How should a 53-year-old male with bilateral groin pain and MRI findings of bilateral adductor tendinosis with undersurface tears at the pubic bone, progressive scar remodeling of the adductor longus tendons, a deep interstitial tear of the left common hamstring tendon origin with edema, mild right greater‑trochanteric bursitis, and an enlarged prostate be managed?

Management of Bilateral Groin Pain with Multiple Tendinopathies

This 53-year-old male should begin with a structured 3-6 month conservative treatment program consisting of relative rest, eccentric strengthening exercises, and physical therapy targeting the adductor and hamstring tendinopathies, while concurrently addressing the enlarged prostate with urologic evaluation and appropriate medical management.

Primary Musculoskeletal Management

Initial Conservative Treatment (First-Line)

The MRI findings demonstrate chronic degenerative tendinopathy rather than acute inflammatory tendonitis, which fundamentally changes the treatment approach 1. Most patients with overuse tendinopathies (approximately 80%) fully recover within 3-6 months with conservative management 1.

Core treatment components:

• Relative rest: Reduce activities that load the damaged tendons (groin movements, hip adduction/flexion) while avoiding complete immobilization to prevent muscle atrophy 1

• Eccentric strengthening exercises: This is the most evidence-based intervention for tendinopathy and may reverse degenerative changes 1. For adductor tendinopathy specifically, progressive eccentric loading has demonstrated effectiveness 2

• Cryotherapy: Apply melting ice water through a wet towel for 10-minute periods for acute pain relief 1

Pharmacologic Pain Management

NSAIDs provide short-term pain relief but do not alter long-term outcomes 1. Topical NSAIDs are equally effective with fewer systemic side effects 1. These should be used for symptom control during the rehabilitation phase, not as primary treatment.

Corticosteroid injections may provide more effective acute-phase pain relief than oral NSAIDs but similarly do not change long-term outcomes 1. Given the MRI findings of progressive scar remodeling (suggesting chronicity), injections should be used cautiously and only if pain significantly limits participation in physical therapy 1.

Specific Anatomic Considerations

Bilateral adductor tendinosis with undersurface tears: The MRI shows nonprogressive changes on the left but progressive scar remodeling on the right. Research indicates that adductor enthesopathy visible on MRI correlates with worse outcomes from isolated injection therapy 3. Physical rehabilitation with progressive strengthening is essential 2, 4.

Left hamstring tendon tear with edema: The progressive deep surface and interstitial tearing with surrounding edema requires careful load management. This represents active pathology that needs protection during healing while maintaining some tensile loading to guide collagen alignment 1.

Right greater trochanteric bursitis: This mild finding should respond to the same conservative measures. Targeted physiotherapy offers superior long-term outcomes (60.5% symptom resolution at 15 months) compared to shock wave therapy or corticosteroid injections alone 5.

Concurrent Urologic Management

The enlarged prostate with bladder wall thickening and trabeculation suggests chronic bladder outlet obstruction 6. This requires separate evaluation and cannot be ignored.

Immediate urologic assessment should include:

• Symptom quantification with validated questionnaire (IPSS)
• Post-void residual measurement (already concerning on MRI)
• Serum PSA if not recently checked
• Urinalysis and culture to exclude infection 6

The patient may require alpha-blocker therapy or 5-alpha reductase inhibitors depending on prostate size and symptom severity 6. Untreated bladder outlet obstruction can cause nocturia and pelvic discomfort that may confound the groin pain assessment 7.

Treatment Timeline and Monitoring

Weeks 0-4:

• Begin physical therapy 2-3 times weekly focusing on eccentric adductor and hamstring exercises
• Ice applications after activity
• NSAIDs as needed for pain control
• Complete urologic evaluation

Weeks 4-12:

• Progress to sport-specific loading as tolerated
• Continue eccentric strengthening with increasing resistance
• Reassess pain and function monthly

Month 3-6:

• Gradual return to full activity if pain-free
• Maintenance strengthening program

Surgical Consideration

Surgery should be reserved only if conservative therapy fails after 3-6 months 1. For adductor tendinopathy specifically, tenotomy of the adductor longus has shown good results when conservative treatment fails, with return to sport averaging 14 weeks post-operatively 8. However, acute adductor tears should generally be treated conservatively given potential surgical complications 9.

Critical Pitfalls to Avoid

1. Do not treat this as acute inflammation: The MRI shows chronic degenerative changes with scar remodeling, not acute tendonitis. Anti-inflammatory medications alone will not address the underlying pathology 1.

2. Do not ignore the prostate findings: Chronic bladder outlet obstruction can cause referred pelvic pain and must be addressed concurrently 6, 7.

3. Do not rush to surgery: The progressive hamstring tear may seem alarming, but conservative management is appropriate for insertional tendinopathy 9. Surgery is indicated only after documented failure of 3-6 months of appropriate conservative therapy 1.

4. Do not use corticosteroid injections as primary treatment: While they may provide short-term relief, they do not improve long-term outcomes and should be combined with physical therapy if used at all 1.

5. Avoid complete rest: Some tensile loading is necessary to guide proper collagen fiber alignment during healing 1.

The bilateral nature of symptoms, multiple anatomic sites of pathology, and concurrent prostate issues suggest this will require a coordinated 3-6 month rehabilitation program with both musculoskeletal and urologic management 1, 2.