Rectus Abdominis Muscle Tear with Suprapubic Hematoma
The most likely diagnosis is a rectus abdominis muscle tear at its pubic insertion, not a quadriceps tear, given the suprapubic location of ecchymosis and swelling limited above the inguinal ligament with extension to the penile base.
Correct Anatomical Diagnosis
The clinical presentation points away from quadriceps pathology for several key reasons:
- Quadriceps muscles insert on the patella via the quadriceps tendon, not the pubic bone 1, 2
- The distribution of ecchymosis (suprapubic area limited above the inguinal ligament with penile base involvement) is classic for rectus abdominis avulsion from the pubic symphysis 3
- The "pop" sensation during a dance move followed by immediate swelling represents an acute muscle-tendon unit disruption 2, 4
Workup Algorithm
Already Completed Imaging
- CT scan has already confirmed hematoma without fracture or pubic symphysis disruption 3
- This rules out bony injury and provides adequate initial assessment 3
Additional Imaging Considerations
MRI is the gold standard for definitive characterization of muscle tears and should be obtained next 1, 2:
- Provides superior soft tissue contrast to delineate the extent of rectus abdominis disruption 1, 2
- Differentiates between partial versus complete tear 2
- Identifies the exact location of muscle-tendon disruption 1
- Ultrasound is an acceptable alternative if MRI unavailable, though operator-dependent 1, 2, 4
Urological Evaluation Required
Given penile base involvement, urethral injury must be excluded before any catheterization attempt 3:
- Perform retrograde urethrography (RUG) if any of the following are present 3:
- Blood at urethral meatus
- Inability to void
- Gross hematuria
- Suprapubic tenderness (present in this case)
- Do not attempt blind urethral catheterization without first ruling out urethral injury 5
- The pattern of hematoma extending to penile base raises concern for potential urethral involvement 3
Treatment Approach
Conservative Management (First-Line)
Most rectus abdominis tears are managed conservatively with excellent outcomes 2, 4:
Initial Phase (First 48-72 hours) - "PRICE" Protocol 2:
- Protection: Avoid activities that stress the abdominal wall
- Rest: Complete rest from athletic activities
- Ice: Apply ice to reduce swelling and pain
- Compression: Abdominal binder if tolerated
- Elevation: Not applicable to this region
Pharmacological Management 2:
- NSAIDs for pain control and inflammation reduction 2
- Avoid anticoagulants that could expand hematoma
Rehabilitation Phase (After Initial 72 hours) 2:
- Gentle range of motion exercises once pain-free 2
- Progressive strengthening after 2-3 weeks 2
- Gradual return to activity based on pain-free function 2
Surgical Indications (Rare)
Surgery is indicated only in specific circumstances 2:
- Complete muscle avulsion with significant functional deficit 2
- Expanding hematoma causing compartment syndrome (not present here) 2
- Failed conservative management after 3-6 months 2
Critical Pitfalls to Avoid
Misidentifying the injured muscle: Quadriceps do not attach to the pubic bone; this is rectus abdominis pathology 1, 2
Blind urethral catheterization: The hematoma pattern extending to penile base mandates RUG before catheter placement to avoid catastrophic urethral injury 3, 5
Premature return to activity: Muscle tears require adequate healing time (typically 6-12 weeks) to prevent re-injury 2
Missing associated injuries: While CT ruled out fracture, the mechanism (twisting during dance) could cause concomitant hip or groin pathology requiring MRI evaluation 1, 2
Expected Recovery Timeline
- Grade I (mild) tears: 2-3 weeks 2
- Grade II (moderate) tears: 4-8 weeks 2
- Grade III (complete) tears: 3-6 months, may require surgery 2
The presence of significant hematoma on CT suggests at minimum a Grade II injury 2, 4.