What is the recommended evaluation and management for inguinal ligament pain in an adult without red‑flag symptoms?

Inguinal Ligament Pain: Evaluation and Management

For adults with inguinal ligament pain without red-flag symptoms, begin with targeted physical examination identifying the exact site of tenderness at the pubic insertion of the inguinal ligament, followed by plain radiographs to exclude serious pathology, then proceed with a trial of conservative management including activity modification and physical therapy for 3-6 months before considering interventional treatments.

Initial Clinical Assessment

Key Physical Examination Findings

• Palpate specifically for point tenderness at the pubic insertion of the inguinal ligament, which is the most common cause of chronic obscure groin pain and may be obscured by the pubic fat pad 1
• Assess for enthesopathy (inflammation at tendon/ligament insertions) at the inguinal ligament, rectus abdominis, and adductor longus tendons 1
• Perform the FADIR test (flexion-adduction-internal rotation) to exclude intra-articular hip pathology—a negative test helps rule out hip-related causes 2, 3
• Examine the lumbar spine and pelvis to exclude referred pain, as radicular pain commonly mimics groin pathology 2, 3

Red-Flag Exclusion

• Rule out serious pathology including tumors, infections, stress fractures, avascular necrosis, and slipped capital femoral epiphysis before proceeding with benign diagnoses 2
• Exclude ureteric stones and nerve entrapment syndromes, which can present similarly 1

Diagnostic Imaging Approach

Initial Imaging

• Obtain anteroposterior pelvis and lateral femoral head-neck radiographs first to exclude fractures, arthritis, dysplasia, and osseous pathology 2, 3
• Plain radiographs are mandatory before proceeding to advanced imaging 4

Advanced Imaging (When Indicated)

• MRI with specific inguinal ligament and pubic assessment can identify tears in the inguinal ligament and associated soft tissue pathology in refractory cases 5, 6
• Dynamic ultrasound may evaluate the greater trochanteric region if lateral hip pathology is suspected, but is less useful for inguinal ligament pathology 4
• MRI is particularly valuable when surgical intervention is being considered or when conservative management has failed 5, 6

Etiopathogenesis

The underlying mechanism involves three key factors 7:

• Compression of the three nerves of the inguinal region (ilioinguinal, iliohypogastric, genitofemoral)
• Muscle imbalance between adductor and abdominal wall muscles caused by hypertrophy and stiffness at the rectus and adductor longus insertions
• Partial weakness of the posterior inguinal wall

Enthesopathy at the pubic insertion of the inguinal ligament represents a "tennis elbow of the groin" and is frequently unrecognized 1.

Management Algorithm

First-Line Conservative Treatment (3-6 Months)

• Activity modification with avoidance of kicking and twisting movements while running 7
• Standardized physical therapy regimen focusing on muscle balance and core strengthening 8, 7
• NSAIDs for symptomatic relief 3

Second-Line Interventional Treatment (If Conservative Fails)

• Local anesthetic (2% lignocaine) and long-acting steroid (1% triamcinolone) injection at the site of maximal tenderness provides short-term relief (effective at 1 week but not sustained at 3-6 months) 8, 1
• Radiofrequency denervation (RFD) of the ilioinguinal nerve and inguinal ligament provides superior and sustained pain relief compared to injection alone, with significant improvements maintained at 6 months 8
• RFD is safe with no persistent adverse events and allows athletes to return to play more quickly 8

Surgical Treatment (If Interventional Fails)

Surgical intervention should include 7, 6:

• Release of all three nerves of the inguinal region
• Partial tenotomy of the rectus and adductor longus muscles to correct muscle imbalance
• Repair of posterior wall weakness with lightweight mesh
• Inguinal ligament tenotomy when tears are identified

This approach has shown excellent results with complete symptom relief after resumption of physical activity 7, 6.

Critical Clinical Pitfalls

• Do not assume inguinal hernia is causative—it may be coincidental rather than the source of pain 1
• Avoid elaborate investigation or unnecessary hernia repair without first attempting conservative and interventional measures 1
• The exact site of tenderness can be obscured by pubic fat—careful palpation is essential 1
• Chronic changes in athletes on imaging must be correlated with clinical examination to avoid misinterpretation 5
• Incidental imaging findings are common in asymptomatic individuals—clinical correlation is mandatory 3