Psoas Hematoma After Resistance Exercise in an Elderly Apixaban User: A Case Report

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Elderly Patient Develops Psoas Hematoma After Weightlifting While on Blood Thinner

A recent case report highlights the potential risks of strenuous exercise for older adults taking anticoagulant medication.

In a striking case that underscores the importance of consulting healthcare providers about exercise regimens, an 81-year-old man developed a spontaneous psoas hematoma. This occurred after he engaged in resistance training while taking apixaban,a common blood-thinning medication.

The incident, detailed in a case report, shows how seemingly routine activities can pose risks for individuals with specific medical conditions or those on certain medications. The psoas muscle, a

What are the key risk factors that increase the likelihood of a psoas hematoma in elderly patients taking apixaban?

Understanding Psoas Hematomas & Risk factors

A psoas hematoma is a collection of blood within the psoas muscle – a deep core muscle connecting the lumbar spine to the femur. While relatively rare, these hematomas can cause important morbidity, especially in elderly patients and those on anticoagulant medications. This case report details a presentation of a psoas hematoma following resistance exercise in an elderly individual taking apixaban, a direct oral anticoagulant (DOAC). Understanding the risk factors and clinical presentation is crucial for prompt diagnosis and management. Key terms related to this condition include psoas muscle injury, hip flexor hematoma, anticoagulation-related bleeding, and elderly patient complications.

The Role of Apixaban and Anticoagulation

Apixaban, a factor Xa inhibitor, is commonly prescribed for stroke prevention in atrial fibrillation and treatment of venous thromboembolism. While effective, DOACs like apixaban increase the risk of bleeding, even with minor trauma. The risk is amplified in the elderly due to age-related physiological changes, including:

Reduced muscle mass and increased frailty.

Decreased bone density, increasing fracture risk.

Impaired renal function, perhaps affecting drug clearance.

Increased prevalence of comorbidities.

This combination of factors makes elderly patients on apixaban particularly vulnerable to spontaneous psoas hematomas or hematomas developing from seemingly minor activities. DOAC-associated bleeding is a growing concern in geriatric populations.

Case Presentation: A 78-Year-Old Male

A 78-year-old male with a history of atrial fibrillation presented to the emergency department with left hip and groin pain that began 24 hours after a moderate-intensity resistance exercise session (squats and lunges) at a local gym. He was taking apixaban 5mg twice daily for stroke prevention. He denied any significant trauma or fall.

Initial examination revealed:

Significant tenderness to palpation over the left psoas muscle.

Limited range of motion in the left hip, particularly with flexion.

Ecchymosis (bruising) developing in the left groin area.

Normal coagulation studies except for his ongoing apixaban use.

Diagnostic imaging & Findings

Initial radiographs were unremarkable, ruling out hip fracture. However, due to the persistent pain and clinical suspicion, a magnetic resonance imaging (MRI) scan of the lumbar spine and hips was ordered. The MRI revealed a large hematoma within the left psoas muscle, measuring approximately 10cm x 7cm x 5cm. The hematoma was causing compression of the femoral nerve. Differential diagnoses considered included iliopsoas abscess, muscle tear, and avascular necrosis, but the MRI findings were consistent with a traumatic hematoma.

Management & Treatment Strategies

The patient’s apixaban was immediately held. management focused on supportive care:

1. Pain Management: Analgesics were administered to control pain.
2. monitoring: Close monitoring of hemoglobin levels and vital signs was initiated to detect any signs of further bleeding or hemodynamic instability.
3. Physical Therapy: Gentle range-of-motion exercises were started onc pain subsided to prevent hip stiffness.
4. Reversal Agent Consideration: While specific reversal agents for apixaban (like andexanet alfa) were considered, their availability and cost-benefit ratio were evaluated. in this case, holding the medication and supportive care were deemed sufficient.
5. Follow-up Imaging: repeat MRI scans were scheduled to monitor hematoma resolution.

Hematoma Resolution & Rehabilitation

Over the following four weeks, the patient’s pain gradually improved, and the hematoma size decreased on follow-up MRI scans. Physical therapy was progressed to include strengthening exercises, focusing on core stability and hip flexor control. Apixaban was cautiously restarted at a reduced dose after consultation with cardiology, considering the patient’s stroke risk. The patient regained near-full functional capacity within three months.

Preventing Psoas Hematomas in Elderly Apixaban Users

Preventive strategies are paramount, especially in vulnerable populations. these include:

Medication Review: Regularly review anticoagulant medications with a physician, assessing the ongoing need and risk-benefit ratio.

Exercise Modification: Encourage low-impact exercise and avoid strenuous activities, particularly those involving forceful hip flexion or extension. Safe exercise for seniors should be emphasized.

Fall Prevention: Implement fall prevention strategies, such as home safety modifications and balance training.

Patient Education: Educate patients on the signs and symptoms of bleeding, including unexplained pain, bruising, or weakness.apixaban side effects and bleeding risks should be clearly explained.

* Dialogue with Healthcare Providers: Patients should inform all healthcare providers about their apixaban use before any invasive procedures, including dental work.

The importance of