Working Diagnosis:
Iliacus tear with resulting hematoma and compressive femoral neuropathy

Treatment:
After MRI established the diagnosis, conservative treatment with NSAIDs and physical therapy was initiated. Surgical decompression of the hematoma surrounding the femoral nerve was discussed, however given the small size of the hematoma and the likelihood that it would self-resolve, the decision was made to treat conservatively.

Outcome:
The patient showed improvement in pain and mobility with physical therapy. MRI two months later showed minimal residual edema in the musculature of the right pelvis and complete resolution of the compressive hematoma. Ultimately the patient did not return to cheerleading however did regain near full mobility of the hip and resolution of pain following a year of physical therapy.

Author's Comments:
Due to the anatomical location of the femoral nerve within the pelvis and anterior thigh, compression is relatively uncommon. Most injuries to the femoral nerve are the result of traumatic hip or pelvic fractures or surgical procedures involving the hip or upper thigh. Masses, including hematomas, within the iliacus muscle can be a cause of compression, due to the course of the femoral nerve between the iliacus and psoas muscles. Significant injury of the femoral nerve can lead to weakness and sensory loss. Management is typically supportive with physical therapy however surgical intervention and decompression is required in cases where a large compressive mass is present.

Editor's Comments:
Uncommon outcome of a rather common injury for a gymnast or cheerleader. Keeping the anatomy of the affected area in mind, a focused exam followed by confirmatory imaging can lead to the diagnosis quickly. Of then physical therapy and cryotherapy can help resolve the issue rather quickly. A surgical intervention is rarely necessary and can pose further complications itself.

References:
Andreani L, Nucci AM, Giuntoli M, Lisanti M. Compressive Femoral Neuropathy Associated with Iliopsoas Hematoma Complicating Hip Hemiarthroplasty: A Case Report. J Orthop Case Rep. 2017;7(5):3-6. doi:10.13107/jocr.2250-0685.872.

Moore AE, Stringer MD. Iatrogenic femoral nerve injury: a systematic review. Surg Radiol Anat. 2011 Oct;33(8):649-58. doi: 10.1007/s00276-011-0791-0. Epub 2011 Feb 17. PMID: 21328076.

Rutkove SB. Overview of lower extremity peripheral nerve syndromes. In: Post T, ed. UpToDate. UpToDate; 2020. www.uptodate.com. Accessed September 10, 2020.

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