Groin pain, which is often related to hip pathology, is a common problem for athletes and nonathletes alike. Making a diagnosis can be challenging, given that groin pain often results from multiple coexisting issues that may or may not be orthopaedic in nature.

Orthopaedists must obtain a thorough medical history and complete a comprehensive, physical examination tailored to diagnose the source(s) of this problem, as outlined in “Comprehensive Approach to the Evaluation of Groin Pain,” a review article in the September issue of the Journal of the AAOS. Lead author Juan C. Suarez, MD, of the Cleveland Clinic in Weston, Fla., recently spoke with AAOS Now about the various methods for determining the source—or sources—of groin pain.

AAOS Now: What was the catalyst for this review article?
Dr. Suarez: Groin pain will surely affect more patients in the future, as aging “baby boomers” are afflicted with hip arthritis, lumbar spine disorders, and other degenerative disorders. By the time people in the United States reach 85 years of age, one-quarter of them will have symptomatic hip arthritis, which can lead to groin pain.

We wrote this article to provide a framework for the practicing orthopaedic surgeon to use when evaluating this problem, which can be a vague complaint that may span multiple medical disciplines. Our goal was to help orthopaedists avoid diagnostic pitfalls and unnecessary testing for groin pain, which may have an acute onset, or may be a chronic issue. Within the study, we provide multiple algorithms for orthopaedists to use as they perform a differential diagnosis.

AAOS Now: What are some of the causes of groin pain?
Dr. Suarez: It is important to distinguish between intra- and extra-articular pathologies linked to groin pain.

Intra-articular conditions—such as degenerative joint disease, osteonecrosis, chondrolysis, labral tear, and fractures—typically present with deep groin pain that radiates to the anterior thigh and medial knee.

Extra-articular conditions may include musculotendinous strains, pelvic fractures, sacroiliac joint disorders, sports hernias, nerve entrapments, lumbar radicular pain, or osteitis pubis. These conditions may present with groin pain along with other disorder-specific symptoms and atypical radiation patterns.

The wide range of possible diagnoses illustrates the importance of obtaining a thorough medical history to guide the physical examination. The history must take into account that many systems—such as the genitourinary, gastrointestinal, vascular and neurological systems—may have a role in groin pain.

AAOS Now: In the study, you note that the physical examination should be tailored to the individual patient. How might the physical examination of a 15-year-old female gymnast with chronic groin pain vary from that of a 65-year-old, mostly sedentary male with acute onset of groin pain?
Dr. Suarez: The differential diagnosis for each patient would be completely different, but both patient work-ups would begin the same way: with a complete medical history.

The musculoskeletal exam would need to be systematic and comprehensive for both of these patients. For the young female athlete, the orthopaedist may be particularly aware that overuse injuries and stress fractures may be involved. In the elderly male, sources of groin pain could include insufficiency fractures and degenerative conditions such as osteoarthritis.

Although the history and examination may focus mainly on the musculoskeletal disorders, nonmusculoskeletal conditions to consider would be different in these two patients. For example, the medical history for the 15-year-old female would focus on any previous sports injuries, congenital disorders, or gynecologic disorders. On the other hand, the elderly male’s history should include previous surgeries, such as hernia repair, as well as gastrointestinal and urogenital conditions.

A recently published meta-analysis concluded that there is no single, meaningfully discriminatory test for any kind of hip pathology, which is why it is important to perform the appropriate types of physical examination. The standing examination can help evaluate factors such as pelvic obliquity and gait, while a seated examination can help determine hip joint mobility by stabilizing the pelvis. A supine examination can assess the internal and external range of motion, as well as hip flexion, extension, abduction, and adduction. In addition, an examination with the patient in the lateral decubitus position may help the orthopaedist evaluate factors such as iliotibial band contracture.

AAOS Now: What are some of the key things to keep in mind when determining the proper laboratory testing and diagnostic imaging to be performed?
Dr. Suarez: The history and physical examination will narrow diagnostic possibilities and guide the imaging and laboratory workups. For example, when constitutional symptoms are present along with groin pain and septic arthritis is suspected, then routine blood tests—including complete blood count, erythrocyte sedimentation rate, and C-reactive protein—should be conducted.

AAOS Now: What about diagnostic tools?
Dr. Suarez: Magnetic resonance imaging (MRI) is the study of choice to diagnose labral and cartilage disorders. The injection of contrast in the joint distends the capsule and outlines the labrum, making labral pathology more obvious. Advancements in nonarthrographic MRIs may obviate the need for magnetic resonance arthrography in the future. The computed tomography scan still has a role in evaluating osseous disorders, such as intra-articular loose bodies, fractures, and deformities.

We have found great utility in the use of injections to help diagnose groin pain. They can be used to include or exclude potential sources of pain when the diagnosis is in question.

AAOS Now: What are the key “take-aways” from your review article?
Dr. Suarez: Orthopaedists should be careful not to overlook non-orthopaedic conditions as potential sources of groin pain. In addition, performing a comprehensive history and systematic physical examination focused around the hip joint is crucial.

Finally, orthopaedists must have access to a good network of physicians in multiple specialties to ensure that patients are referred properly. In my experience, the diagnosis is often not obvious and multiple visits, examinations, and referrals might be required to identify the correct diagnosis.

Dr. Suarez’s coauthors for “Comprehensive Approach to the Evaluation of Groin Pain” include Erin E. Ely, MD; Amar B. Mutnal, MD; Nathania M. Figueroa, MD; Alison K. Klika, MS; Preetesh D. Patel, MD; and Wael K. Barsoum, MD.

Disclosure information: Dr. Suarez—Pacira Pharmaceutical and OrthAlign. Dr. Ely—no information. Dr. Mutnal—Genentech. Dr. Figueroa, Ms. Klika—no conflicts. Dr. Patel—Stryker; OtisMed Corporation; Dr. Barsoum—Exactech, Inc.; Stryker; Zimmer; Custom Orthopaedic Solutions; iVHR; Otismed; Active Implants; Cool Systems; DJO, Inc.; and Orthovita.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom Line

• Groin pain is a vague complaint that may span many medical disciplines, including orthopaedics.
• In addition to the musculoskeletal system, a thorough medical history must take into account other bodily systems that may have a role in groin pain.
• MRI may be the most helpful diagnostic tool, but routine blood tests, computed tomography scans, and injections may also be helpful .

Additional Resources
JAAOS study abstract