Right Groin Pain Work-Up
Begin with plain radiographs of the pelvis and affected hip, followed by targeted physical examination maneuvers to differentiate hip pathology from other causes, and obtain basic laboratory tests if systemic illness is suspected.
Initial Imaging
Plain radiographs (AP pelvis and lateral hip) are the essential first-line imaging study for right groin pain, as they can identify hip osteoarthritis, fractures, and other bony pathology that commonly present with groin pain 1. Hip pathology classically presents as groin pain that is exacerbated by activity and relieved with rest 1.
- CT abdomen and pelvis should be obtained if the clinical presentation suggests non-musculoskeletal pathology (gastrointestinal, genitourinary, or gynecologic causes), as it has excellent diagnostic yield for identifying alternative diagnoses beyond appendicitis in right-sided abdominal/groin pain 1
- MRI of the hip is indicated when initial radiographs are negative but clinical suspicion for hip pathology remains high, particularly for occult fractures, labral tears, or early avascular necrosis 1
Physical Examination Findings
Internal rotation of the hip that reproduces groin pain strongly suggests intra-articular hip pathology 1. Key examination maneuvers include:
- Hip internal rotation test: Pain with internal rotation indicates hip joint pathology (osteoarthritis, labral tears, or femoral neck fractures) 1
- Adductor squeeze test: Patient lies supine with hips abducted and flexed at 80 degrees; sharp groin pain when attempting to adduct against resistance suggests adductor muscle strain or enthesopathy 2
- Palpation of pubic symphysis and inguinal ligament insertion: Localized tenderness at the pubic insertion of the inguinal ligament indicates enthesopathy, a common but underrecognized cause of chronic groin pain 3
- Assessment for inguinal hernia: Examine for bulge with Valsalva; consider dynamic ultrasound if sports hernia is suspected and static examination is negative 4
- Gait assessment: Antalgic gait with assistive device use suggests significant hip pathology 1
Laboratory Testing
Laboratory tests are not routinely necessary for isolated groin pain unless systemic illness, infection, or inflammatory conditions are suspected 1.
When indicated, obtain:
- Complete blood count: To assess for leukocytosis suggesting infection or inflammatory process 5
- Inflammatory markers (ESR, CRP): If osteomyelitis, septic arthritis, or inflammatory arthropathy is suspected 5
- Pregnancy test: Mandatory for all women of reproductive age to exclude ectopic pregnancy 5
Differential Diagnosis Algorithm
Hip osteoarthritis (most common in older adults):
- Groin pain with internal rotation, activity-related pain, radiographic joint space narrowing 1
Occult hip fracture:
- Acute onset after fall, pain with weight-bearing, negative initial radiographs require MRI 1
Adductor strain/enthesopathy:
Sports hernia/inguinal disruption:
- Athletes with activity-related pain, may require dynamic ultrasound for diagnosis 4
Nerve entrapment (ilioinguinal, genitofemoral, lateral femoral cutaneous):
- Burning or sharp pain, may radiate to thigh or genitalia, diagnosed by history and examination 6
Osteitis pubis:
- Pubic symphysis tenderness, common in athletes with repetitive stress 2
Common Pitfalls
- Failing to obtain radiographs first: Plain films must be obtained before advanced imaging, as they identify most significant hip pathology and guide further work-up 1
- Missing occult fractures: If radiographs are negative but clinical suspicion remains high (especially post-fall with persistent pain), MRI is mandatory within 48-72 hours 1
- Overlooking enthesopathy: The pubic fat pad can obscure the exact site of tenderness at the inguinal ligament insertion; careful palpation is essential 3
- Assuming hernia is causative: Inguinal hernias may be coincidental findings rather than the actual cause of groin pain 3
- Neglecting pregnancy testing: Always obtain pregnancy test in women of reproductive age before imaging or treatment 5