Disclosures: Matthew A. Cascio, DO: No financial relationships or conflicts of interest

Case Diagnosis: Femoral neuropathy secondary to iliacus/iliopsoas hematoma

Case Description or Program Description: A 66-year-old Hispanic male presented to PM&R clinic with left leg weakness and left anterior thigh numbness. His symptoms began during a recent hospitalization for COVID-19 pneumonia, during which he developed left thigh pain, swelling, and weakness while on warfarin for a DVT. CT revealed a 6.5 cm by 3.0 cm by 7.4 cm intramuscular hematoma of the left iliacus/iliopsoas. PM&R and physical therapy evaluated him while inpatient. While he was previously independent in ambulation, he was discharged home with a walker.

Setting: Tertiary-care teaching hospital

Assessment/Results: Upon follow up in PM&R clinic, he ambulated with a rolling walker with frequent falls, noting difficulty with activities of daily living. Physical exam demonstrated 1/5 left hip flexion and knee extension strength, without left thigh light touch sensation. EMG demonstrated acute denervation of the left quadriceps muscle with no MUAP recruitment on activation, suggestive of an axonal femoral neuropathy. He began outpatient physical therapy, with improvement in ambulation and ADLs. Five months post hematoma, he continues to ambulate with a rolling walker, however with no further falls.

Discussion (relevance): The femoral nerve originates from the posterior division of L2-L4 and runs between the psoas tendon and iliacus muscle under the inguinal ligament. Femoral nerve compression occurs along the iliopsoas gutter, where it is at highest ischemia risk due to poor vascular supply. Iliacus hematoma occurs most commonly in patients with hemophilia and those receiving anticoagulation. Treatment is typically conservative; however, embolization may be indicated with active bleeding. In cases of femoral neuropathy, early iliacus muscle fasciotomy with or without hematoma evacuation may be considered.

Conclusions: Our patient’s femoral neuropathy was managed conservatively with physical therapy, and he experienced improvements in strength, ambulation, and function. Femoral neuropathy should be considered in patients with weakness following thigh intramuscular hematoma.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-case-of-femoral-neuropathy-secondary-to-iliacus-iliopsoas-hematoma-in-the-setting-of-covid-19-pneumonia/