What is the appropriate evaluation and management for a 23-year-old patient presenting with right groin pain, without signs of swelling, redness, or palpable lymph nodes?

Physical Examination for 23-Year-Old with Right Groin Pain

Physical examination of the right groin reveals no swelling, no redness, and no palpable lymph nodes. This is a critical finding that helps narrow the differential diagnosis for this young patient.

Focused Physical Examination Components

General Inspection

• No visible swelling or redness in the right groin area
• No asymmetry compared to the left side
• No skin changes or discoloration

Palpation

• No palpable lymph nodes in the inguinal region
• Assessment for tenderness at specific anatomical points:
  • Adductor muscle insertion (adductor test): Have patient lie supine with hips abducted and flexed at 80 degrees, apply resistance to adduction to assess for sharp pain 1
  • Pubic symphysis and pubic rami
  • Inguinal ligament insertion at pubic tubercle (common site for enthesopathy) 2
  • Iliopsoas muscle (flexion against resistance)
  • Rectus abdominis insertion

Special Tests

• Hernia assessment: Check for bulges with Valsalva maneuver
• Hip range of motion: Assess for limitations or pain with internal rotation, flexion, and abduction
• FABER (Flexion, ABduction, External Rotation) test for hip pathology
• Straight leg raise test to rule out referred pain from spine

Diagnostic Considerations

Based on the absence of lymphadenopathy, swelling, or redness, several key diagnoses should be considered:

1. Musculoskeletal causes: Most likely in this age group 3

   • Adductor strain/tendinopathy
   • Iliopsoas strain/tendinopathy
   • Osteitis pubis
   • Sports hernia (posterior abdominal wall weakness)
   • Pubic symphysis stress injury

2. Neural causes: Consider if pain has burning or radiating quality 4

   • Ilioinguinal nerve entrapment
   • Genitofemoral nerve entrapment
   • Lateral femoral cutaneous nerve entrapment

3. Less likely given absence of lymphadenopathy:

   • Infectious causes
   • Malignancy (penile, testicular cancer with metastasis)

Next Steps in Evaluation

If the physical examination remains unremarkable with only pain:

• Consider dynamic ultrasonography to evaluate for posterior abdominal wall weakness or occult hernia 3
• If adductor-related pain is suspected, MRI of the pelvis may be warranted if symptoms persist after initial management 3
• For suspected iliopsoas-related pain, hip radiography and MRI should be considered 3

Management Approach

Initial management should focus on:

• NSAIDs and muscle relaxants for pain control 1
• Gradual physical therapy with stretching and strengthening of adductor muscles, abdominal wall muscles, iliopsoas muscle, quadriceps, and hamstrings 1
• For suspected enthesopathy, consider local injection with steroid and anesthetic at the point of maximal tenderness 2

If symptoms persist beyond 6 weeks, further investigation is warranted, including advanced imaging and specialist referral 5.