Chapter 26: The Thorax and
Abdomen
Assessment of the Thorax
Abdomen
• Injuries to this region can produce lifethreatening situations
• ATC’s evaluation should focus on signs and
symptoms that indicate potentially lifethreatening conditions
• Continually monitor breathing, circulation
and any indication of internal bleeding or
shock
• History
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What happened to cause this injury?
Was there direct contact or a direct blow?
What position were you in?
What type of pain, was it immediate or gradual,
location(s)?
Difficulty breathing?
What positions are most comfortable?
Do you feel faint, light-headed or nauseous?
Chest pain?
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Hear or feel snap, crack or pop in your chest?
Muscle spasms?
Blood or pain during urination?
Was the bladder full or empty?
How long has it been since you last ate?
Is there a personal or family history of any
heart, abdominal problems or other diseases
involving the abdomen and thorax?
• Observations
– Is the athlete breathing? Are they having difficulty
breathing? Does breathing cause pain?
– Is the athlete holding the chest wall?
– Is there symmetry of the chest during breathing?
– If the athlete’s wind was knocked out, is normal
breathing returning? How rapidly?
– Body position
• Thorax injury - leaning towards side that is injured and
splinting area w/ hand
• Abdominal injury - lie on side w/ knees pulled to chest
• Male external genitalia injury - lying on side holding
scrotum
– Check for areas of discoloration, swelling or
deformities
• Around umbilicus = intra-abdominal bleed
• Flanks = swelling outside the abdomen
– Protrusion or swelling in any portion of
abdomen (internal bleeding)
– Does the thorax appear to be symmetrical?
– Are the abdominal muscles tight and guarding?
– Is the athlete holding or splinting a particular
part?
– Blood • Bright red = lung injury
• Vomiting bright red and frothy = injury to
esophagus and stomach although blood may be
swallowed from mouth and nose
– Cyanosis - respiratory difficulty
– Pale, cool, clammy skin indicates low BP
– Monitor vital signs (pulse, respiration, BP)
• Rapid weak pulse or drop in BP is an indication of a
serious internal injury (involves blood loss)
• Palpation
– Thorax
• Check for symmetry of chest wall movement and
search for areas of tenderness
• Palpate along ribs and intercostal spaces as well as
costochondral junctions
• AP pressure to rib cage to assess for fracture
• Transverse pressure assesses costochondral junction
• Semi-reclining position is useful if athlete is having
– Abdomen
• Patient should have arms at side, knees and hips
flexed to relax abdomen
• Four abdominopelvic quadrants (move clockwise
starting from upper right quadrant)
• Feel for guarding and tenderness, rigidity (internal
bleeding)
• Rebound tenderness
• Assess each organ (if possible)
• Auscultation
– Heart Sounds
• “Lubbdupp” (may hear 3rd sound in children)
• Listen for murmur (abnormal period due to valve
insufficiency)
– Functional murmur versus pathogenic condition
The Auscultation Assistant.mht
– Breath sounds
• Should be consistent
• Abnormal patterns
– Cheyne-Stokes breathing (rate changes over 1-3 minutes)
– Biot’s breathing - normal rate followed by cessation
– Apneustic breathing - pauses in respiratory cycle at full
inspiration
– Wheeze or rhonchi or rales
• Perform over apex, centrally and at base of each
lung, both anteriorly and posteriorly
– Bowel sounds
• Liquid-like gurgling due to peristalsis
• Percussion
– Place fingers on abdomen and strike with other
hand
– Solid organ = dull sound
– Hollow organ = tympanic or resonant sound
Recognition and Management of
Specific Injuries
• Rib Contusion
– Etiology
• Blow to the rib cage can bruise ribs, musculature or
result in fracture
– Signs and Symptoms
• Painful breathing (particularly if muscles are
involved)
• Point tenderness; pain with rib compression
– Management
• RICE and NSAID’s
• Rest and decrease in activity
• Rib Fractures
– Etiology
• Caused by a direct blow or the result of a violent
muscular contraction
• Can be caused by violent coughing and sneezing
– Signs and Symptoms
• History is critically important
• Pain with inspiration, point tenderness and possible
deformity with palpation
– Management
• Refer for X-rays
• Support and rest; brace
• Costochondral Separation
– Etiology
• Result of a direct blow to the anterolateral aspect of
the rib cage
– Signs and Symptoms
• Localized pain in region of costochondral junctions
• Pain with movement; difficulty with breathing
• Point tenderness and possible deformity
– Management
• Rest and immobilization
• Healing may take 1-2 months
• Sternum Fractures
– Etiology
• Result of high impact blow to the chest
• May also cause contusion to underlying cardiac muscle
– Signs and Symptoms
• Point tenderness over the sternum
• Pain with deep inspiration and forceful expiration
• Signs of shock, or weak rapid pulse may indicate more
severe injuries
– Management
• X-ray and monitor athlete for signs of trauma to the
heart
• Muscle Injuries
– Etiology
• Muscles are subject to contusions and strains
• Occur most often from direct blows or sudden
torsion of the trunk
– Signs and Symptoms
• Pain occurs on active motions; pain with inspiration
and expiration, coughing, sneezing and laughing
– Management
• Immediate pressure and application of cold for
approximately one hour
• After hemorrhaging is controlled, immobilize the
injury to make the athlete comfortable
• Breast Injury
– Etiology
• Constant uncontrolled movement (particularly in
large breasted women)
• Stretching of Cooper’s ligament
• Runner’s and cyclist’s nipple
– Management
• Females should wear well-designed bra that has
minimum elasticity and allows for little movement
• Special plastic cup-type brassieres may be required
in sports with high levels of physical contact
• Use of an adhesive bandage can be used to prevent
runner’s nipple
• Wearing a windbreaker can prevent cyclist nipple
• Breast Cancer
– Should be of great concern to all women
– Most common cause of cancer in females
– Females over 20 years old should perform
breast self-examinations every month and
receive a clinical evaluation every 3 years
– Not all lumps are cancer -- may be benign
fibrous cyst
– Mammograms are not recommended until age
40
• Lung Injuries
– Etiology
• Pneumothorax – pleural cavity becomes filled with air, negatively
pressurizing the cavity, causing a lung to collapse
– Will produce pain, difficulty with breathing and anoxia
• Tension Pneumothorax
– Pleural sac on one side fills with air displacing lung and
heart, compressing the opposite lung
– May cause shortness of breath, chest pain, absence of
breath sounds, cyanosis, distention of neck veins, deviated
trachea
• Hemothorax
– Blood in pleural cavity causes tearing or puncturing of the
lungs or pleural tissue
– Painful breathing, dypsnea, coughing up frothy blood and
signs of shock
• Traumatic Asphyxia
– Result of a violent blow or compression of rib cage
– Causes cessation of breathing
– Signs include purple discoloration of the trunk and head,
conjunctivas of the eye
– Condition requires immediate mouth to mouth
resuscitation
– Management
• Each of these conditions are medical emergencies
and require immediate attention
• Transport athlete to hospital immediately
• Hyperventilation
– Etiology
• Rapid rate of ventilation due to anxiety induced
stress or asthma
• Develop a decreased amount of carbon dioxide
relative to oxygen
– Signs and Symptoms
• Athlete has difficulty getting air in and seems to
struggle with breathing
• Panic state with gasping and wheezing
– Management
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Decrease rate of carbon dioxide loss
Slow respiration rate and alter respiration techniques
Breath into a bag
Normal respiration should return within 1-2
minutes, initial cause must be determined
• Heart Contusion
– Etiology
• Result of compression between sternum and spine
• Most severe consequence would involve an aortic
rupture
– Signs and Symptoms
• Severe shock and heart pain
• Heart may exhibit arrhythmias causing a decrease in
cardiac output, followed by death if medical
attention is not administered
– Management
• Immediate referral to an emergency room
• Prepare to administer CPR and treat for shock
• Sudden Death Syndrome in Athletes
– Etiology
• Hypertrophic cardiomyopathy- thickening of cardiac
muscle w/ no increase in chamber size
• Anomalous origin of coronary arteries
• Marfan’s syndrome- abnormality in connective
tissue results in weakening of aorta and cardiac
vessels
• Series of additional cardiac causes
• Non-cardiac causes include drugs and alcohol,
intracranial bleeding, obstructive respiratory disease
– Signs and Symptoms
• Most do not exhibit any signs prior to death
• May exhibit chest pain, heart palpitations, syncope,
nausea, profuse sweating, shortness of breath,
malaise and/or fever
– Management/Prevention
• Counseling and screening are critical in early
identification and prevention of sudden death
• Screening questions should address the following
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History of heart murmurs
Chest pain during activity
Periods of fainting during exercise
Family history
Thickening of heart or history of Marfan’s syndrome
• Cardiac screening - electrocardiograms and
echocardiograms
• Kidney Contusion
– Etiology
• Result of an external force (force and angle dependent)
• Susceptible to injury due to normal distention of blood
– Signs and Symptoms
• May display signs of shock, nausea, vomiting, rigidity
of back muscles and hematuria (blood in urine)
• Referred pain (costovertebral angle posteriorly
radiating forward around the trunk)
– Management
• Monitor status of urine (hematuria) - refer if necessary
• 24 hour hospitalization and observation with a gradual
increase in fluid intake if an
• Surgery may be required if hemorrhaging continues
• 2 weeks of rest and close surveillance following initial
return to activity is necessary
• Kidney Stones
– Etiology
• Unknown cause
– Signs and Symptoms
• Calculus - stone composed of crystalline mineral
salts that forms in urinary tract
• Painful condition
– Management
• Usually passes through the urethra and is excreted
(very painfully)
• Contusion of Ureters, Bladder and Urethra
– Etiology
• Blunt force to the lower abdomen may avulse ureter
or contuse/rupture bladder
• Hematuria is often associated with contusion of
bladder during running (runner’s bladder)
• Injury to the urethra (more common in males) may
produce severe perineal pain and swelling
– Signs and Symptoms
• Pain, discomfort of lower abdominal region,
abdominal rigidity, nausea, vomiting, shock,
bleeding from the urethra, increased quantity of
bloody urine,
• Inability to urinate will present in case of ruptured
bladder
• Contusion of Ureters, Bladder and Urethra
– Signs and Symptoms (continued)
• Referred pain to low back and trunk as well as upper
thigh region anteriorly and suprapubically
– Prevention
• Check periodically for blood in urine
• Empty bladder prior to practice or competition
• Wear protective equipment
• Cystitis
• Inflammation of the bladder associated with a
urinary tract infection
• May involve kidney, prostate, and urethra
• Causes frequent, painful urination, chills and fever
• Antibiotics are required for treatment
• Urinary Tract Infections
• Caused by staphylococcus bacteria or chlamydia
• Causes burning and painful urination and requires
antibiotics for treatment
• Can be prevented through increased fluid intake,
practicing sanitary bowel and bladder habits,
washing genitals before intercourse, emptying the
bladder after intercourse, removal of contraceptive
diaphragms and sponges following intercourse
• Urethritis
• Inflammation of the urethra -- generally caused by
gonorrhea or by other nongonococcal organisms
• Symptoms include pain on urination along with
urethral discharge
• Treated with antibiotic therapy
• Gastrointestinal Bleeding
– Etiology
• Distance running, gastritis, iron-deficiency anemia,
ingestion of aspirin or NSAID’s, stress, bowel
irritation, colitis
– Signs and symptoms
• Blood in stool
• Abdominal pain, watery stool (w/pus) dehydration,
intermittent fever (if colitis is involved)
– Management
• Refer to physician is bleeding is occurring
• Liver Contusion
– Etiology
• Blunt trauma - right side of rib cage
• More susceptible if enlarged due to illness (hepatitis)
– Signs and Symptoms
• Hemorrhaging and shock may present
• May require immediate surgery
• Presents with referred pain in right scapula, shoulder
and substernal area and occasionally in left anterior
side of chest
– Management
• Referral to a physician for diagnosis and treatment
• Pancreatitis
– Etiology
• Inflammation of pancreas (acute or chronic) due to
obstruction of pancreatic duct
• Acute conditions may lead to necrosis, suppuration,
gangrene and hemorrhage
• Chronic cases may develop scar tissue, causing
malfunction -- may develop due to chronic alcoholism
– Signs and Symptoms
• Acute epigastric pain causing vomiting, belching,
constipation and potentially shock
• Tenderness and rigidity to palpation
• Chronic cases may result in jaundice, diarrhea and
mild to moderate pain that radiates into the back
• Pancreatitis (continued)
– Management
• In acute cases, re-hydration is necessary along with
pain reduction, treatment of shock, reduction of
pancreatic activity through medication
• Surgery if the duct is blocked
• Chronic cases require large doses of analgesics,
pancreatic enzymes and modified diet
• Indigestion (Dyspepsia)
– Etiology
• Some athletes develop food idiosyncrasies which
cause them distress after eating
• Reactions before competition
• Emotional stress, esophageal and stomach spasms,
or inflammation of mucous linings in stomach and
esophagus
– Signs and Symptoms
• Increased HCl secretion, nausea, and flatulence
– Management
• Elimination of irritating foods, development of
regular eating habits, avoidance of anxieties that
cause gastric distress
• If problems persist or athlete appears high strung
and nervous -- follow-up with a physician is needed
• Vomiting
– Etiology
• Result of some irritation, most often in the stomach
• Stimulates vomiting center of the brain, causing a
series of forceful diaphragm and abdominal
contractions to compress stomach
– Management
• Antinausea medications should be administered
• Fluids to prevent dehydration (by mouth or
intravenously depending on the situation)
• Food Poisoning (Gastroenteritis)
– Etiology
• Ranges from mild to severe
• Caused by infectious microorganisms that
contaminate food particularly during warm weather
and periods of improper refrigeration
– Signs and Symptoms
• Nausea, vomiting, cramps, diarrhea and anorexia
• Usually subsides within 3-6 hours (staph. infection)
• Salmonella infection may last 24-48 hours or more
– Management
• Rapid replacement of fluids lost
• Bed rest in all but mild cases
• Nothing should be given by mouth if vomiting and
nausea persist
• Re-introduce easy food first
• Peptic Ulcer
– Etiology
• Acids destroy mucous lining of stomach or small
intestine
• Occurs in individuals with long periods of severe
anxiety
– Signs and Symptoms
• Gnawing pain, localized to gastric region
• Appears 1-3 hours following a meal
• Dyspepsia, heartburn, nausea, vomiting, w/ pain
lasting minutes rather than hours
– Management
• Antacids if pain persists
• If hemorrhaging or perforation occurs, surgery may
be required
• Gastroesophageal Reflux
– Etiology
• Reflux or backward flow of the acidic gastric
contents into the esophagus (malfunctioning
esophageal sphincter)
• Result of a hiatal hernia w/ incidence increased with
activity
• Repeated bouts can result in inflammation of lower
esophagus
– Signs and Symptoms
• Heartburn-like retrosternal pain - similar to angina
pectoris sensation
• Burning feeling with sour liquid taste in throat
– Management
• Medication first, surgery if condition persists
• Diarrhea
– Etiology
• Abnormal, loose stool or passage of fluid, unformed
stool
• Acute or chronic
• Caused by a problem in diet, inflammation of the
intestinal lining, GI infection, ingestion of certain
drugs and psychogenic factors
– Signs and Symptoms
• Abdominal cramps, nausea, vomiting and frequent
elimination of stools
• Loss of appetite, and a light brown or gray, foulsmelling stool
• Extreme weakness caused by dehydration
• Diarrhea (continued)
– Management
• Determine cause (irritant, infection, or emotional
upset)
• ATC can treat less severe cases by omitting certain
foods from athlete’s diet
• Have athlete consume bland food that does not
irritate system
• Provide pectins 2-3 times daily to absorb excess
fluid
• Constipation
– Etiology
• Failure of the bowels to evacuate feces
• Causes include, lack of abdominal tone, insufficient
moisture in the feces, lack of roughage and bulk in
diet to stimulate peristalsis, poor bowel habits,
nervousness, anxiety, and overuse of laxatives and
enemas
– Signs and Symptoms
• Feeling of fullness, with occasional cramping and
pain in lower abdomen
• If straining occurs during defecation, blood vessels
may be ruptured
– Management
• Regulate eating patterns (cereal, fruits, vegetables)
• Deal with psychological aspects
• Avoid medications unless prescribed by a physician
• Irritable Bowel Syndrome
– Etiology
• Group of gastrointestinal tract disorders
– Signs and Symptoms
• Abdominal pain that is relieved with defecation,
irregular pattern of defecation (at least 25% of the
time), alterations in stool frequency, form, and
passage, abdominal bloating and distension
– Management
• Refer to physician for long-term management
• Diet modification and antidiarrheal medications may
be helpful initially as well as psychological
counseling
• Long term prognosis -- good
• Appendicitis
– Etiology
• Inflammation of the vermiform appendix (chronic or
acute)
• Result of blockage, lymph swelling, or carcinoid tumor
• Early stages it presents as a gastric complaint, that
gradually develops from red swollen vessel to a
gangrenous structure that can rupture into bowels
causing peritonitis
– Signs and Symptoms
• Mild to severe pain in lower abdomen, associated with
nausea, vomiting and low grade fever
• Pain may localize in lower right abdomen (McBurney’s
point)
– Management
• Surgical intervention is often necessary (particularly if
it is resulting in an obstructed bowel = life threatening)
• Hemorrhoids (Piles)
– Etiology
• Varicosities of the hemorrhoidal venous plexus of
the anus
• Constant straining or constipation may result in
stretching of anal vessels, protrusion and bleeding,
or a thrombus forming in the external vessels
– Signs and Symptoms
• Painful nodular swellings near the anal sphincter
• May cause slight bleeding and itching
– Management
• Use of proper bowel habits, ingestion of mineral oil
daily to assist in lubricating a dry stool, application
of suppository and anesthetic (for pain and itching)
• Surgery may be required if these measures fail
• Scrotal Contusion
– Etiology
• Result of blunt trauma and contusion to the
vulnerable and sensitive scrotum
– Signs and Symptoms
• Hemorrhaging, fluid effusion, muscle spasm, severe
pain (disabling)
--Management
•Reduction of
testicular spasm
Application of cold
pack
•Unresolved pain
after 15-20 minutes
requires referral to
a physician
• Spermatic Cord Torsion
– Etiology
• Result of testicle revolving in the scrotum following a
direct blow or as the result of coughing or vomiting
– Signs and Symptoms
• Acute testicular pain, nausea, vomiting and
inflammation in the area
– Management
• Immediate medical care is required to prevent
irreparable complications
• Traumatic Hydrocele of the Tunica
Vaginalis
– Etiology
• Fluid accumulation caused by a severe blow to the
testicular region (venous plexus on the posterior
aspect of the testicle becomes engorged)
• Rupture of the plexus results in rapid accumulation
of blood in the scrotum (hematocele)
– Signs and Symptoms
• Pain and significant swelling in the scrotum
– Management
• Cold pack application and referral to a physician
• Vaginitis
– Etiology
• Inflammation of the vagina can be caused by a
variety of microorganisms, bacterial infections,
chemicals from douching, irritation from a tampon
or poor hygiene habits
– Signs and Symptoms
• Purulent and bloody vaginal discharge; strong odor
with vaginal itching
• Frequent and painful urination
• Vagina is red and painful to the touch
– Management
• Vaginitis caused by an STD will require appropriate
antibiotic or antifungal medication
• Instruction on proper bladder and bowel hygiene as
well as sexual behavior may also be necessary
• Contusion of the Female Genitalia
– Etiology
• Low incidence of injury in sports
• Most common occurrence involve contusion of
external genitalia (vulva - including the labia,
clitoris and the vaginal vestibule)
– Signs and Symptoms
• Hematoma results from contusion - may also
involve pubic symphysis resulting in osteitis pubis
• Injury of the Spleen
– Etiology
• Result of a direct blow, infectious mononucleosis
(causing an enlarged spleen)
– Signs and Symptoms
• Indications of a ruptured spleen involve history of a
direct blow, signs of shock, abdominal rigidity,
nausea, vomiting
• Kehr’s sign
– Management
• Ability to splint self may produce delayed
hemorrhaging - easily disrupted resulting in internal
bleeding
• Conservative treatment involves 1 wk of
hospitalization and a gradual return to activity
• Surgery will result in three months of recovery
while removal of spleen will result in a 6 month
removal from activity
• Abdominal Muscle Strain
– Etiology
• Result of sudden twisting or reaching of trunk,
tearing abdominal musculature
– Signs and Symptoms
• Severe pain and hematoma formation
• Generally involves rectus abdominus
– Management
• Ice and compression with conservative treatment
• Exercise within pain free limits
• Contusions of Abdominal Wall
– Etiology
• Caused by a compressive force - generally occurring in
collision sports
• Extent of injury depends on whether force is blunt or
penetrating
– Signs and Symptoms
• May cause a hematoma to develop under fascia of
surrounding muscle tissue
• Swelling may cause pain and tightness w/in the region
– Management
• Cold pack and compression
• Be sure to check for signs of internal injuries
• Hernia
– Etiology
• Protrusion of abdominal viscera through portion of
abdominal wall (congenital or acquired)
• Inguinal vs. femoral hernias
• Complications and strangulated hernias
– Signs and Symptoms
• Acquired hernia occur when natural weakness is
further aggravated by a direct blow or strain
– History of direct blow to groin area, pain and prolonged
discomfort, superficial protrusion with pain increasing
with coughing & reported pulling sensation in groin area
– Management
• Surgery is preferred by most physicians
• Mechanical devices are not suitable for athletics due
to friction and irritation they produce
• Blow to Solar Plexus
– Etiology
• Transitory paralysis of the diaphragm
– Signs and Symptoms
• Stops respiration and leads to anoxia
• Generally transitory
– Management
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Must help athlete overcome apprehension
Use short inspirations and long expirations
Calm athlete, prevent hyperventilation
ATC should question possibility of internal injury
• Stitch in the Side
– Etiology
• Idiopathic condition with obscure cause and several
hypotheses
– Constipation, intestinal gas, overeating, diaphragmatic
spasm, poor conditioning, lack of visceral support and
weak abdominals, distended spleen, breathing techniques
resulting in lack of oxygen, ischemia of diaphragm or
intercostal muscles
– Signs and Symptoms
• Cramp-like pain that develops on either the right or
left costal angle during hard physical activity
– Management
• Relaxation of the spasm
– Stretch arm on affected side as high as possible
– Flex trunk forward on the thighs
• Additional problems may warrant further study