Pelvic Floor Injury - Gymnastics

Abstract

HISTORY: A 16-year-old female gymnast sustained a gymnastic injury resulting in left hip and pelvic pain. She was on the uneven bars and had to straddle in the air and then catch the bar coming from the abducted hip position to an adducted hip position. She felt the outside of her bilateral hips “pop”. She rested for 6 weeks and underwent physical therapy. She returned to competition and reinjured the same area 2 weeks later. She underwent additional physical therapy and again returned to gymnastics but subsequently noticed many activities within her sport now caused “stabbing” pain. When landing from a trick she reported a shock up her left leg into her pubic bone. She was referred to a physiatrist for consideration of pelvic floor involvement given limited improvement in her symptoms with previous treatments and therapies. PHYSICAL EXAMINATION: Bilateral active and passive ROM at the hip was WNL. There was tenderness to palpation (TTP) of the piriformis, glutes, ITB and trochanteric bursa on the left. Special tests including Scour’s, FABER’s, Ober’s and Ely’s were negative. There was TTP of the adductors bilaterally. Pelvic floor examination revealed normal labia with external inspection with intact sensation. Palpation revealed no pain in the introitus or urogenital diaphragm. Obturator internus was tender to touch and with resisted motion L>R. Abdominal exam revealed TTP of the psoas bilaterally L>R, pubic symphysis, and at the attachment of the rectus abdominis on the pubic bone bilaterally L>R. DIFFERENTIAL DIAGNOSIS: 1. High Tone Pelvic Floor Muscle Dysfunction 2. Abdominal Wall Strain 3. Osteitis Pubis TEST AND RESULTS: MRI Abdomen Pelvis -osteitis pubis, questionable pubic symphysis abnormality, and possible sports hernia FINAL WORKING DIAGNOSIS: High-Tone Pelvic Floor Muscle Dysfunction TREATMENT AND OUTCOMES: 1. Manual therapy for pelvic alignment correction 2. Abdominal and pelvic girdle myofascial release 3. Pelvic stability with Kinesio Taping 4. Internal vaginal muscle myofascial release and neuro re-education 5. Padding in leotard to reduce impact at pubic tubercle 6. Trigger point injections of obturator internus muscles 7. Trial of Lyrica 8. Reduction of high-impact & high-speed repetitive sport-related activities 9. Discharge from PT with successful return to gymnastic competition