What could be causing groin pain in an adult after lifting, and how should it be treated?

Groin Pain After Lifting: Diagnosis and Management

Most Likely Diagnosis

In an adult presenting with acute groin pain after lifting, the primary concern is an inguinal hernia or adductor muscle strain, with the critical imperative being to exclude occult hip fracture if pain persists beyond 48 hours. 1, 2, 3

Immediate Red Flags Requiring Urgent Evaluation

• Inability to bear weight, severe pain at rest, or pain that worsens over 48 hours mandates repeat imaging with MRI, as initial radiographs can miss occult hip fractures 1
• Night pain, constitutional symptoms (fever, weight loss), or inability to ambulate suggests fracture, infection, or tumor requiring immediate advanced imaging 1, 4
• Entire leg swelling with tight, bursting pain raises concern for deep vein thrombosis 5

Diagnostic Approach

Initial Clinical Assessment

The physical examination should focus on four specific anatomic regions: adductor tendons (palpation and resisted adduction), inguinal canal (palpation with Valsalva), hip joint (FADIR test and range of motion), and iliopsoas (resisted hip flexion). 3

• Positive adductor test (sharp pain with resisted hip adduction from 80-degree flexed/abducted position) indicates adductor strain 6, 3
• Tenderness along posterior inguinal wall with increased pain during Valsalva maneuvers suggests inguinal hernia or "sports hernia" 3, 7
• Pain with hip internal rotation or positive FADIR test indicates intra-articular hip pathology 1, 2
• Always screen the lumbar spine, as radicular pain can present as groin pain 5, 4

Imaging Algorithm

Plain radiographs (AP pelvis and frog-leg lateral hip views) are mandatory as the first imaging study to exclude fractures, arthritis, and bone tumors. 1, 2

• If radiographs are negative but pain persists or worsens over 2 days, obtain MRI of the hip without contrast to detect occult fractures 1
• For suspected adductor tendinopathy with negative radiographs, MRI hip without IV contrast (rated 9/9 appropriateness) can detect intratendinous tears 2
• Dynamic ultrasound is appropriate for evaluating inguinal hernias and can guide therapeutic injections for adductor pathology 2, 3

Most Common Etiologies After Lifting

Musculotendinous Injuries (Most Common)

Adductor longus strain is the most frequent cause of acute groin pain after lifting, presenting as medial groin pain worsened by resisted adduction. 6, 3

• Adductor strains occur at the musculotendinous junction and typically respond to conservative management over 6-12 weeks 3, 7
• Rectus abdominis strain can cause lower abdominal/groin pain and is diagnosed by tenderness at the pubic insertion with resisted sit-ups 3, 8

Inguinal Pathology

"Sports hernia" (posterior abdominal wall weakness without true hernia) causes groin pain during exertion and Valsalva, with tenderness along the external inguinal canal. 3, 7

• Dynamic ultrasound should be performed to differentiate true inguinal hernia from posterior wall weakness 3
• True inguinal hernias may not be palpable at rest and require dynamic imaging during Valsalva 3

Occult Hip Fracture (Critical Not to Miss)

In patients over 50 or with osteoporosis risk factors, groin pain after lifting that persists beyond 48 hours requires MRI to exclude occult femoral neck or basicervical fracture. 1

• Initial radiographs can be completely normal in occult hip fractures, with MRI revealing the diagnosis 2-3 days later 1
• Basicervical and femoral neck fractures can present as isolated groin pain without obvious trauma 1

Treatment Algorithm

Conservative Management (First-Line for Musculotendinous Injuries)

Active, supervised physical therapy for 6-12 weeks is the initial treatment for adductor-related and pubic-related groin pain. 2, 3

• Physical therapy should include graduated stretching and strengthening of adductor muscles, abdominal wall muscles, iliopsoas, quadriceps, and hamstrings 6, 7
• NSAIDs and muscle relaxants can be used as adjunctive pharmacotherapy 6
• Activity modification with avoidance of provocative movements is essential during the healing phase 2, 3

Diagnostic/Therapeutic Injections

Image-guided anesthetic and corticosteroid injection (rated 8/9 appropriateness) provides both diagnostic confirmation and therapeutic benefit when the pain source remains unclear. 1, 2

• Ultrasound-guided injection into the adductor tendon can be both diagnostic and therapeutic for adductor tendinopathy 2
• Intra-articular hip injection under imaging guidance determines if pain originates from the hip joint versus surrounding structures 2

Surgical Referral Indications

Failure of conservative management after 6-12 weeks warrants surgical referral, particularly for confirmed sports hernia or complete tendon tears. 2, 3

• True inguinal hernias require surgical reinforcement of the inguinal wall 7
• Chronic adductor pain unresponsive to 3-6 months of conservative therapy may require surgical intervention 7

Critical Clinical Pitfalls

• Returning to activity too early with incomplete healing of adductor strains leads to chronic pain that becomes increasingly difficult to treat 7
• Hip pathology frequently presents as groin or medial thigh pain rather than lateral hip pain 1, 5
• Lumbar radiculopathy (L3) can present as medial groin pain with dermatomal sensory loss along the medial lower leg 2
• Patience is essential for complete healing of musculotendinous injuries, as premature return to lifting perpetuates the problem 7