What is the initial workup and treatment for a patient with groin pain or a groin pull?

Groin Pull/Pain Initial Workup and Treatment

For acute groin pain or suspected groin pull, begin with a focused physical examination including the adductor test (patient supine, hips abducted and flexed to 80 degrees, resisted adduction reproducing sharp groin pain), followed by plain radiographs to exclude fracture or osteitis pubis, then initiate conservative management with NSAIDs, physical therapy focused on adductor and core strengthening for at least 3 months, reserving advanced imaging (MRI) only if symptoms persist beyond 4-6 weeks or if there is concern for alternative pathology. 1, 2, 3

Initial Clinical Assessment

Key History Elements

• Mechanism of injury: Distinguish traumatic onset (sudden strain during activity) from insidious onset (overuse pattern) 1, 3
• Pain pattern: Groin strains typically present as dull pain at rest that becomes sharp with activity, particularly with pushing movements or resisted hip adduction 1, 3
• Functional limitations: Assess impact on specific activities like walking, sitting, driving, and sports participation 3
• Duration and progression: Acute (<6 weeks) versus chronic (>6 weeks) presentations require different management approaches 3, 4

Physical Examination Findings

• Adductor test: The most important diagnostic maneuver - patient supine with hips abducted and flexed to 80 degrees; positive test reproduces sharp groin pain with resisted adduction 1
• Palpation: Tenderness along adductor longus muscle belly, pubic ramus, or pubic symphysis suggests musculotendinous injury or osteitis pubis 1, 3
• Hip range of motion: Limited internal rotation reproducing groin pain may indicate intraarticular hip pathology (hip osteoarthritis or labral tear) requiring different management 2, 3
• Pelvic examination: Assess for pubic symphysis dysfunction and core muscle weakness ("sportsman's hernia") 1, 4

Critical pitfall: Do not assume all groin pain is a simple muscle strain - pelvic stress fractures, avulsion injuries, and even tumors can present similarly and require different management 5

Diagnostic Imaging Strategy

Initial Imaging

• Plain radiographs first: Obtain AP pelvis and frog-leg lateral hip views to exclude fracture, avulsion injury, or advanced osteitis pubis with degenerative changes at the pubic symphysis 1, 3
• These are sufficient for most acute presentations and guide initial treatment decisions 3

Advanced Imaging Indications

• MRI: Reserve for symptoms persisting beyond 4-6 weeks despite conservative treatment, or when clinical examination suggests alternative pathology (hip labral tear, stress fracture, core muscle injury) 3, 4
• Ultrasound: May be useful for evaluating adductor tendon pathology in experienced hands, though less commonly used than MRI 3

Do not routinely order MRI for acute groin strains - it adds cost without changing initial management and may lead to overtreatment of incidental findings 3, 4

Conservative Treatment Protocol

Pharmacotherapy

• NSAIDs: First-line when not contraindicated for symptomatic relief 1, 3
• Muscle relaxants: Consider as adjunct therapy for acute muscle spasm 1
• Acetaminophen: Alternative for patients with NSAID contraindications 2

Physical Therapy Program (Minimum 3 Months)

Exercise therapy is the cornerstone of treatment and should include: 2, 1, 6

• Adductor muscle strengthening and stretching: Progressive resistance exercises targeting adductor longus and brevis 1, 3, 6
• Core stabilization: Strengthening of abdominal wall muscles to address muscle imbalance and prevent recurrence 1, 4, 6
• Hip flexor work: Iliopsoas strengthening and stretching 1
• Quadriceps and hamstring exercises: Address kinetic chain dysfunction 1
• Duration: At least 3 months of structured exercise therapy is recommended based on consensus guidelines 2

The evidence strongly supports exercise therapy for both treatment and prevention of groin injuries, with level 4 studies showing benefits for symptom remission, return to sport, and reduced recurrence 6

Manual Therapy Adjuncts

• Hip and pubic symphysis joint mobilizations: May accelerate recovery when combined with exercise 3
• Soft tissue mobilization: Direct treatment to adductor longus muscle belly 3
• Lumbopelvic manipulation: Consider for patients with concurrent pelvic dysfunction 3

Monitoring Response to Treatment

Outcome Measures

• Pain scales: Numeric Pain Rating Scale (NPRS) should improve from baseline 3
• Functional scales: Lower Extremity Functional Scale (LEFS) tracks functional improvement 3
• Return to activity: Progressive return to sport-specific activities as tolerated 2, 6

Expected Timeline

• Acute strains: Most respond within 6-12 weeks with appropriate conservative management 3, 6
• Chronic cases: May require 3-6 months of structured rehabilitation 2, 4

Surgical Considerations

Surgery is reserved for failure of conservative management after 3-6 months, with specific indications depending on the underlying pathology: 1, 4

• Core muscle injury (sportsman's hernia): Surgical repair of abdominal wall weakness if conservative treatment fails 1, 4
• Chronic adductor tendinopathy: Adductor tenotomy or release in refractory cases 4
• Osteitis pubis: Rarely requires surgical intervention; continue conservative management 1

Critical caveat: Inadequate conservative treatment duration (less than 3 months) is a common reason for poor outcomes - ensure patients complete a full rehabilitation program before considering surgery 2, 1, 4

Prevention Strategies

• Preseason conditioning: Exercise programs incorporating adductor and core strengthening reduce injury incidence 6
• Address muscle imbalances: Weakness of abdominal wall relative to adductors is a key risk factor 1
• Gradual return to sport: Avoid premature return to full activity 3, 6