Author: Vasily Rozenbaum, MD
Co Author #1: Vasily Rozenbaum
Co Author #2: Jason J. Waterman
Co Author #3: Quincy C. Wang
Senior Editor: Adam Lewno, DO

Patient Presentation:
An 18-year-old-year male high-level soccer player presented to the clinic complaining of acute left anterior pelvic pain, which started after kicking a soccer ball. The pain was reported to be a moderate achy pain localized to the left superior pubic ramus without radiation. His pain was reported to last for hours and was aggravated with kicking motions and adduction motions. He denied any previous pain in this area. He was diagnosed with a left adductor partial tear, athletic pubalgia syndrome, and a partial rectus abdominis tear confirmed on MRI. He was held from play and underwent physical therapy combined with as needed ibuprofen. He was able to return to practice after eight weeks symptom-free.

Four months later, he presented to the ED complaining of sudden onset atraumatic sharp pelvic pain and inability to ambulate. He had an uneventful practice the day prior without a chance in his practice routine. He was diagnosed with re-straining of the adductor muscle in the ED and instructed to follow up with his primary care provider. However, when he met with his primary care provider, he was noted to have developed abdominal and hip weakness, loss of appetite, 10lbs weight loss, constipation, and burning with urination. Primary care work up was notable for a urinary tract infection for which he was treated with antibiotics. However due to his pain interval MRI was obtained and he was referred to the sports medicine clinic.

History:
The patient denied any personal or family history of bleeding disorders.
He denied any surgical history.
He denied smoking, drinking, or use of recreational drugs.

Physical Exam:
Initial physical Exam:
Left Hip Exam: Skin inspection: no redness or lesions noted
Sensation: normal in both legs L1 - S1 dermatomes.
Tenderness to palpation at the left superior pubic rami and mild tenderness along the adductor tendon.
LEFT Hip Range of Motion: Flexion: 100 degrees, Internal rotation: 30 degrees, External rotation: 40 degrees.
5/5 strength with flexion, extension, abduction, and adduction.
There was pain with resisted adduction.

Physical Exam four months later:
Bilateral Hip Examination: Skin inspection: no redness or lesions noted
Sensation: normal in both legs L1 - S1 dermatomes.
Tenderness to palpation at the pubic symphysis, suprapubic region, and rectus abdominus.
RIGHT Hip Range of Motion: Flexion: 100 degrees, Internal rotation: 30 degrees, External rotation: 40 degrees. LEFT Hip Range of Motion: Flexion: 100 degrees, Internal rotation: 30 degrees, External rotation: 40 degrees.
4/5 strength with hip adduction and flexion while 5/5 strength with hip extension and abduction.
There was pain with flexion, abduction, and internal rotation (FADDIR), Left greater than Right. There was pain with internal log roll test, left side worse than the right.

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