Working Diagnosis:
Atraumatic Pelvic Hematoma

Treatment:
The patient was completely shutdown of all activities and refraining from NSAID use for at least another 4-6 months.

Outcome:
Six months after the initial injury, a follow-up MRI demonstrates resolving pelvic hematomas Case Photo #7 and Case Photo #8 . Repeat ESR and CRP were down-trending, and Von Willebrand Ag levels normalized. He additionally had regained his weight with the return of normal bowel and bladder function. In addition, he reported significant improvement in his pain.

At 11 months after the original injury, the final MRI demonstrated resolution of previous hematomas Case Photo #9 and Case Photo #10 . He was than enrolled within physical therapy and was able to progress to return to soccer play without any symptoms.

Author's Comments:
We suspect the hematomas are associated with the initial injury four months prior in the setting of chronic ibuprofen use. The pelvic masses are unlikely to have a neoplastic process given their acute onset and rapid pelvic mass growth.

Upon literature review, there has been no association of documented cases of spontaneous atraumatic pelvic hematomas in the setting of non-steroidal anti-inflammatory medications. There is one documented case of a spontaneous psoas hematoma in a 92-year-old female with a history of previous total hip replacement on one antiplatelet agent regimen. In addition, two meta-analyses by Walker et al. and Bongiovanni et al. showed that non-steroidal anti-inflammatory agents are unlikely to cause perioperative bleeding.

Editor's Comments:
Athletic groin pain can be diagnostically challenging due the proximity of interrelated musculature and the complex biomechanics of the pubic symphysis, pelvis, and hip joint. There are multiple different terms that are associated with athletic groin pain including athletic pubalgia, Gilmore's groin, sports hernia, sports groin pain, osteitis pubis, hockey goalie syndrome, adductor tendinopathy, and many others making education on this complex topic challenging. Our patient presented with athletic pubalgia, additionally called an rectus abdominis-adductor aponeurosis injury. It is most common in men under the age of 40 and are more prevalent in sports that involve rapid directional changes, accelerations, and hyperextension or hyperabduction movements. As result there is a higher incidence in soccer, football, ice hockey, and baseball.

References:
1. Key T, Kimberley C, Rietz R, Roy SW. Spontaneous psoas haematoma secondary to antiplatelet therapy: a rare cause of atraumatic hip pain. BMJ Case Rep. 2019 Apr 8;12(4):e228973. doi: 10.1136/bcr-2018-228973. PMID: 30962214; PMCID: PMC6453338.
2. Walker NJ, Jones VM, Kratky L, Chen H, Runyan CM. Hematoma Risks of Nonsteroidal Anti-inflammatory Drugs Used in Plastic Surgery Procedures: A Systematic Review and Meta-analysis. Ann Plast Surg. 2019 Jun;82(6S Suppl 5):S437-S445. doi: 10.1097/SAP.0000000000001898. PMID: 30950877.
3. Bongiovanni T, Lancaster E, Ledesma Y, Whitaker E, Steinman MA, Allen IE, Auerbach A, Wick E. Systematic Review and Meta-Analysis of the Association Between Non-Steroidal Anti-Inflammatory Drugs and Operative Bleeding in the Perioperative Period. J Am Coll Surg. 2021 May;232(5):765-790.e1. doi: 10.1016/j.jamcollsurg.2021.01.005. Epub 2021 Jan 27. PMID: 33515678.

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