Groin Pain - Weightlifter

Abstract

HISTORY: A 25 y.o. male weightlifter presented for progressive R groin pain over the past 4 months. He describes gradual onset of intermittent sharp pain located over the anterior groin with radiation down the anterior thigh to the knee. Associated with numbness/tingling in the same distribution and swelling in the R groin. The pain and numbness recently began radiating to the R low back and waking him up at night. Symptoms are aggravated by prolonged standing, sitting, squatting and lifting. He denies focal weakness, change in bowel/bladder function, fevers, chills, night sweats or weight loss. PHYSICAL EXAMINATION: Gait: Normal. Inspection: Unremarkable. Palpation: TTP in the RLQ and groin with fullness. ROM: Full and symmetrical. Strength: Painful 5/5 hip flexion, abduction and adduction. Positive Thomas test. Negative femoral log roll, FADIR, FABER, Trendelenberg. Negative SLR. Neuro: Decreased sensation to light touch over anterior thigh. 2+ patellar and achilles DTR. Intact heel/toe walk. Vascular: DP pulses 2 + . DIFFERENTIAL DIAGNOSIS: 1. Lumbar radiculopathy 2. Meralgia paresthetica 3. Hip flexor/iliopsoas strain 4. Athletic pubalgia 5. Pelvic mass TEST AND RESULTS: XR: Unremarkable. US GROIN: Benign b/l lymphadenopathy w/o hernia or suspicious findings. MR L-SPINE: Unremarkable L-spine. Partially-imaged large R retroperitoneal lesion. CT ABD/PELVIS W CONTRAST: Heterogeneous mass arising from the R psoas muscle (8.5 x 6.4 x 7.5 cm) with calcifications at the inferior aspect. The mass displaces and compresses the R common iliac a/v and encases the R external iliac a/v. CT CHEST WO CONTRAST: No evidence of intrathoracic metastatic disease. FINAL WORKING DIAGNOSIS: Right retroperitoneal pelvic sarcoma with involvement of right external iliac artery and vein TREATMENT AND OUTCOMES: Core needle biopsy showed a low grade spindle cell myofibroblastic neoplasm. Given the lesion’s aggressive appearance, however, this likely represented a sampling of reactive tissue adjacent to an unsampled high grade sarcoma. He underwent radical resection of retroperitoneal pelvic mass with segmental resection and anastomosis of the R external iliac artery and vein, extensive ureterolysis of R ureter and neurolysis of R femoral and obturator nerve. Pathology results are pending and will guide further multimodality treatment.