What are the possible causes and treatments for left groin pain that occurs when walking?

Left Groin Pain When Walking: Diagnostic and Management Approach

The most critical first step is to obtain an ankle-brachial index (ABI) and perform a comprehensive vascular examination to rule out iliac artery occlusive disease, which presents classically with groin/buttock claudication and can progress to limb-threatening ischemia if untreated. 1

Initial Clinical Assessment

Key History Elements to Obtain

• Pain characteristics: Determine if pain is aching, cramping, burning, or fatigue-type discomfort that occurs reproducibly with walking and resolves within 10 minutes of rest (typical claudication pattern) 1
• Distance tolerance: Document how far the patient can walk before symptoms begin, and whether uphill walking worsens symptoms 1
• Risk factors for peripheral artery disease: Age ≥50 years with diabetes, smoking history, dyslipidemia, hypertension, chronic kidney disease, or known atherosclerotic disease elsewhere 1
• Associated symptoms: Erectile dysfunction, rest pain, or non-healing wounds suggest more severe disease 1

Critical Physical Examination Findings

• Pulse assessment: Palpate femoral, popliteal, dorsalis pedis, and posterior tibial pulses bilaterally—asymmetrically diminished left femoral pulse is highly suggestive of iliac occlusive disease 1
• Vascular bruits: Auscultate the groin for bruits indicating turbulent flow 1
• Skin changes: Look for asymmetric hair growth, nail bed changes, calf muscle atrophy, elevation pallor, or dependent rubor 1

Diagnostic Testing Algorithm

First-Line Testing

• Ankle-brachial index (ABI): Perform immediately in the outpatient setting—ABI <0.90 has 75% sensitivity and 86% specificity for peripheral artery disease 1
• Important caveat: Resting ABI may be normal in isolated iliac occlusive disease, so obtain post-exercise ABI if resting values are normal but clinical suspicion remains high 1

Advanced Imaging When Revascularization Considered

• CT angiography (CTA) of abdomen and pelvis with contrast: This is the preferred imaging modality once ABI confirms peripheral artery disease and revascularization is being considered 1
• MR angiography (MRA): Alternative to CTA when contrast is contraindicated 1
• Catheter-directed digital subtraction angiography (DSA): Reserve for the time of endovascular intervention rather than as a diagnostic study 1

Alternative Diagnoses to Consider

Musculoskeletal Causes

• Hip arthritis: Presents with lateral hip/thigh aching that occurs after variable exercise, not quickly relieved by rest, and improves when not bearing weight 1
• Sports hernia/athletic pubalgia: Common in athletes, presents with groin pain exacerbated by activity
• Inguinal hernia: May present with groin discomfort, particularly with straining or walking

Occult Hip Pathology

• If plain radiographs of hip/pelvis are negative but pain persists: Obtain MRI hip without contrast to detect osteonecrosis, occult fractures, or labral tears 2
• Risk factors for osteonecrosis: Diabetes, corticosteroid use, alcohol use 2

Nerve Compression

• Lumbar radiculopathy: Sharp lancinating pain radiating down leg, often worse with sitting, relieved when supine 1
• Spinal stenosis: Neurogenic claudication improves with forward flexion, unlike vascular claudication 1

Management Strategy for Confirmed Iliac Artery Occlusive Disease

Medical Management (All Patients)

• Risk factor modification: Smoking cessation, control of hyperlipidemia, diabetes, and hypertension 1
• Lipid profile: Obtain total cholesterol, LDL, HDL, triglycerides, and homocysteine (in younger patients) 1
• Antiplatelet therapy: Aspirin or cilostazol should be initiated 1
• Supervised exercise program: Strongly recommended, though patients with iliac lesions may be considered for earlier revascularization compared to infrainguinal disease 1

Revascularization Considerations

• Patients with iliac artery occlusive disease may be considered for revascularization without undergoing extensive medical therapy first, unlike those with infrainguinal disease 1
• Endovascular intervention: Preferred initial approach for most iliac lesions 1
• Surgical bypass: Reserved for complex anatomy or failed endovascular approaches 1

Red Flags Requiring Urgent Evaluation

• Acute onset severe pain with absent pulses: Suggests acute thrombosis requiring emergent CTA and immediate anticoagulation with heparin 1
• Rest pain, tissue loss, or gangrene: Indicates chronic limb-threatening ischemia requiring urgent vascular surgery referral 1
• Ankle pressure <50 mmHg or toe pressure <30 mmHg: Confirms critical limb ischemia 1

Common Pitfalls to Avoid

• Do not rely solely on resting ABI in suspected iliac disease—it may be falsely normal; obtain post-exercise ABI 1
• Do not dismiss symptoms in patients who cannot walk far enough to provoke claudication due to other comorbidities (heart failure, arthritis)—this "masked LEAD" population is at high risk for limb events 1
• Do not delay vascular referral in patients with tissue loss or infection—early recognition is mandatory for limb salvage 1