What is the appropriate initial assessment and management for an adult male presenting with groin pain?

Groin Pain in Adult Men: Initial Assessment and Management

In an adult male presenting with groin pain, immediately rule out testicular torsion with urgent scrotal ultrasound if any scrotal symptoms are present, then systematically exclude serious non-musculoskeletal pathology before addressing the most common causes: adductor-related pain, inguinal-related pain (including hernias), hip-related pain (particularly FAI syndrome), and iliopsoas-related pain. 1, 2, 3

Immediate Triage: Rule Out Surgical Emergencies

Testicular Torsion (If Scrotal Pain Present)

• Any acute scrotal pain component must be treated as testicular torsion until proven otherwise, as testicular viability is compromised after 6-8 hours 2, 3
• Obtain urgent Duplex Doppler ultrasound of the scrotum as first-line imaging (sensitivity 69-96.8%, specificity 87-100%) 2, 3
• Key ultrasound findings include decreased/absent testicular blood flow, "whirlpool sign" of twisted spermatic cord, and enlarged heterogeneous testis 2, 3
• Do not delay surgical exploration for imaging if clinical suspicion is high (TWIST score 6-7 or classic presentation) 2, 3
• Testicular torsion occurs more commonly in adolescents but can occur in young adults 3

Other Serious Pathology to Exclude First

• Rule out tumors, infections, stress fractures, slipped capital femoral epiphysis, and lumbar spine pathology before focusing on hip-related causes 4, 1
• Consider Fournier gangrene if signs of systemic toxicity, scrotal erythema, or crepitus are present 4

Systematic Physical Examination Approach

Key Provocative Tests by Anatomic Region

Adductor-Related Pain:

• Palpate adductor longus tendon insertion at pubic tubercle for focal tenderness 5, 6
• Adductor squeeze test: Patient supine with hips flexed 80° and abducted; positive if sharp groin pain occurs when patient adducts against resistance 5
• Pain typically worsens with sports activity and improves with rest 5, 6

Hip-Related Pain:

• FADIR test (Flexion-Adduction-Internal Rotation): A negative test helps rule out intra-articular hip pathology, though specificity is limited 4, 1
• Groin pain is the hallmark symptom but may radiate to back, buttock, or thigh 4, 1
• Most hip examination tests have high sensitivity but poor specificity, useful for screening only 4, 1

Inguinal-Related Pain:

• Palpate superficial inguinal ring for tenderness or palpable defect 6
• Assess for posterior abdominal wall weakness ("sports hernia") 7, 6
• Pain typically worsens with Valsalva, coughing, or sit-ups 6

Iliopsoas-Related Pain:

• Pain with resisted hip flexion or passive hip extension 6
• Often coexists with hip joint pathology 6

Pubic-Related Pain:

• Direct palpation over pubic symphysis for tenderness 6
• Associated with osteitis pubis in athletes 7, 6

Diagnostic Imaging Algorithm

Initial Imaging Based on Clinical Suspicion

For Suspected Hip-Related Pain:

• Hip radiography first to assess for osseous morphology (FAI cam/pincer morphology, dysplasia) 4, 1
• MRI of pelvis/hip if diagnosis unclear or symptoms persist despite conservative management 4, 6
• Combined clinical and imaging approach is essential, as neither alone has sufficient diagnostic utility 4, 1

For Suspected Adductor-Related Pain:

• MRI of pelvis if diagnosis unclear or no improvement after 6-8 weeks of conservative management 6
• Plain radiographs may show chronic changes (osteitis pubis) but are often normal acutely 6

For Suspected Inguinal-Related Pain:

• Dynamic ultrasonography to rule out true hernia and evaluate posterior abdominal wall weakness 6
• This is preferred over static imaging for detecting occult hernias 6

For Suspected Iliopsoas-Related Pain:

• Hip radiography and MRI are preferred due to frequent concomitant hip pathology 6

Initial Management by Diagnosis

Adductor-Related Groin Pain (Most Common in Athletes)

• Active, supervised physical therapy is first-line treatment 6
• Focus on stretching and strengthening adductor muscles, abdominal wall, iliopsoas, quadriceps, and hamstrings 5
• NSAIDs and muscle relaxants as adjuncts 5
• Adductor tenotomy reserved for chronic cases failing conservative management 8

Hip-Related Pain (FAI Syndrome, Dysplasia, Labral Tears)

• The three most common hip conditions in young active males are: (1) FAI syndrome, (2) acetabular dysplasia/hip instability, (3) labral/chondral/ligamentum teres lesions without obvious bony deformity 4, 1
• Initial conservative management with activity modification and physical therapy 4
• Surgical referral if conservative management fails and imaging confirms structural pathology 4

Inguinal-Related Pain Without Hernia

• Core strengthening and neuromuscular rehabilitation physical therapy 6
• Abdominal wall repair if conservative management fails 8

Iliopsoas-Related Pain

• Physical therapy focusing on hip flexor stretching and strengthening 6
• Address any underlying hip joint pathology identified on imaging 6

Critical Pitfalls to Avoid

• Do not assume a single diagnosis: Groin pain often has multifactorial origins with coexisting pathologies 4, 1, 9
• Do not rely on clinical examination alone: Most orthopedic tests have poor specificity; integrate imaging findings 4, 1
• Do not miss testicular torsion: Always ask about scrotal symptoms and examine the scrotum 2, 3
• Do not delay imaging in athletes with persistent symptoms: Chronic groin pain requires MRI to identify structural pathology 6
• Do not overlook non-musculoskeletal causes: Consider genitourinary conditions, hernias, and referred pain from lumbar spine 4, 7, 9
• Normal urinalysis does not exclude testicular pathology if scrotal pain is present 2

Age-Specific Considerations

• Young active males (15-35 years): Consider sports-related causes (adductor strain, FAI syndrome, "sports hernia") first 1, 5
• Adolescents with scrotal component: Testicular torsion has bimodal distribution with peak in postpubertal boys 3
• Adults over 35 years: Epididymitis becomes more common than torsion for scrotal pain; hip osteoarthritis increases in prevalence 3, 9