What is the best course of action for a patient with a 2-year history of intermittent groin pain, previously diagnosed with an inguinal hernia, who experiences worsening pain in winter, radiating to the inner thigh, relieved by sitting and rest, but without weakness?

Chronic Groin Pain with Radiation to Inner Thigh: Diagnostic and Management Approach

This patient most likely has osteitis pubis or athletic pubalgia ("sports hernia"), not a recurrent inguinal hernia, and should undergo MRI of the pelvis to confirm the diagnosis, followed by conservative management including rest, physical therapy focusing on hip and core strengthening, and anti-inflammatory measures.

Clinical Presentation Analysis

The key clinical features that distinguish this from a true hernia recurrence include:

• Pain pattern: Radiates to inner thigh and "inside of muscle" rather than presenting as a discrete bulge 1, 2
• Positional relief: Pain relieved by sitting and rest, which is characteristic of inflammatory/overuse conditions rather than mechanical hernia 1, 2
• Seasonal variation: Worsening in winter (likely related to activity changes) suggests musculoskeletal etiology 1
• Absence of weakness: Rules out significant nerve compression or muscle disruption 1
• Physical examination: "Not hernia" on examination excludes incarcerated or recurrent hernia 3

Most Likely Diagnosis: Osteitis Pubis

Osteitis pubis is the most common inflammatory disease of the pubic symphysis, presenting as a self-limiting inflammation secondary to trauma, surgery, or overuse. 1 This condition:

• Occurs more commonly in men during their 30s and 40s 1
• Causes pain in the pubic area, one or both groins, and lower rectus abdominis muscle 1, 2
• Pain radiates to multiple distributions: inguinal, adductor region, inner thigh, perineal, and suprapubic areas 1, 2
• Described as "groin burning" with discomfort while climbing stairs, coughing, or sneezing 1
• Aggravated by running, cutting, hip adduction and flexion against resistance 2
• Relieved with rest 1, 2

The 2-year history of intermittent symptoms following inguinal hernia surgery fits the postoperative etiology of osteitis pubis, which was first described in patients after suprapubic surgery 1.

Differential Diagnosis to Consider

Athletic pubalgia ("sports hernia") should also be considered, which presents with:

• Chronic groin pain without clear hernial protrusion 4
• Muscular injury from overexertion of the inguinal region 4
• Similar pain distribution and aggravating factors 4, 5

Other causes of chronic groin pain that are less likely given this presentation include nerve entrapment, avulsion fractures, or hip pathology 5.

Diagnostic Workup

Order MRI of the pelvis as the primary diagnostic test. 2, 4

MRI findings that confirm osteitis pubis include:

• Inflammatory exudate around the pubic symphysis 4
• Bone marrow edema in parasymphyseal bone 2
• Tenderness over the pubic bone on examination correlates with imaging findings 4

Plain radiographs and bone scans can aid diagnosis but MRI is superior for soft tissue evaluation and detecting early inflammatory changes 2, 6.

Management Algorithm

Initial Conservative Management (First-Line)

Begin with 6-8 weeks of conservative therapy: 1, 2, 4, 6

1. Activity modification and relative rest

   • Avoid aggravating activities (running, cutting movements, stairs) 1, 2
   • Maintain cardiovascular fitness with non-impact activities 2

2. Physical therapy (most critical component)

   • Strengthening of abdominal and hip muscles 6
   • Improving hip range of motion, particularly internal rotation 6
   • Stretching exercises 4
   • Core stabilization 2

3. Anti-inflammatory measures

   • NSAIDs for symptom control 4
   • Ice application during acute flares 2

Second-Line Interventions

If no improvement after 6-8 weeks of conservative therapy: 4, 6

• Corticosteroid injections into the pubic symphysis or surrounding tissues 4, 6
• Local anesthetic injections for diagnostic and therapeutic purposes 4
• Prolotherapy with dextrose has been reported with variable efficacy 2

Surgical Options (Last Resort)

Reserve for refractory cases after 6-12 months of failed conservative management: 2, 6

• Wedge resection of the symphysis 6
• Curettage of the symphysis 6
• Arthrodesis (rarely needed) 6

Surgical outcomes are variable and should only be considered after exhausting conservative options 2, 6.

Prognosis and Expectations

The prognosis for full recovery is good, although the recovery period is lengthy. 6 Patients should be counseled that:

• Symptoms typically resolve over months, not weeks 1, 2
• This is a self-limiting condition 1
• Premature return to aggravating activities will prolong recovery 2
• Compliance with physical therapy is essential for optimal outcomes 6

Common Pitfalls to Avoid

• Do not assume recurrent hernia based solely on location of pain and history of prior hernia repair 1, 5
• Do not rush to surgery without adequate trial of conservative management, as this is typically a self-limiting condition 1, 6
• Do not neglect physical therapy, which is the cornerstone of treatment and addresses the underlying biomechanical overloading 2, 6
• Do not overlook hip pathology in the differential diagnosis, as hip disorders can present with groin pain 5