Spontaneous Psoas Hematoma Following Resistance Training in an Elderly Patient on Apixaban: A Case Report

Regular physical activity, including resistance training, is strongly recommended for older adults to preserve muscle mass, balance, and functional independence. However, the increasing use of direct oral anticoagulants (DOACs), such as apixaban, in this population introduces important clinical considerations, particularly the risk of spontaneous bleeding in those participating in physical activity. Various scoring systems are used to create better judgement calls when initiating an anticoagulant, however initiating the anticoagulant is up to the discretion of the physician. We present the case of an 80-year-old male with multiple comorbidities, including atrial fibrillation managed on apixaban for anticoagulation, who was diagnosed with a spontaneous psoas hematoma during hospitalization for pneumonia. This case highlights the importance of a risk-aware approach to physical activity counseling in older adults on anticoagulation therapy. Clinicians must maintain a high index of suspicion and provide tailored exercise guidance to minimize injury risk. As the older population and use of DOACs continue to rise, increased awareness and surveillance are essential to promote safe physical activity in this vulnerable group.