What is the likely diagnosis and management for a patient with 2 weeks of right groin pain, worsening with movement and ambulation, tenderness to palpation (TTP) at the midpoint of the right inguinal region, without signs of swelling or erythema?

Right Groin Pain: Likely Diagnosis and Management

Most Likely Diagnosis

This presentation is most consistent with hip osteoarthritis or occult hip fracture, and you must obtain plain radiographs (AP pelvis and lateral hip) immediately as the essential first-line diagnostic test. 1

The key clinical features pointing toward intra-articular hip pathology include:

• Groin pain localized to the midpoint of the inguinal region (classic for hip joint pathology) 2, 1
• Pain worsening with movement and ambulation (activity-related pain is characteristic of hip osteoarthritis) 2, 1
• Absence of swelling or erythema (rules out superficial infection, abscess, or inflammatory processes) 2

Diagnostic Algorithm

Step 1: Immediate Physical Examination Maneuvers

Perform internal rotation of the right hip while the patient is supine. If this reproduces the groin pain, it strongly suggests intra-articular hip pathology such as osteoarthritis, labral tears, or occult fracture. 2, 1, 3

Assess the patient's gait pattern. An antalgic gait (limping to avoid weight-bearing on the affected side) indicates significant hip pathology requiring urgent imaging. 2

Perform the FABER test (Flexion-Abduction-External Rotation). A negative test helps rule out hip-related pain, though its clinical utility is limited due to poor specificity. 2

Step 2: Obtain Plain Radiographs First (Mandatory)

You must obtain AP pelvis and lateral hip radiographs before any advanced imaging. 1, 3 This is the most critical step that identifies:

• Hip osteoarthritis (joint space narrowing, osteophytes, subchondral sclerosis) 2, 1
• Occult hip fractures (femoral neck or intertrochanteric) 1
• Femoroacetabular impingement morphology 2, 3
• Acetabular dysplasia 2, 3

Common pitfall: Failing to obtain radiographs first violates consensus guidelines and may miss significant bony pathology. 1, 3

Step 3: If Radiographs Are Negative But Clinical Suspicion Remains High

Obtain MRI of the hip without contrast within 48-72 hours. 1, 3 MRI is mandatory when:

• Radiographs are negative but the patient has persistent pain with weight-bearing 1
• You suspect occult hip fracture (especially if there was a fall or trauma) 1
• You need to evaluate for labral tears, early avascular necrosis, or soft tissue pathology 3

MRI is superior for detecting soft tissue pathology, labral tears, and early osteonecrosis that plain films miss. 3

Step 4: Consider Alternative Diagnoses Systematically

While hip pathology is most likely, you must exclude:

Inguinal hernia: Typically presents with a palpable bulge that may disappear when supine, often with gurgling or dragging sensation. 4 However, the absence of a palpable mass on your examination makes this less likely.

Adductor-related groin pain: The adductor test (patient supine with hips abducted and flexed at 80 degrees, attempting to pull legs together against resistance) would reproduce sharp groin pain. 5, 6 The midpoint inguinal location makes this less likely than hip joint pathology.

Nerve entrapment (ilioinguinal, iliohypogastric, genitofemoral, or lateral femoral cutaneous): These typically cause burning or shooting pain with specific dermatomal patterns, not mechanical pain worsening with ambulation. 7

Lumbar spine or sacroiliac joint referred pain: Examine the lumbar spine and perform sacroiliac joint provocation tests, as these are common sources of referred pain to the groin region. 2, 3

Initial Conservative Management (While Awaiting Imaging)

Start oral NSAIDs immediately if not contraindicated (no renal disease, GI bleeding history, or cardiovascular contraindications). 2 NSAIDs provide symptomatic relief for hip osteoarthritis with strong evidence.

Consider oral acetaminophen as an alternative if NSAIDs are contraindicated. 2

Recommend activity modification: Avoid prolonged walking, stair climbing, and high-impact activities until diagnosis is confirmed. 2

Provide an assistive device (cane in the contralateral hand) if the patient has an antalgic gait. 2

Management After Diagnosis Confirmation

If Hip Osteoarthritis Is Confirmed:

Refer to physical therapy for mild-to-moderate symptomatic hip osteoarthritis. 2, 3 PT focused on hip strengthening and range of motion has high-quality evidence supporting its use.

Consider intra-articular corticosteroid injection if conservative measures fail after 6-8 weeks. 2, 3 This provides both diagnostic confirmation and therapeutic benefit.

Do NOT use intra-articular hyaluronic acid injection for hip osteoarthritis—strong evidence recommends against it. 2

Avoid opioids for chronic hip pain, as consensus recommendations oppose their use for symptomatic hip osteoarthritis. 2, 3

If Occult Hip Fracture Is Confirmed:

Immediate orthopedic surgery consultation for surgical fixation or hip replacement depending on fracture location and patient factors. 1

Critical Pitfalls to Avoid

Never proceed to advanced imaging without plain radiographs first. 1, 3 This violates evidence-based guidelines and increases costs unnecessarily.

Do not miss occult fractures. If radiographs are negative but the patient has acute onset after a fall with persistent pain on weight-bearing, MRI is mandatory within 48-72 hours. 1

Do not diagnose based on imaging alone. Incidental findings (cam morphology, labral tears) are common in asymptomatic individuals—clinical correlation is essential. 2, 3

Screen for lumbar spine and sacroiliac joint pathology systematically, as hip-related pain requires comprehensive examination including the spine and pelvis. 2, 3

In women of reproductive age, always obtain a pregnancy test before imaging or treatment to exclude ectopic pregnancy. 1