From the Core to the (Pelvic) Floor

Abdominopelvic Pain and Injuries in the Athlete

James Cornwell, DO

I declare no conflicts of interest….

My Background

• Tulsa, OK
• Undergrad - University of Oklahoma
• Medical School - Lake Erie College of Osteopathic Medicine (LECOM)
• Family Medicine Residency - LECOM
• Primary Care Sports Medicine Fellowship - LECOM
• Returned to OK in 2018, started with OSU Medicine

My Background

• My Practice
• Traditional Family Medicine
• Sports Medicine
• Injury management and prevention
• Injection therapy
• MSK Ultrasound
• Concussion management
• Sideline Coverage
• And more….

My Background

• Team Coverage
• Tulsa Oiler Hockey (ECHL)
• Sara Latos
• Tulsa Oiler Football (IFL)
• Michael Daniels
• FC Tulsa Soccer Club (USL)
• Destiny Lalaguna
• USA BMX
• Luke Akande

Objectives

By the end of this session, participants will be able to:

• Identify common and uncommon causes of abdominopelvic pain in athletes, including musculoskeletal, visceral, and traumatic conditions.
• Differentiate between acute and chronic abdominopelvic conditions, integrating mechanism of injury, symptom progression, and red flag signs.
• Recognize clinical signs of abdominal trauma, including solid organ injury and internal bleeding in athletic contexts.

Objectives

By the end of this session, participants will be able to:

• Describe basic diagnostic workup and appropriate imaging modalities for evaluating abdominopelvic pain and trauma in sport-specific scenarios.
• Discuss evidence-based management strategies, including acute care, surgical referral criteria, rehabilitation, and return-to-play considerations.
• Recognize sex-specific considerations, including gynecologic and urologic sources of pain in male and female athletes.

Case #1

• DII football player developed severe left sided abdominal pain, diaphoresis and left shoulder pain suddenly while watching film with team
• Spring training, no-contact day, team meetings and film review

Case #2

• International BMX athlete falls forward from bike during a race and falls directly on abdomen on a roller (small hill)
• Was able to walk off of track with help of on track medical staff to medical tent
• Lower BP, HR in the high 80s, pale
• FAST exam performed (negative)

Case #3

• 18 y/o softball athlete developed sudden, severe RLQ abdominal pain
• Currently on an road trip, 2 hours after team meal and meeting.

Patterns and Mechanisms of Pain

Visceral

• Hollow abdominal organs (intestines, biliary tree) - contract forcefully or are distended/stretched
• Solid organs - pain when capsule is stretched
• Difficult to localize
• Typically palpable along midline at levels that vary according to structures involved
• Varies in quality - gnawing, burning, cramping, or aching. Severe pain will be associated with sweating, pallor, nausea, vomiting and restlessness

Patterns and Mechanisms of Pain

Parietal Pain

• Originates from inflammation of the parietal peritoneum (lining of the abdominal cavity)
• Aching pain that is usually more severe than visceral pain
• More precisely localized over the involved structure
• Aggravated by movement, coughing. Will prefer to remain still

Patterns and Mechanisms of Pain

Referred pain

• Pain felt in more distant sites which are innervated at approx the same spinal levels and disordered structure.
• Often develops as initial pain - becomes more intense and seems to radiate or travel from the initial site
• Pain may also be referred to the abdomen from the spine, chest or pelvis
• Ex - duodenal, pancreatic pain —> back
• biliary system —> R posterior chest, shoulder
• pleurisy, acute MI —> epigastrum

How to Approach Exam

• Relevant historical questions, PMHx, PSHx
• Vitals
• Temp, RR, HR, BP, SPO2
• Exam
• Look sick, in pain or playing on their phone?
• diaphoretic, pale

Abdominal Examination

• Observation (Look) - skin (rashes, lesions), contour of the abdomen (flat, protuberant/distended, scaphoid/hollowed)
• Auscultation (Listen) - bowel sounds (clicks and gurgles) typically with frequency of 5-34 per minute
• Hyperactive - gastroenteritis, diarrhea
• Hypoactive - peritonitis, paralytic ileus
• borborygmi

Abdominal Examination

• Palpation (Feel) - Light, gentle dipping motions, raise just off skin
• Percussion - tympanic or dull
• In all 4 quadrants
• Involuntary rigidity - muscular spasm —> peritoneal inflammation
• Abdominal pain w/ coughing or light percussion —> peritoneal inflammation
• Rebound tenderness - press down with fingers firmly, then withdraw quickly. “Which hurst more, when I press or let go?” Localize pain exactly, if felt elsewhere may be real source of pain —> peritoneal inflammation

Abdominal Examination

• Signs and symptoms may be subtle
• May be OBVIOUS —> shock
• Maintain high index os suspicion (trauma)
• Signs of injury may be delayed
• 50% - athletes with significant abdominal injury have negative initial exam —> no red flags
• 20% of athletes with hemoperitoneum have benign initial exam

Red Flags

History

• Nausea and vomiting - especially if developing later or related
• Hematuria (blood in urine)
• Pain radiating to the left shoulder (Kehr sign)
• Free intraperitoneal air, blood irritating diaphragm
• If delayed presentation:
• Signs of bacterial or chemical (blood, bile, other irritants) peritonitis
• Fever
• Pain worsening over time
• Pain with bumps in road

Red Flags

Physical Examination

• Vital sign abnormalities
• Tachycardia (relative tachycardia)
• “Thready” pulse (weak), decreased pulse volume
• Decreased Blood pressure
• Typically later = significant blood loss has occurred
• Peritoneal signs on exam
• Pain with light palpation, coughing
• Involuntary rigidity
• Rebound tenderness

Management

• Goal = Identify signs and symptoms of pathology requiring further evaluation and management
• Primary goal on sideline is not identification of specific pathology
• Be prepared to initiate initial management
• Disposition appropriately
• Outpatient eval - UC, family doc, team doc, etc
• Inpatient - Emergency/Trauma Department

Management

• Sideline Management —> Suspecting acute injury
• Lie flat
• Activate EAP —> EMS —> Hospital
• IV fluids if available (keep them NPO)

Abdominopelvic Pain (Non-traumatic)

Anxiety/Stress Reaction

• Performance anxiety
• Inhibitory on GI function —> decreased acid production, slowed motor activity, reduced blood flow
• Continued anxiety may result in acid hypersecretion
• Symptoms = dry mouth, dyspepsia (“knot in stomach”), heart burn, reflux, abdominal cramping or diarrhea or even vomiting (“nervous poker”)
• Treatment = reassurance, education, behavior mods

Acute Gastroenteritis

• Very common, incidence 2nd only to URIs
• Typically viral, can be bacterial or protozoa
• Peak incidence - winter in cities, summer in rural or outdoor sports
• Symptoms = N/V, generalized abdominal cramping, diarrhea, fevers, myalgia
• Treatment = self-limiting (2-3 d), FLUIDs, electrolytes, anti-motility meds (may prolong carrier state), antibiotics
• RTP - depends on hydration status, infective nature of problems, symptoms, reconditioning

Exercise-Related Transient Abdominal Pain

• “Side-Stitch”
• Lateral aspect of mid abdomen
• Worse in post-prandial state
• Greatest in sports involving repetitive torso movement (swimming, running, equestrian sports)
• Incidence declines with age
• Proposed mechanisms: diaphragmatic spasm/ischemia, stress placed on peritoneal ligaments connecting diaphragm to viscera, exertional irritation of peritoneum, mechanical compression of the thoracic intercostal nerves

Hypoperfusion of GI tract during intense exercise

• First few minutes - 15% central blood volume shunted to muscles
• As core temp increases - 20% shunted to skin for cooling
• Central blood volume maintained by redirection of blood from organs, splanchnic bed (1.56 L down to 0.3 L)

Upper GI Problems

• Heartburn, reflux, nausea, vomiting, bloating, epigastric pain
• Related to training or competition is a diagnostic dilemma
• Gastroesophageal Reflux Disease (GERD)
• Vigorous exercise causes GERD symptoms in normal subjects
• Frequency, amplitude and duration of esophageal contractions decline with increased intense exercise
• Can produce belching, chest pains
• Hypoperfusion result from shunting, reduced esophageal motility
• Tx - H2 blockers, PPIs - 4 hrs before exercise, alterations in oral intake (~3 hrs) prior to activity

Upper GI Problems

• Gastritis (erosive)
• May be induced by hypoperfusion, NSAIDs, anxiety
• Often hemorrhagic
• Tx - H2-blockers, PPI, antacids
• Peptic Ulcer Disease (PUD)
• No more common in athletes
• Delayed Gastric Emptying
• Bloating, reflux or both
• Hypoperfusion

Upper GI Problems

• Dyspepsia
• Upper GI pain with no identified cause
• Treated empirically - H2-blockers, PPIs 4 hrs before activity
• Hypoferritinemia
• Has been associated with exercise induced abdominal pain
• Angina or cardiac ischemia
• To be considered in our older athletes

Upper GI Problems

• Asthma
• Symptoms can overlap with GERD
• Upper GI bleeding
• Hemorrhagic gastritis, PUD
• Mechanical proposed - Sheering forces of diaphragm on gastric fundus
• Acid reducing medications
• Improve hydration before and during performance
• Increased plasma volume may not reduce ischemia

Lower GI Problems

• Cramping, urge to defecate, diarrhea, rectal bleeding, flatulance
• Runner’s Diarrhea
• “Runner’s Trots”
• Stimulated by intense endurance running with or without GI bleeding
• Can be accompanied by cramping
• 30% incidence, 60% of those with abdominal pain or urgency, 12% of those with frank blood

Lower GI Problems

• Diarrhea
• Anxiety-induced
• Increased GI motility
• Irritable Bowel Syndrome
• Cramping, abdominal pressure
• Dietary Factors - high fiber diet can cause exercise-induced diarrhea, sorbitol, fructose, fruit, intensive diets, large doses of caffeine or vitamin C
• Possible immune system etiology - variant of exercise induced anaphylaxis, generalized urticaria including in the intestines.
• Endotoxins from bacteria

Lower GI Problems

• Diarrhea
• Prevention - bowel movement before competition, light jog after pre-cometition meal (gastrocolic reflex)
• Improve hydration - before and during
• Fiber mods
• Decrease trigger foods
• Anti-motility medications - Imodium (risk of hyperthermia), Lomotil
• “Gut training” —> Decrease training and competition levels by 20-40% - titrate slowly

Lower GI Problems

• Lower GI Bleeding
• Can be stimulated by intense performance
• Severe lower abdominal pain
• Passing large amounts of red, maroon or clotted blood

Lower GI Problems

• Intestinal Ischemia
• Hypoperfusion caused by shunting from mesentery to skin and muscles
• Relative gut ischemia causes focal areas of necrosis and ulceration
• May cause intestinal malabsorption, diarrhea
• Generalized abdominal pain
• Cecal Slap Syndrome - mechanical trauma from running can cause hemorrhagic cecal lesions and diarrhea

Celiac Artery Compression Syndrome

• Rare, controversial
• External compression of the celiac artery, sometimes superior mesenteric artery by the arcuate ligament of the diaphragm, especially during exhalation —> causing ischemia
• Athletes with anatomic setup may become symptomatic with decreased splanchnic/mesentric blood flow during exercise, dehydration, high ambient temps or poor acclimatization
• Diagnosis of Exclusion
• No clear diagnostic criteria or imaging modality
• Most common in young people, recent weight loss, females
• Pain may be sharp, dull, steady, or crampy —> worsens after meals, causes weight loss or even elicit pain with position changes

Celiac Artery Compression Syndrome

Acute Appendicitis

• Approximately 100 to 230 cases per 100,000 person-years, peaking in the 15–19-year age group
• Initial vague periumbilical pain that migrates to the right lower quadrant
• Anorexia, nausea/vomiting, and low-grade fever
• Right lower quadrant tenderness (McBurney's point), Rovsing, psoas, and obturator signs may be present
• CT (adults) vs U/S (kids and pregnant)
• Nonoperative management with antibiotics is an option for select patients, but carries a 30–40% risk of recurrence over five years and may delay definitive return to high-level activity.
• Laparoscopic appendectomy remains the gold standard, offering rapid symptom resolution and a typical return to full activity within 1–2 weeks

Gastrointestinal Pathologies

• Lactose intolerance - lack enzyme lactase - avoid dairy
• Celiac Disease - Gluten allergy
• Malabsorption of iron/folate
• Inflammatory Bowel Disease
• Crohn’s Disease
• Ulcerative Colitis
• Irritable Bowel Syndromes

Gastrointestinal Pathologies

• FODMAPs (fermentable dietary components cause gas production and distention of gut —> pain)
• Small Intestinal Bacterial Overgrowth (SIBO)
• Disruption of microflora balance
• Malabsorption - carbs, fats, vitamin B12
• Chronic Constipation

Nephrolithiasis (Kidney Stones)

• 0.5% general population
• Flank pain, colicky —> radiation to ipsilateral groin
• Peak incidence in 4th-5th decade of life
• Incidence is rising among adolescents, particularly those aged 12–19 years, with a notable increase in adolescent girls.
• Factors that promote kidney stone formation = low urine volume (dehydration), dietary excesses (sodium, animal protein, fructose), genetic predisposition, metabolic abnormalities (e.g., hypercalciuria, hyperoxaluria, hypocitraturia), and certain systemic diseases (e.g., obesity, diabetes, gout, hyperparathyroidism)
• Calcium (85%M:65%F) —> Uric acid —> infection related
• <5 mm - may pass spontaneously, >5 mm - Urologic consult/intervention

Urinary Tract Infections

• F>>>>M
• Numerous causative agents —> E. coli, bacterial cystitis most common
• Hematuria, pyuria (WBCs in urine)
• Symptoms - suprapubic pain, flank pain, urethral pain
• dysuria, cramping, frequency, urgency, etc
• Pyelonephritis —> very sick (F/N/V/Pain)

Urinary Tract Infections

• Prostatitis
• Acute bacterial is uncommon
• Symptoms = chills, fevers, pain in back and perineum, dysuria and obstruction with voiding
• Chronic prostatitis common cause of recurrent UTI
• <35 y/o —>  Neisseria gonorrhoeae and Chlamydia trachomatis are more common causes
• Sexually Transmitted Diseases
• If suspected - needs testing and treatment

Testicular Torsion

• Pre-existing scrotal abnormalities —> increased risk for injury
• Mobility of testes limited by tunica vaginalis
• Torsion to be considered whenever there is pain and swelling
• = true urologic emergency —> prompt urology consultation
• Develops from increasing abdominal and groin pain —> excruciating testicular pain
• High riding testicle, abnormal epidydimal position
• Cremasteric reflex is absent
• Increased pain with elevation of the testicle
• Surgical intervention should not be delayed.

Epididymitis

• Tender indurated epidydimis
• May become hard and fixed, swollen spermatic cord
• Fever, elevated WBC
• U/A will show Leukocytes
• Relieved pain with elevation of scrotum
• <35 y/o chlamydia, >35 y/o E. Coli —> Abx treatment accordingly

Scrotal Masses

• Gynecomastia eval in presence of mass —> Lydig
• Varicocele —> varicosities of the internal spermatic cords
• Painful, can cause infertility
• Spermatocele —> cystic mass w/in epididymis
• surgical if painful
• Hydrocele —> cystic mass surrounding testicle, epidiydimis
• Collection of peritoneal fluid between parietal and visceral layers of tunica vaginalis, transilluminates
• Painful if quite enlarged - surgical
• Hematocele —> blood accumulation in tunica vaginalis
• Dull, painful - does not transilluminate
• Testicular cancer —> most common malignancy in 16-35 y/o males

Female Pelvic Pain

• Categorize according to age
• Pre-menarche/reproductive age
• Reproductive years
• Postmenopausal

Female Pelvic Pain

• All groups —> Common Diagnoses
• Appendicitis
• Diverticultis
• IBD
• IBS
• MSK (abdominal wall pain)
• UTI
• Kidney stone

Female Pelvic Pain

• Post-menopausal
• Malignancy
• Ischemic colitis
• Reproductive Age —> not pregnant vs pregnant vs undergoing fertility treatments
• Endometriosis
• Ovarian cyst, ruptured
• Ovarian torsion
• Pelvic inflammatory disease
• Ectopic pregnancy
• Spontaneous abortion
• And many more….

Endometriosis

• Growth of endometrial-like tissue outside the uterus
• Influenced by genetic, hormonal, and immunologic factors, leading to chronic inflammation
• Pelvic pain (including dysmenorrhea, non-menstrual pelvic pain, and dyspareunia) and infertility
• GYN eval

Ruptured Ovarian Cyst

• Spontaneous rupture of a functional (physiological) cyst, such as a corpus luteum or follicular cyst ~2 weeks after last day of previous menstrual cycle
• Sudden onset of unilateral lower abdominal pain
• Peritonitis, hemodynamic instability
• Vaginal bleeding
• N/V/F
• U/S for diagnosis

Ovarian Torsion

• Twisting of the ovary —> compromised blood flow
• Often with a cyst or mass as a lead point
• Sudden-onset, severe, unilateral lower abdominal pain
• Dull, Intermittent, non-radiating, usually associated with adnexal mass
• U/S w/ doppler

Pelvic Inflammatory Disease

• Migration of Sexually transmitted pathogens form lower GU tract to upper (uterus, fallopian tubes, ovaries or pelvic peritoneum)
• Chlamydia trachomatis, Neisseria gonorrhoeae >>> Mycoplasma genitalium and anaerobic bacteria
• Pelvic or lower abdominal pain
• Abnormal vaginal discharge, intermenstrual or postcoital bleeding, dyspareunia
• Sometimes dysuria or fever
• Pelvic organ tenderness on examination - Key clinical finding

Ectopic Pregnancy

• Implantation of fertilized ovum outside uterine cavity —> typically fallopian tube
• Lower abdominal pain
• Pelvic pain and vaginal bleeding early in pregnancy
• In cases of rupture - signs of hemodynamic instability, peritinitis
• Beta-hcg testing, U/S
• Can be life threatening

Spontaneous Abortion

• Most commonly caused by chromosomal abnormalities
• Vaginal bleeding and abdominal pain
• Heavy bleeding most associated with miscarriage
• Passage of tissue and cramping may also occur

Abdominopelvic Injuries/Trauma

Rupture of the Diaphragm

• Blunt chest/abdominal trauma
• Herniation of the abdominal contents into chest
• 4x more common on L with blunt trauma (Liver protects on R)
• Chest pain, dyspnea, intestinal obstruction
• Decreased breast sounds, Excessive percussive tympani in chest
• Bowel sounds in the chest, scaphoid abdomen

Splenic Injury/Rupture

• Most commonly injured intra-abdominal organ in sport (>25% cases)
• Direct trauma, sudden deceleration, displaced rib fracture
• Infectious mononucleosis - enlarges and weakens during illness
• Initial sharp pain LUQ —> dull L-sided flank pain, abdominal distension
• Left shoulder pain = Kehr’s sign, neck pain (phrenic nerve)
• Peritoneal signs, tachycardia, hypotensive, diaphoretic, rapid respirations
• If suspected —> immediate transports to hospital, IVF, elevate legs (modified Trendelenburg)

Liver Laceration

• Relatively Rare
• 15% cases
• 50% of deaths
• Motor racing and skiing
• Capsular hematoma is most common in athletes
• Direct trauma to the RUQ, sudden declaration
• Pain with palpation over RUQ, tachycardia, hypotensive, may be associated with rib fractures

Renal Injury

• Exact incidence unknown
• Blunt trauma to abdomen, back or flank
• Gross hematuria = red flag
• Hypovolemic shock possible with extensive bleeding

Rupture of Stomach/Intestine

• Rare
• Kick or blow to abdomen, fall from horse or against equipment, dog piles, spearing in football, handlebar injuries in cycling, diving decompression accidents
• Persistent abdomen pain with signs of chemical or bacterial peritonitis
• Fevers, N/V, hypotensive and tachycardia
• Absence of normal bowel sounds
• Rigid stomach
• Often delayed diagnosis (h to d)—> initial presentation can appear benign

Pancreatic Injury

• Rare - relatively immobile and protected retroperitoneum
• Direct contact, compression agains spine
• High morbidity/mortality especially if diagnosis is delayed >24hrs
• Historical feature - pain decreased during first 2 hrs after injury, then increases in next 6-8 hrs

Bladder Rupture

• Direct trauma
• Typically associated with other injuries (pelvic fractures)
• Children/adolescents higher risk for isolated bladder rupture
• Hematuria, gross blood at the meatus, peritonitis, inability to void urine, presence of pelvic fracture

External Genitalia Injuries

• Testicular Trauma
• Blunt trauma —> rupture or torsion
• Swelling, pain or ecchymosis
• Emergent U/S with doppler and Urologic consultation

External Genitalia Injuries

• Penile Injuries
• Direct blow to pubis, saddle injuries
• Possible vascular injuries
• Urethral rupture/injury —> blood at the urethral meatus
• Fracture of the tunica albuginea - erect penis - Urologic emergency
• Penile Frostbite - runners in cold weather
• Traumatic irritation —> pudendal nerve in touring cyclist - may cause priapism or ischemic neuropathy

External Genitalia Injuries

• Female Genital Injuries
• Vulva is vascular —> direct trauma can result in hematoma formation
• Falls while water skiing —> forcing water into vagina, laceration and possible internal bleeding (related to cases of endometritis and salpingitis)

FAST Exam

Focused Assessment with Sonography in Trauma

• Screening tool for blood around heart and in abdomen
• Need up to 200 mL of blood to see abnormalities
• Purpose - identify those who should forgo CT and go to OR immediately
• Unstable vital signs and abnormal exam
• Used in ERs, sideline evals
• 20% of those with hemoperitineum may have benign initial physical exam
• May be useful in early identification for these cases

Differential Diagnoses

• Systematic list of possible conditions that could explain a patient's clinical presentation, prioritized based on the likelihood and clinical context

Case #1

• DII football player developed severe left sided abdominal pain, diaphoresis and left shoulder pain suddenly while watching film with team
• Spring training, no-contact day, team meetings and film review

Case #2

• International BMX athlete falls forward from bike during a race and falls directly on abdomen on a roller (small hill)
• Was able to walk off of track with help of on track medical staff to medical tent
• Lower BP, HR in the high 80s, pale
• FAST exam performed (negative)

Case #3

• 18 y/o softball athlete developed sudden, severe RLQ abdominal pain
• Currently on an road trip, 2 hours after team meal and meeting.

Sources

• Galli BM, et al. Abdominal and genitourinary trauma in sports: Evaluation and management. Curr Sports Med Rep. 2020;19(10):377–384.
• Nwariaku FE, et al. Sports-related blunt abdominal trauma: Solid organ injuries in contact sports. J Trauma. 2002;53(1):100–103.
• McCrory P. Abdominal trauma in sport. BMJ. 2001;322(7293):1180–1181.
• American College of Radiology. ACR Appropriateness Criteria® – Blunt Abdominal Trauma. (for imaging decisions)
• Harmon KG, et al. Non-orthopedic causes of groin pain in athletes. Sports Health. 2010;2(3):253–262.
• Orchard J, et al. Consensus statement: nomenclature and classification of groin pain in athletes. Br J Sports Med. 2015;49(12):768–774.
• Jansen J, et al. Abdominal wall injuries: diagnosis and management. Clin Sports Med. 2013;32(2):279–290.
• Campbell SE, et al. The role of the transversus abdominis in core stabilization: implications for injury prevention. J Sport Rehabil. 2013;22(2):59–70.
• Brukner P, Khan KM. Clinical Sports Medicine, 5th ed. McGraw-Hill Education, 2020. (Chapters on abdominal pain, groin injury, and trauma)
• AMSSM Position Statements (e.g., Athletic Pubalgia, Sport-Related Concussion, Return-to-Play Guidelines)
• Madden C, Putukian, M, Young C, & E McCarty. Netter’s Sports Medicine. Saunders Elsivier, 2010. (Chapters on abdominal pain and Genitourinary problems)
• Bate’s Guide to Physical Examination and History Taking, 10th edition. (Chapter on abdominal examination)

Thank you!