What is it?

Spleen injuries in athletes are rare, but potentially life-threatening if missed. It is therefore important to always keep this diagnosis in mind when evaluating athletes after an abdominal injury. Common mechanisms of injury include tackling in football, checking in hockey, falling off a horse, and hitting bicycle handlebars. Spleen injuries are typically associated with athletes who have a recent diagnosis of Infectious Mononucleosis (IM), but can occur in any athlete.

Splenomegaly is found in 50-60% of patients with IM, and splenic rupture occurs in approximately 1-2 in 1000 of these patients. This rare complication typically occurs around day 14 of illness, but has been documented up to 8 weeks after diagnosis. Seventy percent of splenic ruptures in patients with IM are males under 30 years old.

Evaluation & Treatment

Stable Patient:

When presenting with a possible spleen injury, your sports medicine physician will first check your vital signs (blood pressure and heart rate in particular). If you are deemed stable, a good history will be obtained to include how the injury occurred. A complete exam will be performed with focus on your abdomen and ribcage. Labs may be required such as hemoglobin/hematocrit, blood type, liver function tests, or amylase/lipase to rule out other organ involvement. Your physician may order a CT scan to further evaluate the spleen injury. Over 90% of children and 50-70% of adults can be treated non-operatively with temporary rest and restricted activity.

Unstable Patient:

If vital signs are concerning for a low blood pressure and/or a fast heart rate, you will be promptly transferred to the closest Emergency Department (ED) for evaluation and stabilization, as these are signs of a splenic rupture. A focused bedside ultrasound may be required to evaluate for spleen laceration. If clinically indicated, the patient may receive intravenous fluids. Approximately 5% of cases will require a blood transfusion. Surgery or angiographic embolization may be required to stabilize the patient depending on injury severity.

Symptoms/Risks

Signs/symptoms of a spleen injury include pain over the left upper abdomen, left sided rib pain, referred pain to the left shoulder, bruising over the abdominal wall, abdominal wall distention, low blood pressure, delayed capillary refill, pallor, and/or an elevated heart rate.

Some risks that increase the chance of splenic injury include a current or recent diagnosis of IM, participation in contact sports, mountain climbing, skiing, bicycles without handlebar padding, weightlifting (Valsalva), and an improperly tacked horse (saddle, stirrups, etc.).

Injury Prevention

Prevention is key with splenic injuries. In children, pad-less handlebars have been linked to increased rates of abdominal blunt trauma so it is important to ensure children have some sort of padding on their bikes. In equestrian events, it is important to check the tack prior to riding because this has also been linked to abdominal blunt trauma. Finally, if you have a recent diagnosis of IM, avoid high risk activity for at least the first 21 days of illness and in accordance with medical advice.

Return to Play

After a spleen injury, athletes may participate in light activity for 3 months prior to gradually increasing activity intensity. It is important to avoid contact sports during this healing time.

Return to play is a collaborative decision that is individualized to the patient. After an IM infection the literature suggests that athletes in non-contact sports can return to play in 21 days, while athletes in contact sports can return to play in 30 days. This recommendation assumes that the athlete is afebrile, asymptomatic, doesn’t have a palpable spleen on exam, and did not incur a splenic injury already. Some physicians may do serial ultrasounds and/or a repeat CT scan to ensure the spleen has recovered prior to clearing an athlete to participate in sports.

AMSSM Member Authors
Alex P. Houser, DO, Shane L. Larson, MD

References
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