What could be causing left-sided abdominal pain that occurs when bending down after playing hockey?

Left-Sided Abdominal Pain After Hockey with Bending

This presentation most likely represents either exercise-induced gastrointestinal syndrome (EIGS) from mechanical stress and splanchnic hypoperfusion during hockey, or a sports hernia/athletic pubalgia involving the external oblique aponeurosis and ilioinguinal nerve—both common in hockey players and exacerbated by bending movements.

Primary Differential Considerations

Exercise-Induced Gastrointestinal Syndrome (EIGS)

• Mechanical causes of gastrointestinal problems are related to impact and posture, with symptoms triggered by the repetitive high-impact mechanics and forward-flexed positioning common in hockey 1
• Exercise results in splanchnic hypoperfusion (up to 80% reduction in blood flow during maximal exercise), leading to gut ischemia and abdominal pain that can persist after activity 1
• The bending position increases intra-abdominal pressure on the gastrointestinal tract, similar to the "aero" position in cycling that causes upper gastrointestinal symptoms 1
• Pain from EIGS is typically diffuse or cramping in nature and may be accompanied by nausea, bloating, or urgency 1

Hockey Groin Syndrome/Sports Hernia

• "Hockey groin syndrome" is highly prevalent in NHL players, with cumulative incidence increasing from 12.99 to 19.87 injuries per 100 players per year over a 6-year period 2
• The pathophysiology involves tearing of the external oblique aponeurosis with entrapment of the ilioinguinal nerve, causing debilitating groin and lower abdominal pain 3
• Pain is characteristically exacerbated by movements that stress the abdominal wall, including bending, twisting, and skating motions specific to hockey 3, 4
• Over 90% of these injuries occur through non-contact mechanisms during play, making them consistent with the described scenario 2

Critical Assessment Approach

History Elements to Clarify

• Precise pain location: Lower abdominal/groin region suggests sports hernia; mid-to-upper left abdomen suggests EIGS 1, 2
• Pain character: Sharp, stabbing pain with specific movements favors musculoskeletal/sports hernia; cramping, diffuse pain favors EIGS 3, 5
• Associated symptoms: Gastrointestinal symptoms (nausea, bloating, urgency) point to EIGS; isolated pain without GI symptoms suggests sports hernia 1
• Timing: Pain during/immediately after exercise suggests EIGS; pain persisting hours later or with daily activities suggests structural injury 1, 2

Physical Examination Priorities

• Palpation of the external oblique aponeurosis and inguinal region for tenderness or defects 3
• Resisted sit-up or abdominal crunch to reproduce pain (positive in sports hernia) 4
• Assessment for peritoneal signs to exclude acute surgical abdomen 6, 5
• Evaluation during hip flexion and adduction movements that stress the groin musculature 2, 3

Imaging Recommendations

CT abdomen and pelvis with IV contrast is the most useful initial imaging study for left-sided abdominal pain when structural pathology is suspected 1. However:

• For suspected sports hernia, MRI of the pelvis may be more sensitive for detecting tears in the external oblique aponeurosis and musculotendinous injuries 1
• For suspected EIGS, imaging is typically not indicated unless red flags are present (fever, peritoneal signs, severe unremitting pain) 1
• Ultrasonography can identify sports hernias but is operator-dependent and less commonly used in the United States 1

Management Algorithm

If Sports Hernia/Hockey Groin Syndrome is Suspected:

1. Initial conservative management for 6-8 weeks emphasizing intrinsic core control and stability with progressive peripheral demand challenges 4
2. Structured rehabilitation should focus on core muscular deficits before considering surgical intervention 4
3. Surgical exploration (ilioinguinal nerve ablation and external oblique reinforcement) achieves 82% pain-free outcomes and 85% return to NHL play when conservative treatment fails 3
4. Mean time loss is approximately 10.59 sessions for abdominal injuries versus 6.59 for isolated groin injuries 2

If EIGS is Suspected:

1. Macronutrient intake optimization: Ensure adequate carbohydrate and protein intake before and during exercise with maintenance of euhydration 1
2. Dietary FODMAP manipulation has shown consistent beneficial outcomes for gastrointestinal functional issues 1
3. Gut training with feeding tolerance adjustments to improve gastrointestinal adaptation to exercise stress 1
4. Heat mitigation strategies show promising but require further exploration 1
5. Avoid low-carbohydrate high-fat diets and unnecessary probiotic supplementation, which have shown negative outcomes 1

Critical Red Flags Requiring Urgent Evaluation

• Signs of complicated diverticulitis: Fever, systemic inflammatory response, immunosuppression (though less likely in young athletes) 1
• Peritoneal signs: Guarding, rebound tenderness, rigid abdomen suggesting perforation or acute surgical abdomen 6, 5
• Vascular compromise: Severe pain out of proportion to examination suggesting mesenteric ischemia 1
• Progressive symptoms: Worsening pain, inability to bear weight, or systemic symptoms 6

Common Pitfalls to Avoid

• Dismissing sports hernia because no palpable hernia is present—the pathology involves aponeurotic tears, not true hernias 3
• Assuming all exercise-related abdominal pain is benign EIGS—23.5% of groin/abdominal injuries in NHL players are recurrent, suggesting underlying structural pathology 2
• Ordering inappropriate imaging: Radiography has limited utility; CT is preferred for acute assessment when structural pathology is suspected 1
• Premature surgical referral for sports hernia without adequate trial of structured conservative management emphasizing core stability 4