His working diagnosis was proximal psoas strain with secondary facet mediated symptoms related to altered mechanics.
Right iliopsoas trigger point injections were performed just inferior to the inguinal ligament with mild improvement, however, he was unable to return to full sports participation. Due to persistent pain over the proximal psoas region, it was determined to perform right sided proximal psoas trigger point injections at L3, L4, and L5 with a posterior approach under fluoroscopic guidance [ Photo 3 ] [ Photo 4 ]. We concurrently treated his facet mediated symptoms by performing right sided medial branch blocks at L3, L4, and L5.
After the injections, symptoms significantly improved and the patient was able to return to full sports activity. He continued to report 100% improvement of symptoms when seen in follow up 1.25 years later.
Proximal psoas muscle may be a pain generator for athletes with unexplained lower abdominal or anterior hip pain and should be included in the differential diagnosis for recalcitrant abdominal pain and anterior hip/groin pain. Additionally if conservative management fails to improve symptoms, proximal psoas trigger point injections with fluoroscopic guidance may be considered.
Keep in mind cross sectional area of muscle groups when looking at MRI.
Wan Q et al. Magnetic resonance imaging assessment of paraspinal muscles in patients with acute and chronic unilateral low back pain. Br J Radiol. 2015 Jun.
The present findings show that there is selective ipsilateral atrophy of paraspinal muscles, specific to the symptomatic side, in both acute and chronic LBP patients. The reduction of muscle cross sectional area and increased fatty infiltration occurred synchronously, and the extent of change is significantly greater in chronic LBP in erector spinae muscle.
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