Side Strain (Abdominal)

Side Strain (Abdominal)

Article by John Miller

back-pain

What is an Abdominal Side Strain?

Side strains are an injury almost unique to cricket’s fast bowlers. Javelin throwers are the only other athletic participants who also regularly strain the side abdominal muscles.

In bowlers, side abdominal strains occur on the non-bowling side of the body and the majority are strains of abdominal muscle insertions on to the lower ribs. Side strain injury is caused by tearing of the internal oblique muscle from the under surface of one of the lower four ribs or costal cartilages. MRI scans can document the site of a muscle tear, characterise the severity of injury, and monitor healing. Bony stress lesions (such as stress fractures of the 10th or 11th ribs) can occur but are less common.

There is a traditional belief that a side strain is almost a ‘rite of passage’ for an elite fast bowler that is almost certain to occur once early in his playing career and is thereafter unlikely to return. However, there are cases of recurrent side strains that plague bowlers throughout their career.

 

Diagram 1

Normal anatomy of the anterolateral abdominal wall. The diagram shows internal oblique muscle arising from the iliac crest and inserting into lower fourth rib under cover of external oblique muscle.

 

Diagram 2

Normal anatomy of the anterolateral abdominal wall. Diagram of the coronal section through abdominal wall shows three flat muscles. Internal oblique muscle lies immediately underneath ribs.

What Causes Side Strain?

Side strains are strongly related to bowling speed, with the fastest bowlers much more likely to suffer this type of injury. It is postulated that the mechanism of injury for internal oblique muscle strain is sudden eccentric contracture with rupture of muscle fibres. An eccentric contraction is one that stops a muscle or joint from excessively lengthening.

Movements associated with bowling and throwing cause lengthening of the muscle, which is then subjected to superimposed eccentric contraction, making it vulnerable to rupture.

In research studies focusing on fast bowlers, the muscle tear occurs on the non–bowling arm side. For example, in a right-handed bowler, the left arm is initially hyperextended and then forcefully pulled through to allow the right arm to follow through and release the ball. In the hyperextended position, the internal oblique muscle on the left side can be assumed to be at maximum tension or eccentric contraction. The sudden vigorous motion from this eccentric contraction or pull through that allows the dominant shoulder to flex and release the ball is the probable point at which the internal oblique muscle is likely to rupture. A similar mechanism can be proposed for other throwing sports.

How is Side Strain Diagnosed?

MRI appears to be a sensitive test for evaluating side strain injury, showing an abnormality in all patients who had a clinical suspicion of a muscular tear. Stripping of the periosteum occurs as the muscular attachment is avulsed from the osseous or cartilaginous origin; this can result in excessive haemorrhage even though the muscle tear may be low grade.

How to Prevent Side Strain

Warming up and stretching the injury before spells of bowling is very important. Keeping the torso warm and performing a series of trunk rotation and side flexion exercises are recommended.

Side Strain Treatment

It is important to cease bowling and throwing immediately after injury and ice the painful area. For best results and reduced recovery time, seek professional treatment for a side strain. Most side strain injuries require 4 to 6 weeks of rehabilitation prior to a return to sport.

Common Cricket Injuries

Back Pain

Shoulder Pain

Thigh & Hamstring Pain

Knee Pain

Shin & Calf Pain

Ankle Injuries

Neck Pain

FAQs for Abdominal Side Strain

What is Physiotherapy Treatment?

Physiotherapists help people affected by illness, injury or disability through exercise, manual joint therapy, soft tissue techniques education and advice.  Physiotherapists maintain physical health, help patients to manage pain and prevent disease for people of all ages. Physiotherapists help to encourage pain-relief, injury recovery, enabling people to stay playing a sport, working or performing activities of daily living while assisting them to remain functionally independent.

There is a multitude of different physiotherapy treatment approaches.

Acute & Sub-Acute Injury Management

Hands-On Physiotherapy Techniques

physiotherapy treatment

Your physiotherapist's training includes hands-on physiotherapy techniques such as:

Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors and occupational therapists, just to name a few.

Physiotherapy Taping

Your physiotherapist is a highly skilled professional who utilises strapping and taping techniques to prevent and assist injuries or pain relief and function.

Alternatively, your physiotherapist may recommend a supportive brace.

Acupuncture and Dry Needling

Many physiotherapists have acquired additional training in the field of acupuncture and dry needling to assist pain relief and muscle function.

Physiotherapy Exercises

Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly-skilled in the prescription of the "best exercises" for you and the most appropriate "exercise dose" for you depending on your rehabilitation status. Your physiotherapist will incorporate essential components of pilates, yoga and exercise physiology to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.

Biomechanical Analysis

Biomechanical assessment, observation and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.

Hydrotherapy

Aquatic water exercises are an effective method to provide low bodyweight exercises.

Sports Physiotherapy

Sports physio requires an extra level of knowledge and physiotherapy skill to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports Physiotherapist.

Vestibular Physiotherapy

Women's Health

Women's Health Physiotherapy is a particular interest group of therapies.

Workplace Physiotherapy

Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstation set up for your body at work or home. Whether it be lifting technique improvement, education programs or workstation setups, your physiotherapist can help you.

Electrotherapy

Plus Much More

Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your individual problem, please contact your PhysioWorks team.

Back Pain is Multifactorial

Lower back pain is a complex condition, especially if it has been present for some time. Retraining the Transversus Abdominis and Multifidus are significant milestones in the road to recovery. It is, however, often not the whole solution. Depending on your needs, a comprehensive rehabilitation program will be designed for you by your physiotherapist. In addition to the Transversus Abdominis and Multifidus and core strengthening exercises, your rehabilitation will probably require other interventions. These techniques may include joint mobilisation, lumbopelvic alignment techniques, massage, muscle releases and stretches, leg and arm strengthening, posture correction and various other modalities to reduce your pain. Your physiotherapist will discuss your treatment options specific to your needs during your consultation.

Lower Back Pain Treatment Guidelines?

While lower back pain treatment will vary depending on your specific diagnosis, your physiotherapist will have the following aims.

PHASE I - Back Pain Relief & Protection

Managing your back pain is the main reason that you seek treatment for lower back pain. In truth, it was the final symptom that you developed and should be the first symptom to improve. Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These include ice, electrotherapy, acupuncture, de-loading taping techniques, soft tissue massage. A course of non-steroidal anti-inflammatory drugs such as ibuprofen may also help in this phase.

PHASE II - Restoring Normal ROM and Strength. Early Back Exercises.

As your lower back pain and inflammation settles, your lower back pain may feel better. Still, you are more vulnerable to re-injury during this honeymoon period when you don't have pain, but your muscles and ligaments are weak. During this phase, your physiotherapist will turn their attention to restoring your normal lumbar spine motion. Plus they'll assess your muscle length and resting tension, muscle strength and endurance, proprioception, balance and gait (walking pattern). Your physiotherapist may commence you on a lower abdominal core stability program to facilitate your important muscles that dynamically control and stabilise your lower back and pelvis. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best back exercises for your specific needs.

PHASE III - Restoring Full Function

Depending on your chosen work, sport or activities, your physiotherapist will aim to restore your back's function to allow you to return to your desired activities safely. Everyone has different demands for their lower back that will determine what specific treatment goals you need to achieve. For some, it is merely to walk around the block. Others may wish to run a marathon or be a fast bowler. Your physiotherapist will tailor your back pain rehabilitation to help you achieve your own functional goals.

PHASE IV - Back Exercises - Preventing a Recurrence

Recurrence of lower back pain can occur. The main reason for a recurrence is due to insufficient rehabilitation. In particular, poor compliance with deep abdominal core muscle exercises. You should continue a version of these back exercises routinely a few times per week. Your physiotherapist will assist you in identifying the best activities for you to continue indefinitely.

Core Exercises

While all back exercises that strengthen the muscles that traverse your back are essential, back pain researchers have emphasised retraining your deep core muscles as a priority. "Core Stability" is your body's ability to control and support your spine via specific muscles dynamically. Your spine is an inherently unstable area of your body. Your lower back has five vertebrae that allow twisting, bending and arching with no other bones to assist. They sit on top of a triangular bone called the sacrum, which wedges itself into the pelvis. Unfortunately, without strong support, all of these bones would fall in a heap on the ground. Your deep core muscles are the main structures that support, control and move your lower spine and pelvis. They are also the most energy-efficient and best-positioned muscles to do the job for 24 hours a day. However, when they turn off, your spine is not fully supported by its usual muscular corset. This lack of support makes it quite vulnerable to injury and chronic pain. Research has shown that our back pain causes your "deep core stability" muscles to STOP working in EVERY case. The first time you experience low back pain, your brain automatically inhibits the regular activity of the Transversus Abdominis (TA) muscle. This inhibition occurs in 100% of sufferers. Unfortunately, even once the back pain has eased the TA muscle does not automatically switch on again. Inhibition of the TA muscle exposes your spine to further trauma and hence "recurrent back pain". Each incident becomes a little more severe, and consequently, further wasting of the TA occurs. Other causes of muscle inhibition include previous abdominal surgery, pelvic pain and post-pregnancy.

What are the Benefits of Core Stability Training?

Researchers have shown that the correct use of your core stability muscles not only prevents pain but also alleviates pain if you're already suffering. Also, your body's strength, power, endurance and performance will improve. You'll be able to run faster, jump higher and even throw further when these muscles work correctly. For more information, please contact your physiotherapist.

Core Stability Muscles

The deep core stability muscles of the lower spine include:
  • Transversus Abdominis (TA)
  • Multifidus (MF)
  • Pelvic Floor (PF)

Transversus Abdominis

core.stability.muscles The Transversus Abdominis (TA) is the deepest abdominal muscle. It is the "corset muscle" of the spine and pelvis. In the typical situation, TA contracts in anticipation of body motion to guard the spinal joints, ligaments, discs and nerves.

Multifidus

Multifidus (MF) muscles are very short muscles running from the transverse processes (on the sides) of one vertebra up to the spinous process (the middle of the back) of the next vertebra upwards. Their primary function is back stability. They do not produce an extensive range of movement, but work to provide small, "fine-tuning" postural changes, all day long.

Pelvic Floor & Diaphragm

The TA and the MF work in conjunction with your pelvic floor and diaphragm to make a flexible but stable region around your lumbar spine. It is this ability to stabilise your lumbar spine in its many positions that enable you to overcome back problems and reduce your chances of a reoccurrence.

What Are The Ideal Core Exercises?

Your deep core stability muscles retraining uses specific low-level activation exercises. While a very skilled physiotherapist who has training in deep core activation can observe and palpate for the correct muscle contraction, the best way is to see them working on a real-time ultrasound scan. Real-Time Ultrasound Physiotherapy guidance allows you to see how your muscles are contracting in real-time. This visual feedback will enable you to correct your specific deep core muscles inside your stomach, lower back, and pelvic floor as you attempt to contract those muscles.

Beware of “Core Stability” Exercises!

The fitness industry is full of fitness instructors who profess to know how to activate your core stability muscles. Unfortunately, the wrong core exercises will do you harm. Most progress your core exercises far too quickly and bypass these critical muscles to strengthen your outer abdominal muscles further and leave your deep core muscles weak. Research evidence has found that this renders you vulnerable to lower back pain and injury.

How Good is Your Core Stability?

Research clearly shows that core stability retraining has short and long-term benefits for low back pain sufferers. The good news is that we also know that core stability training markedly reduces your chances of re-injury. Research on lower back pain sufferers has shown us that if you can re-activate your core stability muscles, your chance of recurring back pain reduces. Your chances of not experiencing another bout of low back pain (LBP) within twelve months are almost three times better if you have undertaken an ultrasound-guided exercise program84% vs 30%. After three years, you still have a two in three chance of not experiencing low back pain if you did the exercises. Adding even more research support, if you didn't do the exercises, you only have a one in four chance of being pain-free. You're still over twice as likely to not experience another episode of back pain. Hides et al. (2001). PhysioWorks physiotherapists have professional knowledge in the training of core stability muscles. The difficulty has always been how to quantify a patient's level of stability control. That is, until now. The solution has been to develop a useful and clinically practical method of assessing your level of core stability. We can then determine and at what level it fails to cope when the demands placed upon your body. That is, what is the individual client's functional Back Stability Score (BSS)?

How Do We Assess Your Core Stability?

Your PhysioWorks physiotherapist will assess you to determine your current symptoms, pathology and functional requirement. Then, they'll physically test you to decide on your back stability based your ability to activate your core control muscles (transversus abdominis, multifidus and gluteals). If you can isolate these muscles, we are then able to test further when your core stability muscles lose control of your spine, become inhibited or fatigue. This testing assists us in determining what tasks make you vulnerable to back pain or injury.

What Happens After Your Core Stability Score is Determined?

Based on your functional needs, your treatment directs towards your specific areas of weakness. The result is a much stronger, stable and pain-free back. If you would like to know your Back Stability Score, please contact PhysioWorks.

What are the Benefits of the Functional Back Stability Score?

For Patients

  • You have a quantitative guide to your functional goals
  • You have a current status score. Progress is measurable.
  • You can progress quickly through the BSS levels to maintain motivation and self-esteem
  • Individualised treatment. Different retraining options depending upon desired outcomes.
  • You can self manage in long-term
  • Your goals are functional (task-related) rather than merely a strength score.
  • Quantitative Feedback for You, Your Health Practitioners and Insurers.
  • Achieve stepped goals and sensible, steady exercise and treatment progressions.
  • We'll educate you on how to prevent future injuries.
  • You'll be introduced to ergonomics and understand the best postures for you
  • You will prevent future bouts or at least minimise their severity
  • It's a research-backed solution.
  • It's perfect for all ages and physical ability.
  • There is a clear path for progression.
  • You perform your exercises in the comfort of your own home without expensive gym equipment or membership
  • You'll have personalised professional guidance for assessment, reassessments and progressions.
  • You'll be pain-free ASAP

For Clinicians & Insurers

  • It's a precise measure of your functional capacity
  • It allows better judgments on patient directions, e.g. returns to work
  • It offers better-individualised advice and treatment
  • It reduces jargon through measurable standardisation
  • It's a practical measure that can be related to other outcome measures such as Oswestry Disability Score
  • There is a clinically relevant correlation between subjective and objective findings
  • It reduces malingering.

What Conditions Does the Back Stability Program Improve?

  • Spinal Pain
  • Spinal Posture
  • Pelvic floor function
  • Sciatica
  • Spondylolisthesis
  • Spondylosis
  • Degenerative Disc Disease
  • Poor Balance or Fall History

Core Stability vs Pilates

The whole 'core stability' phenomenon started back in the 1920s with a chap named Joseph Pilates, who's exercise regimes have become quite trendy in the last ten years. Pilates talked about developing a 'girdle of strength' by learning to recruit the deep-trunk muscles. Even without complete knowledge of anatomy and the benefits of the latest muscle activity research, he was aware of the importance of these deep muscles and their supportive effects. Put simply; core stability training targets explicitly the smaller and deeper back and stomach muscles. Once recruited, these muscles control the position of the spine during dynamic movements of your body.

Is Pilates for Everyone?

Sadly, No! Exercise programs that aim to develop your deep core strength can often do just the opposite. The most common reason for injury and back pain is the incorrect timing of core muscle recruitment.  Pilates, Yoga, gym strengthening and other forms of exercise place high demands on your core stability system. Abnormal core muscle recruitment order increases your injury chance proportion with the exercise difficulty. Remember, if you build a tower on a weak foundation, it will eventually topple. Look what happened to the Leaning Tower of Pisa. It's got lousy core stability! The same goes for your core stability muscles. However, recruiting the deeper core muscles before your superficial layers just like adding floors to a sturdy skyscraper and your back will be healthy and pain-free forever.

Why is it Important to Specially Retrain your Core Stability Muscles?

Once the core muscles become weak, and their timing is incorrect, you can experience prolonged back pain and are at much higher risk of re-occurrence. Research has identified that the order of core muscle recruitment is one of the most critical factors in the prevention or resolution of pain.  Real-Time Ultrasound Physiotherapy has proven particularly useful to correct the muscle recruitment order. To solve your back pain and to reduce your re-injury risk, you must retrain these muscles back to an appropriate level for your needs. If you are relatively sedentary, you may only need a low level of control, however, if you are a high-level sportsperson or a manual worker you will need to work up to a much higher level of core strength.

What Should You Expect?

In the initial stage, you need to be able to activate these muscles consciously and incorporate them into an exercise program. A lot of people find it difficult to isolate these muscles and need help to be able to activate them effectively. Research has discovered that real-time ultrasound-guided treatment is the most effective way to retrain an isolated and well-timed core stability contraction successfully.

More information

Pilates is available at some of our PhysioWorks clinics.
Real-Time Ultrasound Physiotherapy is available at some of our PhysioWorks clinics.
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