What causes a prominent groin ligament and how is it treated?

Prominent Groin Ligament: Causes and Treatment

A prominent groin ligament is most commonly caused by inflammation at the pubic insertion of the inguinal ligament, a condition known as enthesopathy, which can be effectively treated with corticosteroid injections. 1

Causes of Prominent Groin Ligament

Primary Causes

• Enthesopathy (inflammation) at the pubic insertion of the inguinal ligament - this has been identified as the most common cause of chronic groin pain and can lead to a prominent or painful groin ligament 1
• Imbalance between adductor and abdominal muscles, which places stress on the pubic region where kinematic forces cross 2
• Overload of the adductor muscles, particularly common in athletes and especially soccer players 2
• Weakness of the abdominal muscle wall (sportsman's hernia), which alters the biomechanics of the groin region 2, 3

Secondary Causes

• Surgical clips intentionally placed during surgery that may cause a visible or palpable prominence in the groin area 4
• Degenerative arthropathy of pubic symphysis in advanced stages of groin pain syndrome 2
• Tendon inflammation affecting the rectus abdominis or adductor longus insertions 1

Diagnosis

Clinical Examination

• The adductor test is crucial for diagnosis: patient lies supine with hips abducted and flexed at 80 degrees; the test is positive if attempting to pull legs against resistance causes sharp groin pain 2
• Careful palpation of the exact site of tenderness, which may be obscured by the pubic pad of fat 1
• Differentiation from other causes of groin pain such as:
  • Pelvic stress fractures
  • Avulsion injuries
  • Tumors
  • Nerve entrapment
  • Spinal referred pain
  • Ureteric stones 5, 1

Imaging

• MRI assessment specific to the inguinal ligament and pubic region is recommended for accurate diagnosis 3
• Regular monitoring through clinical examination is sufficient in most cases, with imaging only necessary if symptoms develop or worsen 4

Treatment

Conservative Management

• Gradual physical therapy combined with pharmacotherapy is effective in most cases 2
• Physical therapy program should include:
  • Stretching and strengthening of adductor muscles
  • Strengthening of abdominal wall muscles
  • Exercises for iliopsoas muscle, quadriceps, and hamstrings 2
• Pharmacotherapy options:
  • Nonsteroidal anti-inflammatory drugs
  • Muscle relaxants 2

Interventional Treatment

• Infiltration with long-acting corticosteroid (such as 1% triamcinolone) and local anesthetic (2% lignocaine) at the site of localized tenderness has shown better outcomes than when injection was declined 1
• This treatment approach targets the enthesopathy directly and can provide significant relief 1

Surgical Management

• Surgery is indicated only when physical therapy and pharmacotherapy fail 2
• The specific surgical approach depends on the underlying cause:
  • For sportsman's hernia, repair of the abdominal wall weakness may be necessary
  • For other ligamentous issues, specific repair techniques may be employed 2, 3
• For surgical clips causing symptoms, evaluation by a surgeon with expertise in the relevant area is advised, though routine removal is not recommended 4

Follow-up and Monitoring

• Regular clinical examination to assess improvement in symptoms 4
• Further evaluation should be considered if the patient develops:
  • Persistent pain or discomfort at the site
  • Signs of infection
  • Palpable mass or abnormality 4

Prevention

• Maintaining balance between adductor and abdominal muscles through appropriate training 2
• Proper warm-up and stretching before athletic activities 2
• Early intervention when mild symptoms first appear to prevent progression to chronic condition 1