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Side Strain

Injuries > Upper Back & Chest > Side Strain

 

(Also known as Back Side Strain, Abdominal Side Strain, Internal Oblique Strain, Internal Oblique Tear, Torn Internal Oblique Muscle)

 

What is a side strain?

A side strain is a condition that is commonly seen in cricket fast bowlers and is characterized by a tear in one of the side abdominal muscles (known as the "internal oblique") where it attaches to the lower ribs.

The chest comprises of 12 rib bones on each side of the body. Each rib attaches to the spine at the back of the body and then travels around to the front of the chest (figure 1). The top 7 ribs attach to the sternum, the 8th to 10th ribs attach to the ribs above via cartilage and the 11th and 12th ribs are known as 'floating' ribs as they are unattached at the front of the chest.

Relevant Anatomy for a Side Strain

Figure 1 - Relevant Anatomy for a Side Strain

Numerous muscles of the abdomen, shoulder girdle and back attach to one or more ribs. The internal oblique muscle primarily attaches above, to the ribs and rib cartilages of ribs 8 to 12 and below to the pelvis (iliac crest) and strong connective tissue of the lower back (thoracolumbar fascia). It acts to side bend the trunk and rotate the trunk to the same side.

During contraction or stretch of the internal oblique, tension is placed through the muscle. When this tension is excessive due to too much repetition or high force, the internal oblique muscle can tear. This is known as a side strain. Side strains typically involve tearing of the internal oblique muscle at its rib or rib cartilage insertion on the side of the body at ribs 9, 10 or 11.

In addition to cricket fast bowlers, side strains also sometimes occur in other sports, such as javelin throwers, rowers and ice hockey players.


Cause of a side strain

A side strain can occur either suddenly (e.g. from a forceful bowl, particularly if not warmed up properly) or gradually over time from excessive or repetitive activity (e.g. overtraining). It typically occurs due to a sudden contraction of the internal oblique muscle when it is in a position of stretch (such as during the fast bowling action).


Signs and symptoms of a side strain

In cricket fast bowlers, side strains tend to occur on the non-bowling arm side of the body. Patients typically experience a sudden, sharp pain or pulling sensation in the side of the chest (in the region of the lower ribs) or abdomen during the provocative activity. Pain typically occurs suddenly (e.g. during a forceful bowl), but can also occur gradually over time (e.g. over the course of a match or training session). In minor cases, the patient may be able to continue the activity only to have an increase in symptoms upon cooling down. In more severe cases, the patient may be unable to continue the activity and will often have to cease sports participation.

Patients with this condition typically experience pain that increases with activities that place strain on the internal oblique muscle. These activities may include: bowling, throwing, heavy lifting, rowing, side sit ups, twisting, turning or side bending. It is also common for patients to experience pain or stiffness after these activities with rest, especially upon waking in the morning (or at night). Patients with this condition may also experience swelling, muscle spasm, weakness and bruising in the side abdominal region. Symptoms typically increase on firmly touching the affected region of the muscle or ribs or when performing a side stretch. In more severe cases, deep breathing, laughing, coughing or sneezing may also provoke symptoms.


Diagnosis of a side strain

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a side strain. Further investigations, such as a MRI or ultrasound, are sometimes required to confirm diagnosis, determine the severity of injury and monitor healing.


Prognosis of a side strain

With appropriate physiotherapy management, most patients with a side strain can make a full recovery (i.e. return to sport or normal activities) in a period of 4-6 weeks. In more severe cases, recovery may take longer. It is important to note that there is a high recurrence rate with this injury. Often symptoms may appear to resolve within the first couple of weeks only for bowlers to re-injury themselves upon prematurely returning to sport. It is therefore advised that patients complete a full rehabilitation program closely guided by their treating physiotherapist, and a thorough fitness test, prior to returning to sport. In rare cases, some patients with a side strain may experience ongoing or recurrent symptoms or complications which may require further management.


Treatment for a side strain

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Contributing factors to the development of a side strain

There are several factors which may contribute to the development of this condition. These need to be assessed and, where possible, corrected with direction from the treating physiotherapist. Some of these factors include:

  • inappropriate warm up
  • inappropriate or excessive training
  • inadequate recovery periods from training or activity
  • poor sporting technique (e.g. bowling technique, throwing technique)
  • bowling speed (i.e. more common in faster bowlers)
  • poor core stability
  • muscle weakness
  • poor flexibility
  • joint stiffness (particularly the upper back or lower back)
  • poor posture
  • fatigue
  • a lack of fitness or conditioning
  • inadequate rehabilitation from a previous abdominal or lower back injury

Physiotherapy for a side strain

Physiotherapy treatment for patients with this condition is vital to hasten healing, prevent injury recurrence and ensure an optimal outcome. Treatment may comprise:

  • soft tissue massage
  • joint mobilization
  • joint manipulation
  • stretches
  • electrotherapy (e.g. ultrasound)
  • ice or heat treatment
  • anti-inflammatory advice
  • dry needling
  • activity modification advice
  • technique correction
  • exercises to improve strength, flexibility, core stability and posture
  • education
  • a gradual return to activity plan

Other intervention for a side strain

Despite appropriate physiotherapy management, some patients with this condition do not improve and require other intervention to ensure an optimal outcome. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as an ultrasound, MRI, X-ray, CT scan or bone scan, extended periods of rest, or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the injury.


Exercises for a side strain

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily once the physiotherapist has indicated it is safe to do so and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.


Initial Exercises

Deep Breathing

Begin sitting or standing tall with your back and neck straight (figure 2). Breathe in as deeply as possible without increasing symptoms and then relax. Focus on breathing with your lower lungs (instead of elevating your shoulders) and allow your stomach to gently expand. Repeat 5 times.

Exercises for a Side Strain - Deep Breathing

Figure 2 Deep Breathing (in standing)

Foam Roller Stretch

Place a foam roller under your upper back as demonstrated (figure 3). Breathe normally keeping your back and neck relaxed. Hold this position for 15 90 seconds provided it is comfortable and does not cause pain. This exercise can be progressed by taking your arms overhead.

Exercises for a Side Strain - Foam Roller Stretch

Figure 3 Foam Roller Stretch

Rotation in Lying

Begin this exercise lying on your back as demonstrated (figure 4). Slowly take your knees from side to side as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch. Repeat 10 times to each side provided the exercise is pain free.

Exercises for a Side Strain - Rotation in Lying

Figure 4 Rotation in Lying

Transversus Abdominus Retraining

Slowly pull your belly button in "away from your belt line" and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony process at the front of your pelvis (figure 5). Practise holding this muscle at one third of a maximal contraction for as long as possible during everyday activity (e.g. when walking etc.) provided it is pain free. Repeat 3 times daily.

Exercises for a Side Strain - Transversus Abdominus Retraining

Figure 5 Transversus Abdominus Retraining


Intermediate Exercises

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Advanced Exercises

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Rehabilitation Protocol for a side strain

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Physiotherapy products for a side strain   Physiotherapy products for a side strain

 

Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with this condition include:

To purchase physiotherapy products for a side strain, click on one of the above links or visit the PhysioAdvisor Shop.


Find a Physio for a side strain   Find a Physio for a side strain

 

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