Working Diagnosis:
Although, the patient could still have an MSK diagnosis, ovarian tumor rose on the differential diagnosis. She was referred to gynecology.

Treatment:
During gynecology evaluation, the patient reported crampy RLQ pain with radiation to the back and down her legs over a few months. A transvaginal ultrasound detected a right septated ovarian cyst (42 x 34 x 36mm), which was normal 8 years prior. Given a possibility of malignancy, she underwent a salpingo-oophorectomy.

Outcome:
Surgical pathology showed a mature cystic teratoma without malignant potential. She subsequently had a follow-up appointment with her PCP and was doing well. She did not have further hip and back pain, and continued to work as a Pilates instructor.

Author's Comments:
Adnexal masses including teratomas present with gynecologic symptoms or are discovered incidentally on pelvic imaging. Most teratomas are benign, known as mature teratomas or dermoid cysts. Excision with histopathology confirms the diagnosis and prevents potential malignant transformation. When dermoid cysts are symptomatic, symptoms such as pelvic pain depend on the size. As demonstrated in this case, maintaining a broad differential, including non-MSK etiologies, is important for patients presenting with hip or back complaints, as the sports medicine physician may be the first point of contact for serious medical concerns.

Editor's Comments:
The differential diagnosis for adnexal masses is very broad. The gynecologic causes of adnexal masses include benign sources, such as luteal cysts, polycystic ovaries, ectopic pregnancy, and tubo-ovarian abscess. Malignant causes include endothelial carcinoma, sarcoma, and
borderline tumors. Because adnexal masses can have gastrointestinal, urinary, or metastatic sources, ovarian origin should not be assumed. An adnexal etiology can mimic musculoskeletal complaint

References:
1.Maher C. et al. Non-specific low back pain. Lancet. 2017. 389: 736-747.
2.Biggs W, Tully S. Diagnosis and Management of Adnexal Masses. American Family Physician. 2016. 93(8): 676-8.
3. Sahin H, Abdullazade S, Muzaffer S (2017) Mature cystic teratoma of the ovary: a cutting edge overview on imaging features. Insights Imaging. 2017. 8:227-241.

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