GROIN PAIN - SOCCER

Abstract

HISTORY:A 20 yo collegiate female soccer player presented with two weeks of insidious onset left groin pain. Pain was achy, without radiation, and intermittent. Pain with cutting and lateral ball dribbling/drills. No additional symptoms. She had decreased activity for a year due to the pandemic. Prior to preseason, she independently began a vigorous training program with hours of daily activity. She lost twenty pounds in two months and consuming about 1800 calories daily. Menses remained regular on oral contraceptives. PHYSICAL EXAMINATION: Inspection: Normal. Palpation: Nontender at all bony prominences and muscles of pelvis, hip, and lumbar spine. ROM: Full. Strength: Normal. Left groin pain with hip adduction and flexion. Neuro: Normal. Hip: Log roll, FABER, FADIR, Ober, Thomas, Ely’s, Scour all normal. Sacroiliac: normal including figure four, compression and thigh thrust. Lumbar : normal with negative straight leg raise. Single leg hop was nonpainful and nonantalgic gait with normal proprioception. DIFFERENTIAL DIAGNOSIS:1. Adductor Strain or Psoas Strain2. Pubic Rami Avulsion Fracture3. Sacral Ala Stress Fracture4. Femoral neck stress fracture5. Labral tear TEST AND RESULTS: AP Pelvis Xray: Sacroiliac joints, sacrum, lumbar spine, pelvis, and bilateral hips normal alignment without fracture. She completed one month of physical therapy with improvement initially, however, her pain then progressed to bilateral groin pain. MRI pelvis: symmetric transverse bilateral inferior pubic rami fractures. Nondisplaced with normal alignment. FINAL WORKING DIAGNOSIS:1)Bilateral Inferior Pubic Rami Transverse Stress Fractures2)Relative Energy Deficiency Syndrome TREATMENT AND OUTCOMES: Physical therapy and soccer were discontinued. Crutches provided. Calcium and vitamin D supplementation recommended. CBC, CMP, PTH, TSH, Ferritin, Vitamin D testing indicated iron deficiency anemia. Bone Density testing: normal. Referred to sports dietician•Repeat Pelvic AP xrays indicated interval progression of her stress fractures bilaterally, now radiographically present with evidence of callus formation at bilateral inferior pubic rami. No displacement. Plan: Slowly progress activity as tolerated over several months with repeat exam, lab work, and xrays to ensure healing and resolution.