Groin Pain

The spectrum of groin pain ranges from simple  muscle strains with subtle performance compromise to recurrent, debilitating groin pain preventing sports participation. The most frequently discussed causes of resistant groin pain are

1. Osteitis Pubis

2. Sports hernia (Gilmores Groin)

3. Adductor Enthesopahties

I’ve put together a detailed list of differential diagnostic factors to consider under both mechanical and non-mechanical categories.

Clinical features and treatment

Musculoskeletal Causes	Key features	Treatment options
Abdominal muscle tear	Localised tenderness to palpation; pain with activation of rectus abdominus	Relative rest, analgesics
Adductor tendinitis	Tenderness over involvd tendon, pain with resisted adduction of lower extremity	NSAIDS, rest, physiotherapy (PT)
Avascular necrosis of the femoral head	Inguinal pain with internal rotation of hip; decreased hip ROM	Mild: conservative measures severe: THR
Avulsion fracture	Pain on plpation of injury site; pain with stretch of involved muscle	Relative rest; ice; NSAIDS; possibly crutches
Bursitis	Pain over site of bursa	Injection of cortisone, anesthtic, or both
Conjoined tendon dehiscence	Pain with Valsalva’s manouver	Surgical referral
Herniated nucleus pulposis	Positive dural or sciatic tensions signs	PT or appropriate referral
Muscle strain	Acute pain over proximal muscles of medial thigh region; swelling; occasionally bruising	Rest; avoidance of aggravating activities; initial ice, with heat after 48hrs; hip spica wrap; NSAIDS for 7 to10 days
Myositis Ossificans	Pain and decreased ROM in involved muscle; palpable mass within substance of muscle	Moderately aggressive active or passive ROM exercises; wrap thigh with knee in max flexion for first 24 hrs; NSAIDS used sparingly for 2 days after trauma
Nerve entrapment	Burning or shooting pain in distribution of nerve; altered light touch sensation in medial groin; pain exacerbated by hyperextension at hip jt, possibly radiating; tenderness near superior iliac spine	Infiltration of site with local anesthetic; topical cream ( eg capsaicin )
Osteitis pubis	Pain around abdomen, groin, hip or thigh increased by resisted adduction of thigh	Relative rest; initial ice and NSAIDS; possibly crutches; later stretching exercises
Osteoarthritis	Inguinal pain with hip moton, especially internal rotation	Nonnarcotic analgesics or NSAIDS; hip replacement for intractable pain
Pubic instability	Excess motion at pubic symphysis; pain in pubis, groin or lower abdomen	PT, NSAIDS, compressive shorts
Referred pain from knee or spine	Hip ROM and palpation response normal	Identify true source
Seronegative spondyloarthropathy	Signs of systemic illness, other joint involvement	Refer to rheumatologist
Slipped capital femoral epiphysis	Inguinal pain with hip movement; insidious development in ages 8 to 15; walking with limp, holding leg in external rotation	Discontinue athletic activity; refer to orthopaedic surgeon
Stress fracture
Pubic ramus	Chronic ache or pain in the groin, buttock and thighs	Relative rest; avoid aggravating activities
Femoral neck	Chronic ache or pain in the groin, buttock and thighs or pain with decreased hip ROM ( internal rotation in flexion)	Refer to orthopod if radiographs show lesion; for nonoperative fractures strict non-weight bearing until pain free with gradual return to activity
Non-musculoskeletal Causes	Key features	Treatment options
Genital swelling/inflam
Epididymitis	Tenderness over superior aspect of testes	Antibiotics if appropriate, or refer to urologist
Hydrocele	Pain in lower spermatic cord region	Refer to urologist
Variocele	Rubbery, elongated mass around spermatic cord	Refer to urologist
Hernia	Recurrent episodes of pain; palpable mass made more prominent with coughing or straining; discomfort elicited by abdominal wall tension	Refer for surgical treatment
Lymphadenopathy	Palpable lymph nodes just below inguinal ligaments; fever, chills, discharge	Antibiotics
Ovarian cyst	Groin or perineal pain	Refer to gynecologist
Pelvic inflammatory disease	Fever, chills, purulent discharge	Refer to gynecologist
Postpartum symphysis separation	Recent vaginal delivery with no prior history of groin pain	Physiotherapy, relative rest, analgesics
Prostatitis	Dysuria, purulent discharge	Antibioics, NSAIDS
Renal lithiasis	Intense pain that radiates to scrotum	Pain control, ­fluids until stone passes; Hospital adm sometimes necessary
Testicular neoplasm	Hard mass palpated on the testicle; may not be tender	Refer to urologist
Testicular torsion or rupture	Severe pain in the scrotum; nausea, vomiting; testes hard on palpation or not palpable	Refer immediately to urologist
Urinary tract infection	Burning with urination; itching, frequent urination	Short course of antibiotics

The key differential criteria are to exclude surgical cases – which constitute a small proportion of the total population and then decide on a specific course of targeted rehabilitation to address the groin pain. More on the specific’s for another post.

Enjoy the clinical challenge.

David

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