What are the likely causes, workup, and management for intermittent right‑sided groin pain in a 79‑year‑old woman?

Right Intermittent Groin Pain in a 79-Year-Old Woman

Immediate Red-Flag Exclusion

In a 79-year-old woman with intermittent right groin pain, you must first exclude vascular claudication from peripheral arterial disease, which presents as exercise-induced groin/thigh pain that resolves within 10 minutes of rest, and gynecologic causes including ovarian pathology and uterine fibroids, which are the most common causes of acute pelvic pain in this age group. 1

Critical Red Flags Requiring Urgent Evaluation

• Peripheral arterial disease (PAD): Iliac artery occlusive disease produces hip, buttock, and thigh pain that is exercise-induced and relieved with rest (classic intermittent claudication). 1 Check for diminished femoral pulses, femoral bruits, and risk factors including age >65 years, smoking, diabetes, hypertension, or known atherosclerotic disease elsewhere. 1, 2

• Gynecologic pathology: In postmenopausal women, ovarian cysts account for one-third of acute pelvic pain cases, uterine fibroids are the second most common cause, pelvic infection accounts for 20%, and ovarian neoplasm causes 8% of cases. 1 Night pain, constitutional symptoms, or progressive worsening raise concern for malignancy. 3

• Stress fracture: Insidious onset with night pain, inability to bear weight, and focal bone tenderness over the femoral neck or pubic ramus requires immediate exclusion. 3, 2

• Infection or tumor: Fever, inability to bear weight, severe rest pain, or systemic symptoms mandate urgent evaluation. 3, 2

Diagnostic Algorithm

Step 1: Characterize the Pain Pattern

• Vascular claudication: Aching, burning, or cramping that occurs predictably with walking a specific distance and resolves within 10 minutes of rest. 1, 2 The pain is distance-dependent and reproducible. 2

• Hip osteoarthritis: Medial groin and thigh aching discomfort exacerbated by activity, relieved by rest, but not quickly relieved after variable exercise; improved when not bearing weight. 1, 2 Pain with internal rotation of the hip and limited range of motion on examination. 2

• Gynecologic origin: Poorly localized pelvic/groin pain without the predictable exercise-rest pattern of claudication. 1

• Lumbar spine referral: Sharp lancinating pain radiating down the leg, induced by sitting, standing, or walking, often present at rest, improved by position change. 2 History of back problems is common. 2

Step 2: Physical Examination Priorities

• Vascular assessment: Palpate femoral, popliteal, posterior tibial, and dorsalis pedis pulses bilaterally. 1 Auscultate for femoral bruits. 1 Examine for asymmetric hair growth or nail changes suggesting chronic ischemia. 2

• Hip examination: Assess pain with internal rotation, perform FADIR test (flexion-adduction-internal rotation) to evaluate for intra-articular pathology. 3 Limited range of motion suggests osteoarthritis. 2

• Pelvic examination: Essential in postmenopausal women to assess for masses or tenderness. 1

• Lumbar spine screening: Mandatory in all cases—perform neurologic examination and assess for radiculopathy, as lumbar pathology commonly mimics hip/groin pain. 3, 2

Step 3: Initial Imaging Strategy

First-line imaging depends on the clinical presentation:

• If vascular claudication is suspected: Obtain ankle-brachial index (ABI) as the initial diagnostic test. 1, 2 An ABI <0.9 confirms PAD. 1

• If gynecologic pathology is suspected: Transvaginal or transabdominal ultrasound is the initial imaging modality of choice for evaluating ovarian cysts, masses, and uterine pathology in postmenopausal women. 1

• If musculoskeletal hip pathology is suspected: AP pelvis and lateral femoral head-neck radiographs are first-line to detect osteoarthritis, dysplasia, or fractures. 3, 2

• If presentation is nonspecific with broad differential: CT abdomen and pelvis with IV contrast is appropriate first-line imaging, with 89% sensitivity for urgent diagnoses and ability to evaluate gynecologic, urologic, gastrointestinal, and vascular etiologies simultaneously. 1

Step 4: Advanced Imaging When Initial Workup Is Inconclusive

• MRI pelvis: Indicated when radiographs are negative but intra-articular hip pathology (labral tear, FAI syndrome) remains suspected, or to characterize adnexal masses detected on ultrasound. 3, 4

• CT angiography: If ABI is abnormal or high clinical suspicion for PAD persists despite normal ABI (which can occur with calcified vessels in diabetics). 1

Most Likely Diagnoses by Age and Presentation

In a 79-Year-Old Woman with Intermittent Groin Pain:

1. Hip osteoarthritis (most common musculoskeletal cause in this age group): Activity-related groin pain, limited internal rotation, diagnosed by plain radiographs showing joint space narrowing. 1, 2

2. Peripheral arterial disease (critical to exclude): Exercise-induced pain relieving with rest, diminished pulses, diagnosed by ABI. 1, 2

3. Ovarian cyst or fibroid (most common gynecologic causes): Poorly localized pelvic pain, diagnosed by pelvic ultrasound. 1

4. Lumbar spine pathology with referred pain: Radicular symptoms, worse with sitting, diagnosed by lumbar spine imaging if hip examination is inconsistent. 3, 5, 2

5. Iliopsoas tendinopathy: Anterior/medial groin pain with hip flexion against resistance, diagnosed by ultrasound or MRI. 3, 5, 4, 6

Critical Clinical Pitfalls to Avoid

• Missing vascular claudication: In patients >65 years, always assess vascular status—iliac artery disease specifically causes groin/hip pain that mimics musculoskeletal pathology but has life-threatening implications if untreated. 1

• Assuming all groin pain is musculoskeletal: In postmenopausal women, gynecologic pathology (especially ovarian neoplasm) must be excluded given the 8% malignancy rate in this presentation. 1

• Failing to screen the lumbar spine: Lumbar radiculopathy is a common, frequently missed source of groin pain and must be systematically assessed in every patient. 3, 2

• Overlooking coexisting pathologies: Hip osteoarthritis, iliopsoas pathology, and lumbar spine disease commonly coexist in elderly patients—identifying one does not exclude others. 3

• Misinterpreting incidental imaging findings: Asymptomatic labral tears and FAI morphology are common in older adults; clinical correlation is mandatory before attributing symptoms to imaging abnormalities. 3