What is the recommended workup and treatment for a patient presenting with groin pain?

Workup and Management of Groin Pain

The recommended initial workup for groin pain should include plain radiographs of the affected area, followed by MRI if radiographs are negative but clinical suspicion remains high. 1, 2

Initial Assessment

• A thorough history should focus on pain characteristics (onset, duration, quality), exacerbating/relieving factors, and radiation patterns 1, 2
• Physical examination should include direct palpation of key structures and specific testing for major musculoskeletal causes of groin pain: adductor, pubic, inguinal, and iliopsoas regions 3
• The adductor test (patient lying supine with hips abducted and flexed at 80 degrees) is positive if the patient feels sharp pain in the groin when attempting to pull legs against resistance 4
• Internal rotation of the hip often reproduces pain in patients with hip arthritis 1, 2

Common Causes of Groin Pain

Musculoskeletal Causes

• Hip arthritis typically presents with groin pain that may radiate to the buttock or thigh, exacerbated with activity and alleviated with rest 1, 2
• Adductor muscle strain or tendinopathy is common, especially in athletes 4, 3
• Osteitis pubis presents with pain at the pubic symphysis 4
• Enthesopathy at the pubic insertion of the inguinal ligament (sometimes called "tennis elbow of the groin") 5
• Stress fractures of the femoral neck or pubic ramus 6

Non-Musculoskeletal Causes

• Sports hernia (weakness of the abdominal muscle wall) 4
• True inguinal hernia 3
• Neural causes including ilioinguinal, iliohypogastric, or genitofemoral nerve entrapment 7
• Referred pain from lumbar spine or sacroiliac joints 2

Diagnostic Imaging

First-Line Imaging

• Plain radiographs of the hip/pelvis are the recommended first imaging study 1, 2
• For patients on long-term bisphosphonate treatment with groin pain, femur radiographs are strongly recommended (rating 9/9) 1

Second-Line Imaging

• If radiographs are negative but clinical suspicion remains high, MRI without contrast is the preferred next step (rating 9/9) 1, 2
• For patients on long-term bisphosphonates with negative radiographs, bilateral MRI of the thighs without contrast is recommended (rating 9/9) 1
• CT without contrast is an alternative when MRI is contraindicated 1

Treatment Approach

First-Line Treatment

• NSAIDs are strongly recommended for hip arthritis when not contraindicated 1, 2
• Physical therapy focusing on stretching and strengthening of adductor muscles, abdominal wall muscles, iliopsoas, quadriceps, and hamstrings 4, 3
• Acetaminophen may be considered when NSAIDs are contraindicated 1, 2

Second-Line Treatment

• Appropriate manual physical therapy techniques for patients with pelvic floor tenderness 1
• Intra-articular corticosteroid injections for hip arthritis 2
• Local steroid and anesthetic infiltration for enthesopathy 5

Advanced Treatment

• For patients with hip arthritis refractory to conservative measures, total hip arthroplasty may be indicated 1, 2
• Surgical management may be necessary for neural causes of groin pain if conservative measures fail 7

Special Considerations

• Pain management should begin as soon as possible when indicated; diagnosis should not delay administration of analgesics 1
• For chronic pain, a comprehensive pain assessment including the patient's self-report of pain is critical 1
• In elderly patients with groin pain following falls, consider occult hip fractures and perform comprehensive multidisciplinary assessment 8
• For patients with suspected neural origin of groin pain, consider whether one or more of four different nerves (lateral femoral cutaneous, ilioinguinal, iliohypogastric, or genitofemoral) are the source 7

Management Algorithm

1. Obtain plain radiographs of the affected area 1
2. If radiographs are negative but clinical suspicion remains high, proceed to MRI without contrast 1
3. Begin first-line treatment with NSAIDs (if not contraindicated) and physical therapy 1, 2, 4
4. For persistent symptoms, consider second-line treatments based on specific diagnosis 1, 2, 5
5. For refractory cases, consider surgical consultation 1, 2, 7