What is the initial workup for a patient presenting with groin pain?

Initial Workup for Groin Pain

For patients presenting with groin pain, the initial workup should include a focused history, physical examination with special attention to the groin area, and appropriate imaging starting with plain radiographs of the femur. 1, 2, 3

History and Physical Examination Components

Key History Elements:

• Pain characteristics (onset, duration, quality, radiation)
• Exacerbating and alleviating factors
• Associated symptoms (fever, urinary symptoms, testicular pain)
• History of trauma or repetitive activities
• Risk factors (age, sports participation, bisphosphonate use)

Physical Examination:

1. Direct palpation of key anatomical structures:

   • Adductor muscles and tendons
   • Pubic symphysis and rami
   • Inguinal region (for hernias)
   • Iliopsoas muscle
   • Hip joint

2. Special tests:

   • Hip internal/external rotation (reproduces pain in hip pathology) 1
   • Adductor squeeze test (for adductor-related pain)
   • Resisted sit-up test (for rectus abdominis pathology)
   • FABER/FADIR tests (for hip joint pathology)

Diagnostic Imaging Algorithm

First-line Imaging:

• Plain radiographs of the femur are rated 9/9 (usually appropriate) as the initial imaging study for patients with groin pain, particularly those on long-term bisphosphonate treatment 1

If Initial Radiographs are Negative:

1. For suspected musculoskeletal causes:

   • MRI of the thigh/hip without IV contrast (rated 9/9) is the preferred next step 1
   • CT of the thigh without IV contrast (rated 8/9) is an alternative 1
   • Bone scan may be considered (rated 7/9) 1

2. For suspected testicular/scrotal causes:

   • Duplex Doppler ultrasound of the scrotum is the first-line imaging test 1

3. For suspected abdominal causes:

   • CT is recommended for evaluating lower quadrant pain 1
   • Ultrasound is recommended for right upper quadrant pain 1

Common Etiologies of Groin Pain

1. Musculoskeletal causes:

   • Adductor strain/tendinopathy
   • Osteitis pubis
   • Stress fracture (femoral neck or pubic ramus)
   • Hip joint pathology (labral tears, osteoarthritis)
   • Iliopsoas bursitis

2. Hernias:

   • Inguinal hernia
   • Sports hernia/athletic pubalgia

3. Genitourinary causes:

   • Testicular torsion
   • Epididymitis
   • Varicocele

4. Other causes:

   • Nerve entrapment (ilioinguinal, genitofemoral)
   • Referred pain from lumbar spine
   • Enthesopathy at pubic insertion of inguinal ligament 4

Management Approach

The management should be directed by the specific diagnosis:

1. For adductor-related and pubic-related pain:

   • Active, supervised physical therapy focusing on core strengthening 3
   • NSAIDs for pain management (when not contraindicated) 1

2. For inguinal-related pain without hernia:

   • Physical therapy focusing on core strengthening 3
   • Consider surgical consultation for persistent symptoms

3. For iliopsoas-related pain:

   • Address any concomitant hip pathology 3
   • Physical therapy and anti-inflammatory medications

Common Pitfalls to Avoid

1. Missing serious pathology:

   • Femoral neck stress fractures can be missed on plain radiographs
   • Testicular torsion requires immediate surgical intervention

2. Inadequate physical examination:

   • Failure to perform a comprehensive examination of all potential pain generators
   • Not testing for specific entities (adductor strain, sports hernia)

3. Delayed or inappropriate imaging:

   • Not progressing to advanced imaging when initial radiographs are negative
   • Using the wrong imaging modality for the suspected pathology

4. Treating symptoms without diagnosis:

   • Initiating therapy without a clear understanding of the underlying cause
   • Failing to address biomechanical factors contributing to pain

By following this systematic approach to evaluation and management, clinicians can effectively diagnose and treat patients presenting with groin pain, improving outcomes and reducing unnecessary interventions.