area above the belly button becomes more swollen looking in appearance. Looking in a mirror, it will stretch out, almost like Pinocchio’s nose, when I excessively relax it, before pulling back in again by itself. I am 5’11”, 140 pounds, and appear lean with some muscle tone. With the pooch, when it originally happened, I looked pregnant. The entire muscle seemed to go flaccid/release overnight, though the six pack was still visible, just not firm and more rubbery feeling. Looking in a mirror, you can see that portion of the abdomen become fuller. I also developed prickliness and sensitivity in and around the belly button and some weird twitching sensations in the abdominal area below the belly button. The twitching sensations have decreased dramatically over the past six months, and the sensitivity in the belly button has begun to get better. Everyone that I have spoken with and past personal experiences suggest dry needling to be at best, helpful, and at worst, have little impact, but it is unusual for these symptoms to appear a week after the initial injury but only a day after dry needling.

    I saw an internist, who did not find a hernia upon feeling the tender areas. I then saw a general surgeon, who did not find anything using ultrasound, which he said is extremely accurate in that area of the abdomen, and checked my groin areas as well through physical examination. He fortunately did not find anything and did not know what happened or why I had a pooch. He said hernias usually happen in the groin area or at the belly button, not in the area where I saw something pop out, and they do not pop back in by themselves.

    After a couple of months, I saw a second internist. He felt a very tender spot in the area of the six pack where I believe the pop out occurred. The body quivered slightly when he felt the area. He thinks I saw fluid pop out, creating something looking like water shooting out of a hose, and said that it could take up to a year and a half for the nerves to heal. He thought that fluid in my abdomen created the swollen appearance, and that it would take time for the fluid to reabsorb. However, I have been told that the ultrasound would have shown fluid.

    After some more time, I saw a physiatrist. He felt my abdominal area and found an extremely tender point, I believe in the general area where the injury occurred. He said that this could be a tear or small defect that has not healed properly but that he wanted to get an image of it to get a better idea. He did not seem to have any thoughts yet concerning how an injury here would connect with the aches that I have been feeling in/around my belly button (where I had been dry needled one week after the injury – I did not have soreness here after the injury, only happened after the dry needling), the right groin strain, and the weird up and down movement in my abdomen that creates some flabbiness and a pooch (which also did not happen after the injury, only after the dry needling). The up and down movement of the pooch has begun to decrease and become less uncomfortable. He wants me to get an abdominal MRI without contrast, as he thinks that an MRI will show more than an ultrasound. I have not yet had the MRI. He says that the MRI will also show the thoracic spine, which will allow him to see if maybe a disc injury is causing the weirdness in my abdomen. The physical therapist checked me for spine injuries and the Beevor’s sign for injuries in the thoracic region, where the belly button would move when coming up from a supine position, and fortunately did not find anything. I recently had a treatment of a topical anti-inflammatory with ultrasound over the injured area.

    I recently went back to my internist to discuss whether to get the MRI, and he said that an ultrasound is extremely accurate for diagnosing a hernia in that area of the abdomen. He thinks that I have a muscle/fascia injury or slight tear. He said that the mechanism is similar though not as severe as rupturing a bicep. I likely had a slight tear as opposed to a rupture, so I saw a brief bulge, and then it flattened back out when relaxed. He said that I might be more susceptible to a hernia in the future. He did not think that I had fluid buildup or injury to an internal organ, as my symptoms do not match these issues. He said that the injury could take a long time to heal, and that I likely will have scar tissue. He did not think that the injury was nerve related, as that would not produce a brief pop out. He also did not think that the injury was spine related, as that would occur after a major injury with significantly more pain. He saw no need to expose myself to contrast or a CT Scan, as my issue does not warrant those tests. He did not know about pain in and around the belly button, other than nerves running from the tear. He said that activity would not make it worse but stretching was not suggested at this point. He also thought that the injury did not look as bad as when first seen, suggesting healing.

    The abdominal muscles are starting to become firm again and have less of a floating/not engaged sensation. I sometimes feel a connection, as if they are settling back into place. The abdominal muscles still feel a little strange if I try to contract them, as if I were preparing for a punch. My groin injury has gotten significantly better over the past 6 months but is not 100% yet. I am walking about an hour per day right now for exercise, warming up, then briskly walking, and then cooling down. I do not feel comfortable attempting anything more rigorous at this point.

    Have you heard of or examined a patient with an abdominal injury of this nature? Do you have any recommendations or know of anyone who could further evaluate me in or near Atlanta, Georgia? Ideally, I would talk with someone who has evaluated a similar injury, as the injury and symptoms have been incredibly perplexing.

    I greatly appreciate you taking the time to read this long message and offer any suggestions. I wanted to offer as complete a background as possible. I really do not know what else to do at this point, other than hope that the injury continues to get better and hopefully fully heal.

    drtowfigh replied 8 years, 10 months ago 3 Members · 7 Replies
  • 7 Replies
  • seekadvice

    May 28, 2015 at 7:19 pm

    Unusual Abdominal Injury

    Thank you again for taking the time to help. I have tried to allow for complete rest, but it seems impossible to isolate the abdominal muscles, as the core works with every movement. As mentioned previously, I have been walking and trying to stand tall to maintain some fitness but, other than that, have been allowing the injury to heal. The injury is not as bad as when it first happened in late October 2014, but I still feel that it has a ways to go before fully healing. The physical therapist says that the transverse abdominal muscle typically has a baseline level of tightness that can decrease as a person ages, particularly with less activity. My level of tightness seems to have decreased overnight as a result of this indescribable injury, which the physical therapist cannot really explain, as I have stayed in shape and am very lean with little body fat percentage. In addition, my abdominal muscles exhibited tone and firmness when they were being dry needled while I was relaxed on my back. No one has quite solved this injury, but your explanation seems to make sense. I am keeping my fingers crossed that the injury continues to heal and hopefully fully heals.

  • drtowfigh

    May 26, 2015 at 4:52 am

    Unusual Abdominal Injury

    It’s possible dry needling in the acute stage (6days) may have exacerbated your problem. I am not an expert in this method but typically this method should be reserved until after the acute phase.

    Yes, 6 weeks after injury.

    6-½ months is a long time, unless you have not allowed it to fully heal, ie no full rest. Typically, for muscle tears, we recommend 3-6 months of complete rest.

    Yes, CT or MRI can show this as can ultrasound.

  • seekadvice

    May 15, 2015 at 4:11 am

    Unusual Abdominal Injury

    Thank you, Dr. Towfigh and Dr. Goldstein, for taking the time to help. I have a much better understanding of the injury and what I need to do as the injury continues to heal.

    Dr. Towfigh, I appreciate your advice concerning dry needling. You mentioned that dry needling is not good in the acute stage, but I did have it done 6 days after the injury. Would this have set me back or done any damage? Does 6 weeks refer to 6 weeks after late October 2014, when the injury happened? I am about 6.5 months into the healing process. Can a muscle tear take this long to heal? I completely understand that these questions might not have any clear answers.

    You also mentioned that imaging can show the girth of each muscle. Would an MRI provide this imaging?

    Thanks again.

  • drtowfigh

    May 14, 2015 at 10:15 pm

    Unusual Abdominal Injury

    This is clearly an abdominal wall muscle issue and I don’t believe most gastroenterologists will be finding interest in this. I do not feel there is anything intestinal with your story.

    The more I think about it, the more I feel you must have had a tear in the rectus muscle. It peaked when it tore off its medial insertion. Then it smoothed out.

    Initially, allow your body to heal and follow its natural inflammatory state. Dry needling is good but not in the acute stage. You can dry needle after 6 weeks.

    Scar tissue constantly remodels. Do not worry about it. Your body takes care of that. It will not hinder any of your activities.

    Minimize rectus muscle engagement exercises. Focus on the transversu abdominis muscles.

    Muscles tear when there is an imbalance. For example, it is being tugged more in one direction than another. In your case, either you had not stretched enough, or you made a very rapid movement, or your rectus muscles are too large in comparison with your transversus muscles. There needs to be a balance in order to reduce the amount of strain between muscles. I would focus on that. If you’ve had imaging, you can analyze the girth of each muscle to see which you should focus on more.

  • sngoldstein

    May 8, 2015 at 3:33 pm

    Unusual Abdominal Injury

    Gastroenterologists take care of your intestines and internal organs. The surgeon is the person for abdominal wall issues. Exercise is generally beneficial as long as it is not causing pain.

  • seekadvice

    May 8, 2015 at 5:06 am

    Unusual Abdominal Injury

    Thank you for reading through my lengthy post and offering helpful advice. I looked online for information about diastasis and checked myself by lying on my back, lifting my head slightly, and feeling along the linea alba. I did not notice a separation.

    I appreciate your suggestions for exercises. I have not done crunches in years, due to suggestions that the flexion created by crunches can injure the back, and prior to the injury, mostly did planks and other variations using an inflatable exercise ball. The physical therapist gave me an exercise closer to the initial injury date where, lying on my back with my knees bent and feet flat on the floor, I placed fingers on each ASIS and slowly raised and lowered each foot, one at a time, without allowing each ASIS to drop. I am supposed to slightly flatten my back to maintain a neutral position. This exercise is supposed to teach my abdominal muscles to work without having to consciously tighten them.

    Do you know how long it could take an injury of this nature to heal? The strange thing is when I saw something pop out for a few seconds, it felt weird but not painful. I did not really notice much soreness until the next day. I assumed a tear or contraction strong enough to produce a brief bulge would be painful. Do I need to worry about scar tissue, or are the types of exercises that you suggest sufficient for providing an adequate healing process? Do you have any opinions about dry needling? I am guessing that it is more of a coincidence that my current symptoms happened a week after the injury but only a day after the dry needling session. I am thinking about trying it again, as it is supposed to help recovery from injuries.

    I mentioned that I suffered a right groin strain about two weeks after the injury, probably due to my body overcompensating. Do I need to be more careful to make sure that I do not set back the healing process for that injury, or can I rely on whether the soreness there increases during exercise? One thing that I have noticed is that if I stand tall with a neutral spine and the feeling like a rope is pulling my head towards the ceiling, I will feel a slight stretching sensation in my abdominal area. This sensation has decreased over the past 6 months, but I want to make sure that I do not do anything that will set it back or make any potential tear worse. I do not know if continuing to exercise after the injury caused my current symptoms, but I made sure not to force anything. I am very perplexed concerning how the particular movement from the exercise routine I was following caused the injury.

    Lastly, friends have suggested that a gastroenterologist might be able to diagnose the injury. I assume my internist would have mentioned this to me if he thought I needed to see someone else, and my understanding is that a general surgeon is the specialist to see for abdominal muscle issues, but do you have any opinions here?

    Thank you again for taking the time to help. Your response has given me more confidence as I continue to recover.

  • drtowfigh

    May 7, 2015 at 2:34 pm

    Unusual Abdominal Injury

    Thank you for the details as this is certainly a perplexing situation.

    I would like to agree with your internist.

    I wonder if you developed a tear or the beginning of a diastasis (spreading of the rectus muscles from their insertion in the middle), thus your symptoms. In either situation, there is no active intervention that is taken. Sounds like no hernia. I would not pursue any imaging. I would focus on more transversus abdominis exercises and reduce rectus abdominis and oblique muscle training for a while. That would reduce the strain on the rectus while maintaining your core. There are great forums, videos, and pictures online about transversus abdominis muscle training. Basically it is core muscle training without straining or crunches. These can include planks, squats against the wall, etc.

    I would like to hear back from you in a few months after such training. I feel you had a rectus tear or diastasis occur and that is why you had the peak in the muscle and then it settled down with the lingering soreness for a while. Rest it and don’t strain it. No more crunches or engagement of the rectus. Focus on the rest of your core.

    I hope this is helpful.

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