From the Guidelines
The next best step for a 65-year-old female with chronic right groin pain and normal X-ray and CT scans would be to obtain an MRI of the hip and pelvis. This recommendation is based on the highest quality and most recent evidence available, which suggests that MRI is the most sensitive and specific imaging modality for detecting soft tissue abnormalities, such as labral tears, tendinopathies, and bursitis, that may be causing the patient's symptoms 1.
Rationale for MRI
The American College of Radiology (ACR) Appropriateness Criteria for chronic hip pain recommend MRI as the first imaging technique to use after radiographs, due to its high sensitivity and specificity for detecting osseous and soft tissue abnormalities 1. Additionally, a more recent study published in the British Journal of Sports Medicine in 2020 recommends the use of MRI or magnetic resonance arthrogram (MRA) for diagnosing hip-related pain, particularly when three-dimensional morphological assessment is indicated 1.
Conservative Management
While waiting for the MRI, the patient should be started on conservative management, including:
- NSAIDs such as ibuprofen 400-600mg three times daily with food or naproxen 500mg twice daily for pain relief
- Physical therapy focusing on hip strengthening and range of motion exercises
- Heat or ice application for 15-20 minutes several times daily for symptomatic relief
- If pain is severe, a short course of muscle relaxants like cyclobenzaprine 5-10mg at bedtime may be beneficial
Importance of Detailed Evaluation
The persistence of groin pain despite normal initial imaging warrants this more detailed evaluation, as chronic groin pain in older adults can stem from various conditions, including osteoarthritis, athletic pubalgia, or referred pain from lumbar spine pathology that standard imaging might miss 1.
Key Points to Consider
- MRI provides superior soft tissue contrast that can detect conditions not visible on X-ray or CT
- Conservative management should be initiated while waiting for the MRI results
- The diagnosis of the primary cause of hip-related pain should never be made using imaging alone, but rather in combination with the patient's symptoms and clinical signs 1
From the Research
Next Best Step for Diagnosis
Given the normal X-ray and CT scans, the next best step for a 65-year-old female with chronic right groin pain would be to consider an MRI scan. This is because MRI provides superb soft tissue contrast resolution, multiplanar capabilities, and a wide field of view to evaluate many potential causes of groin pain 2.
Potential Causes of Groin Pain
There are several potential causes of groin pain, including:
- Iliopsoas disorders such as bursitis, tendonitis, impingement, and snapping 3
- Stress fracture of the femoral neck or pubic ramus 4, 5
- Osteitis pubis, characterized by sclerosis and bony changes about the pubic symphysis 5, 6
- Avulsion fracture of the apophyses 5
- Sports hernia, which can cause prolonged groin pain 5
- Adductor strains, common in kicking sports such as soccer 5
- Nerve compression, which can occur to the nerves supplying the groin 5
Role of MRI in Diagnosis
MRI can provide an accurate depiction of pubic bone alterations and of adjacent myotendinous structures, and can help diagnose conditions such as osteitis pubis, myotendinous posttraumatic changes, and inguinal hernia 6. MRI can also monitor the alterations with reference to their response to treatment, which may help bring the athletes back to their activities 6.
Considerations for Treatment
Treatment for groin pain will depend on the underlying cause, but may include conservative measures such as activity modification, physical therapy, nonsteroidal anti-inflammatory drugs, and corticosteroid injections 3, 4, 5. In some cases, surgical treatment may be necessary, such as arthroscopic lengthening of the musculotendinous unit or treatment of concomitant intra-articular abnormality 3.