Severe Groin Pain: Treatment Approach
For severe groin pain, immediately rule out emergencies (testicular torsion, renal colic, hip fracture), then initiate multimodal pain control with acetaminophen up to 3g/day plus NSAIDs, combined with active supervised physical therapy targeting the specific pain source identified on examination. 1, 2
Emergency Exclusion First
Severe groin pain constitutes a medical emergency requiring prompt response 3, 1. You must immediately exclude:
- Hip fracture in older adults or trauma patients - obtain plain radiographs immediately, followed by MRI if radiographs are negative but clinical suspicion remains high (MRI detects occult fractures missed on plain films) 3
- Testicular torsion - requires immediate surgical intervention 4
- Renal colic - presents with severe unilateral pain radiating to groin/genitals, hematuria in >80% of cases 5
- Incarcerated hernia - requires urgent surgical evaluation 2
Systematic Physical Examination
After excluding emergencies, perform targeted examination to identify the pain source 2:
- Adductor test: Patient supine with hips abducted and flexed at 80 degrees; test is positive if sharp groin pain occurs when patient attempts to pull legs together against resistance 6
- Direct palpation of pubic rami, adductor tendons, inguinal canal, and iliopsoas 2
- Hip range of motion testing - internal/external rotation reproduces pain in hip pathology 3
- Palpation for hernias with Valsalva maneuver 2
First-Line Pharmacological Management
Start with acetaminophen up to 3g/day as the safest first-line option 1. This provides effective analgesia with minimal adverse effects when dosed appropriately.
Add NSAIDs for additional pain control and anti-inflammatory effects 1. For musculoskeletal groin pain, this combination addresses both pain and underlying inflammation.
For neuropathic groin pain (ilioinguinal, iliohypogastric, genitofemoral, or lateral femoral cutaneous nerve involvement), add:
- Gabapentin or pregabalin with appropriate renal dose adjustments 1
- SNRIs (duloxetine) or tricyclic antidepressants as alternatives 1
- Topical lidocaine for localized neuropathic pain 1
For muscle spasm component, add muscle relaxants 1.
Non-Pharmacological Interventions (Mandatory, Not Optional)
Active, supervised physical therapy is the primary treatment for adductor-related and pubic-related groin pain 2. This is not adjunctive - it is first-line treatment.
The physical therapy program must include 6, 2:
- Stretching and strengthening of adductor muscles
- Abdominal wall muscle strengthening
- Iliopsoas, quadriceps, and hamstring exercises
- Core strengthening and neuromuscular rehabilitation for inguinal-related pain
Cognitive Behavioral Therapy (CBT) should be initiated for chronic pain management (strong recommendation, moderate quality evidence) 1.
Additional evidence-based modalities 1:
- Yoga for chronic musculoskeletal pain (strong recommendation, moderate quality evidence)
- Hypnosis specifically for neuropathic pain (strong recommendation, low quality evidence)
Imaging Strategy Based on Clinical Findings
For adductor-related groin pain: Obtain MRI pelvis if diagnosis is unclear or symptoms persist after 4-6 weeks of conservative management 2
For inguinal-related groin pain: Perform dynamic ultrasonography to rule out true hernia and evaluate posterior abdominal wall weakness 2
For iliopsoas-related groin pain: Obtain hip radiography and MRI because concomitant hip pathology is common 2
For suspected occult hip fracture: MRI is mandatory when plain radiographs are negative but clinical suspicion remains (MRI demonstrates fractures missed on initial radiographs) 3
Interventional Procedures for Refractory Pain
When conservative management fails after 6-8 weeks, consider referral to pain management for 3, 1:
- TENS (transcutaneous electrical nerve stimulation) - noninvasive first-line interventional option
- Intercostal nerve blocks - for nerve-mediated pain
- Dorsal column stimulation - for chronic refractory pain
- Surgical nerve management - neurolysis for lateral femoral cutaneous nerve entrapment, or resection of ilioinguinal, iliohypogastric, or genitofemoral nerves (68% achieve excellent pain relief and 72% achieve functional restoration) 7
Monitoring and Reassessment
Reassess at each contact to evaluate pain severity, functional improvement, and treatment-related adverse events 1. Functionality is a better endpoint than numerical pain ratings alone.
Set realistic expectations: The goal is functional restoration, not complete pain elimination 1.
Monitor for:
- Liver function with acetaminophen use 1
- Renal function with NSAIDs and gabapentin/pregabalin 1
- Cardiac status with pharmacological treatments 1
Critical Pitfalls to Avoid
Do not treat new severe groin pain as simply requiring more medication - new pain requires thorough reevaluation to exclude emergencies 1.
Do not delay MRI in suspected hip fracture with negative plain radiographs - occult fractures cause significant morbidity if missed, and patients may worsen over 2 days before returning for care 3.
Do not rely on clinical diagnosis alone - misdiagnosis rates are 34-68% without imaging for acute conditions 8.
Do not focus solely on pharmacological management - physical therapy is first-line treatment for most musculoskeletal groin pain, not adjunctive 2.
Do not neglect screening for substance use disorders in patients requiring ongoing pain management - this requires addiction specialist consultation when identified 1.