Working Diagnosis:
It was determined that as the patient was performing squats, the weight of the bar was heavy enough to cause the necessary shearing force to separate the subcutaneous and deep fascial layers causing Morel Lavallee lesion Case Photo #1 .

Treatment:
The patient and physician opted to proceed with conservative therapy. The was treated with ibuprofen 800 mg every 8 hours as needed. Alternating heat and ice therapy were added. The patient was also treated with osteopathic manipulative treatment targeting an increase in lymphatic drainage weekly. The patient was told to refrain from any weight training exercises that place load over the area or over utilize the muscles underlying the region for a period of at least two weeks.

Outcome:
The patient's symptoms resolved over a period of three weeks and he has returned to powerlifting without any complications. The only remaining side effect noted is that the area no longer has any hair growth.

Author's Comments:
Morel-Lavallee lesions, also known as closed degloving injuries, result from a shear force that separates the skin and subcutaneous tissue from the underlying fascia, which creates a potential space where complex serosanguinous fluid, often containing blood, lymph, and necrotic fat, collects. These lesions are quite rare and usually only occur as a result of trauma with sliding on an object for example across pavement or turf. Examples include bicycle and motorcycle wrecks, motor vehicle ejection accidents, or occasionally with athletic injuries. The hip and proximal thigh, overlying the greater trochanter, are the most common sites of injury and also occur at or around the buttocks, low back and knee. These lesions can be easily missed and should be actively looked for with a high level of suspicion in any instance of pelvic trauma.

MRI is currently the diagnostic option of choice; however, ultrasound is a great, inexpensive, alternative modality commonly used for diagnosis. Ultrasound is highly dependent upon the operator, which can lead to variability. The imaging appearance can be variable but often has heterogeneous echogenicity due to the many components of the fluid. It may be difficult to differentiate between Morel Lavellee lesions, seromas, bursitis, hematomas, lymphoceles, and neoplasms.

Treatment options are dependent on the acuity, size, and severity of the injury and range from conservative to surgical. Injuries that are acute and mild severity are often treated conservatively with compression bandages, ice, and NSAIDs. Larger acute lesions or small chronic lesions can be treated with doxycycline sclerotherapy. Large chronic lesions may require surgical intervention with open drainage and mass resection with possible quilting sutures, fibrin glue, or low suction drains. Serial drainages may also be required as fluid may reaccumulate.

In this case, it would have been ideal to have serial ultrasound imaging to certify resolution, but the effects of COVID-19 on clinic appointments precluded it.

Editor's Comments:
Morel Lavallee lesions occur when a shear force separates the subcutaneous tissue from the fascia plane creating a space where lymphatics collect. The lesion can be frequently missed, so a high level of suspicion is needed to make the diagnosis. Common mechanisms are a bike crash with the person sliding on the pavement on their side, motor bike accident, person thrown from vehicle. They most commonly occur on the lateral hip. They can also be seen on the knee area. Ultrasound is a great inexpensive modality to diagnose it. Diagnosis can also be made on MRI.
Treatment acutely usually consists of compression and ice. If the lesion is large, US diagnostic drainage can be performed followed by compression and ice. Serial drainages can be required as fluid may reaccumulate. Chronic lesions or lesions that continue to reaccumulate can be treated with doxycycline sclerotherapy. If it is a large lesion with over 200 cc of fluid then surgery may be required.
In this case, it would have been nice to have serial ultrasound imaging to certify resolution but COVID19 affects on clinic appointments precluded it.

References:
1. Bonilla-Yoon, Iris, et al. "The Morel-Lavallee lesion: Pathophysiology, Clinical Presentation, Imaging Features, and Treatment Options". Emergency Radiology, 16 Aug. 2013, pp. 35-43.
2. Nickerson, Terry P., et al. "The Mayo Clinic experience with Morel-Lavallee lesions". Journal of Trauma and Acute Care Surgery, vol. 76, no. 2, 2014, pp. 493-497., doi:10.1097/ta.00000000000000111.
3. Patel, Maulik S. "Morel-Lavallee lesion". Radiopaedia, 2015, radiopaedia.org/cases/morel-lavallee-lesion-5?lang=us.

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