Information
Editors
Groin Pain
Essentials
- Septic infections warranting immediate treatment should be identified.
- One should be able to clinically suspect a possible fracture of the femoral neck (including a stress fracture) even prior to x-ray to avoid additional damage due to weight bearing .
Paediatric and adolescent patients
- Stress-induced ligament or muscle injury
- An injury or stress condition of the adductor muscles of the thigh is common, resulting in painful or weak forced adduction of the thigh at clinical examination. The injury is first of all encountered in athletes (also adults) either in the muscle (tear), in the adductor tendon (tendinitis) or in the muscle insertion (enthesitis).
- Tendinopathy or bursitis of the iliopsoas muscle may cause groin pain. Forced flexion of the hip is painful or lacking in strength.
- In the conjoined tendon injury (“inguinal disruption”, earlier “sports hernia") Treatment and Prevention of Sports Injuries the muscles of the lower abdomen (presumably mainly the oblique abdominal muscles or their tendons) become painful without actual hernial bulge that would be visible from the outside. There is vague dull pain on exertion either unilaterally or in the middle of the lower abdomen, strong enough to prevent exercising.
- Osteitis pubis, i.e. a sterile inflammation of the pubic bone may cause groin pain. The pain is felt unilaterally or in the middle of the lower abdomen. The pubic symphysis is always tender when pressed from the front with the palm.
- Acute synovitis of the hip joint in pre-adolescent patients Hip Pain in Children
- Often after respiratory infection
- Distinctly restricted internal rotation of the hip joint (picture 1)
- Stress fracture of the femoral neck or pubic bone
- Due to extreme strain, e.g. in military conscripts
- Femoral head epiphysiolysis Hip Pain in Children
- Osteonecrosis of the epiphysis of the femoral head, i.e. Perthes disease Hip Pain in Children
- Usually in boys aged 5 to 9 years
- Bone tumours Sarcomas
- Osteoid osteoma is the most frequent tumour to cause pain
- Nocturnal pain
- Reactive arthritis or rheumatoid arthritis
- Usually symptoms also in other joints
- Septic arthritis
- Painful lymph node in the groin
- Erysipelas, tularaemia, genital or lower extremity infection
- Inguinal hernia
- Bursitis in the hip region
- Hip ganglia
- Usually associated with tears of the cartilaginous labrum
- Referred pain
- In ureteric colic pain is referred into the side distinctly above the groin.
- Referred pain may also originate from the testicles and prostate.
Adult and elderly patients
- The reliability of the clinical tests mentioned below has not been assessed, and hence they should be taken with some reservation.
- In addition to the above
- Hip osteoarthritis Osteoarthritis of the Hip and Knee
- Inflammation or injury of sacroiliac joint Buttock and Hip Pain
- SI joint provocation tests may be positive.
- Walking and physical strain worsen the pain (note that walking often alleviates pain that is caused by back problems).
- FAI (femoroacetabular impingement)
- Abnormal contact between the femur and the acetabulum, which manifests as limits to the normal range of movement. This is caused by changes in the area of the acetabulum and the femoral head and neck.
- Anterior impingement sign: the patient lies in supine position, the hip is flexed to 90°, adducted and brought to internal rotation. Pain in the groin is a positive sign (pincer and cam, two subtypes of FAI)
- Nerve entrapments
- In meralgia paresthetica (entrapment of n. cutaneus femoris lateralis Meralgia Paraesthetica) the pain localizes to the anterolateral aspect of the thigh. Pain is accompanied by numbness and tingling. The patients are often obese.
- N. ilioinguinalis, n. obturatorius, n. genitofemoralis: pain in the inside of the thigh
- If nerve entrapment is suspected, the “arch & twist” manoeuvre may be useful: the patient stands lumbar spine hyperextended (arched) and twists the trunk towards and away from the painful side. If turning away from the painful side provokes pain, it may indicate nerve entrapment in the inguinal area (stretching of the nerve).
- Obturator nerve entrapment: the patient stands on one foot and brings the other hip to abduction and external rotation. Pain in the area innervated by obturator nerve indicates positive test.
- In irritation of upper lumbar (L1-L2) nerve roots the pain may also be referred to the groins.
- Femoral neck fracture
- An impacted fracture is possible despite ability to walk after the fall.
- Osteonecrosis of the femoral head
- E.g. due to glucorticoid treatment
Testing
- X-rays are always necessary when pain arising from the hip joint or femur is suspected. X-ray pictures must be taken in two perpendicular projections.
- Except for suspicion of fracture, an x-ray is not necessary in off-hours but weight bearing is prohibited prior to ruling out fracture.
- Ultrasound reveals fluid in the hip joint and possibly bursitis or ganglion.
- Pelvic MRI is indicated in prolonged pain if the x-rays are normal (stress fracture of the femoral neck, avascular necrosis, tumour).
References
- Sheen AJ, Stephenson BM, Lloyd DM et al. 'Treatment of the sportsman's groin': British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 2014;48(14):1079-87. [PubMed]
- Amanatullah DF, Antkowiak T, Pillay K et al. Femoroacetabular impingement: current concepts in diagnosis and treatment. Orthopedics 2015;38(3):185-99. [PubMed]
- Rassner L. Lumbar plexus nerve entrapment syndromes as a cause of groin pain in athletes. Curr Sports Med Rep 2011;10(2):115-20. [PubMed]
- Awender JF, Lawton CD, Jenkins TJ ym. A Current Update on Pelvifemoral Conditions That Should be in the Differential Diagnosis for Patients With Lower Extremity Radiculopathy. Clin Spine Surg 2021;34(6):206-215. [PubMed]
- Gollwitzer H, Banke IJ, Schauwecker J ym. How to address ischiofemoral impingement? Treatment algorithm and review of the literature. J Hip Preserv Surg 2017;4(4):289-298. [PubMed]