Comprehensive Sports Medicine Narrative

Chief Complaint

Right lower quadrant and right groin pain exacerbated by running, alongside exercise-induced gastrointestinal distress.

History of Illness

Marcus Vance (34M, MRN: 492-810-44) presents for evaluation of right groin and lower abdominal pain that began on 02/03/2025 while training for a marathon. Marcus reports feeling a "sharp pull deep in my lower belly" during a sprint interval at 16:30 PST. Since the onset, the pain has persisted as a dull ache rated 4/10 at rest, escalating to 7/10 sharp pain with high-impact training, coughing, or sit-ups. He also notes concurrent post-exertional bloating and loose stools, which he initially attributed to his sports nutrition gels. He evaluated with a primary care sports medicine physician on 10/03/2025, who recommended physical therapy for a suspected adductor strain and advised avoiding NSAIDs due to his history of reflux. Three weeks of targeted adductor rehab yielded minimal relief. He currently manages the pain with paracetamol (acetaminophen, Tylenol®) 1,000 mg PO Q8H PRN and local ice application, which provides temporary mild relief. Rest and supine positioning also alleviate the discomfort. He explicitly denies hematochezia, melena, fever, chills, testicular radiation, or urinary tract symptoms. On his intake forms, Marcus documented a Severe Effect on his ability to perform heavy lifting and running, and a Moderate Effect on bending over to tie his shoes and transitioning from supine to sitting.

Summary

Current Condition/Complaint

• Right lower quadrant and inguinal pain radiating slightly to the proximal adductor insertion, accompanied by exercise-induced diarrhea.
• Onset: 02/03/2025.
• Mechanism: Acute onset during high-intensity sprint intervals while marathon training.
• Prior interventions: 3 weeks of outpatient physical therapy focusing on hip adductor strengthening, with minimal improvement.
• Progression/Character: Stationary course; dull ache at rest (4/10) progressing to sharp, stabbing pain (7/10) with Valsalva and core engagement.
• Negative symptoms: Denies hematochezia, melena, fever, weight loss, testicular pain, or dysuria.
• ADL Impact: Severe Effect on running and heavy lifting (> 10 kg); Moderate Effect on donning footwear and sit-to-stand transitions.

Medical History

• Gastroesophageal reflux disease (GERD), irritable bowel syndrome with diarrhea (IBS-D).
• Laparoscopic appendectomy (14/08/2015).
• Allergies: Penicillin (urticaria).
• Omeprazole (Prilosec®) 20 mg PO QD; paracetamol (acetaminophen, Tylenol®) 1,000 mg PO Q8H PRN; dicycloverine (dicyclomine, Bentyl®) 10 mg PO TID PRN.
• Competitive amateur marathon runner (60 km/week prior to injury); non-smoker; consumes 2 units of alcohol per week; works as a software engineer.
• Father with Crohn's disease; mother with hypertension.
• Previous treatments: Physical therapy (adductor protocol), cryotherapy, oral analgesics.
• Omeprazole (Prilosec®) 20 mg PO QD; paracetamol (acetaminophen, Tylenol®) 1,000 mg PO Q8H PRN; dicycloverine (dicyclomine, Bentyl®) 10 mg PO TID PRN.
• MRI Pelvis (athletic pubalgia protocol) on 18/03/2025: Mild bone marrow edema at the right pubic tubercle and microtearing of the right rectus abdominis-adductor longus aponeurosis. No true inguinal hernia or bowel loop protrusion identified. Small bowel loops visualized in the pelvis appear unremarkable without wall thickening.

Subjective

• Patient presents today seeking clearance to resume marathon training and management of concurrent GI symptoms and right lower quadrant/groin pain. Reports frustration with lack of progress in standard PT.
• Baseline high activity level (endurance runner), currently limited to swimming and stationary cycling without resistance. Works a sedentary desk job, which does not aggravate symptoms unless sitting for > 2 hours.
• Goal is to complete the autumn marathon pain-free and resolve runner's diarrhea. Previous adductor-focused PT aggravated the lower abdominal component.
• Wife present at visit; corroborates that patient wakes up at night when rolling over in bed due to sharp lower abdominal pain.

Examination

Vitals (10:15 PST): BP 118/72 mmHg, HR 54 bpm, Temp 36.7 °C, Wt 74.5 kg, BMI 22.1 kg/m². General: Well-developed, fit male in NAD. Abdomen: Soft, non-distended. Well-healed laparoscopic scars. Normoactive bowel sounds. No rebound or guarding. No palpable masses or hepatosplenomegaly. Carnett's sign is positive in the extreme RLQ/suprapubic region, indicating an abdominal wall/myofascial source rather than visceral tenderness. Musculoskeletal/Groin: Focal tenderness to palpation over the right pubic tubercle and conjoined tendon insertion. Pain reproduced with resisted abdominal curl-up (7/10) and resisted bilateral hip adduction in 45° flexion (5/10). Full passive ROM of bilateral hips without intra-articular impingement (FABER and FADIR negative). No palpable inguinal hernia on Valsalva in standing or supine positions.

Impression

Athletic pubalgia (core muscle injury) involving the right rectus abdominis-adductor aponeurosis, superimposed on underlying IBS-D exacerbated by endurance training ("runner's diarrhea"). No evidence of occult inflammatory bowel disease or true inguinal hernia.

• Clinical presentation and positive Carnett's sign confirm the primary pain generator is musculoskeletal (athletic pubalgia) rather than visceral GI pathology, though endurance training triggers concurrent IBS-D symptoms.
• 1. Right athletic pubalgia (rectus-adductor aponeurosis microtear). 2. Exercise-induced GI distress / IBS-D exacerbation. 3. GERD (stable).
• Minimal progress toward return-to-run goals due to initial misdirection of PT toward isolated adductor strain rather than comprehensive core/pelvic floor stabilization.
• Family history of Crohn's disease warrants baseline noninvasive screening given RLQ pain and diarrhea, though mechanical etiology is primary. PT plan requires modification to avoid isolated adductor loading and incorporate lumbopelvic stability. Avoidance of NSAIDs must be maintained to prevent GI mucosal injury.

Plan

Initiate conservative management for athletic pubalgia alongside dietary and pharmacologic optimization for exercise-induced IBS-D, with baseline stool studies to definitively exclude occult IBD.

• Modify physical therapy to a dedicated athletic pubalgia protocol focusing on core stabilization, pelvic tilt control, and transverse abdominis activation: 2 times per week for 6 weeks. Order fecal calprotectin, CRP, and CBC to rule out occult IBD. Continue omeprazole 20 mg PO QD. Trial loperamide (Imodium®) 2 mg PO 1 hour prior to endurance exercise to manage runner's diarrhea.
• Achieve pain-free ADLs (bending, bed mobility) within 3 weeks; return to pain-free jogging within 8 weeks; reduce exercise-induced GI episodes by > 80%.
• Core compression shorts (use during low-impact cross-training to provide external pelvic ring stability).
• Educated patient on low-FODMAP pre-race nutrition strategies, avoiding high-fructose energy gels, and maintaining strict NSAID avoidance to protect GI mucosa. Reviewed red-flag GI symptoms (bloody stools, nocturnal diarrhea, unexplained weight loss).
• Referral to specialized sports physical therapy for core muscle injury rehabilitation; referral to sports dietitian for endurance GI nutrition planning.
• 99204, 97110, 97140