Review Article

Comprehensive Approach to the Evaluation of Groin Pain

Abstract
Juan C. Suarez, MD Erin E. Ely, MD Amar B. Mutnal, MD Nathania M. Figueroa, MD Alison K. Klika, MS Preetesh D. Patel, MD Wael K. Barsoum, MD

Groin pain is often related to hip pathology. As a result, groin pain is a clinical complaint encountered by orthopaedic surgeons. Approximately one in four persons will develop symptomatic hip arthritis before age 85 years. Groin injuries account for approximately 1 in 20 athletic injuries, and groin pain accounts for 1 in 10 patient visits to sports medicine centers. Many athletes with chronic groin pain have multiple coexisting pathologies spanning several disciplines. In treating these patients, the orthopaedic surgeon must consider both musculoskeletal groin disorders and nonorthopaedic conditions that can present as groin pain. A comprehensive history and physical examination can guide the evaluation of groin pain.

pproximately 25% of the population will develop symptomatic hip arthritis before age 85 years.1 Groin injuries account for up to 6% of all athletic injuries, and groin pain accounts for 10% of all visits to sports medicine centers.2,3 Furthermore, 27% to 90% of athletes with chronic groin pain are found to have multiple coexisting pathologies spanning several disciplines.4,5

History
When evaluating a patient who presents with groin pain as the chief complaint, it is important to perform a medical history that guides the physical examination, diagnostic tests, and referrals. The history of symptoms related to the presenting complaint should be characterized in terms of onset, location, quality, severity, exacerbating and alleviating factors, and radiation pattern. The location and quality of pain can help distinguish between intra- and extraarticular sources. Acute onset of pain

From the Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL. J Am Acad Orthop Surg 2013;21: 558-570 http://dx.doi.org/10.5435/ JAAOS-21-09-558 Copyright 2013 by the American Academy of Orthopaedic Surgeons.

has a differential diagnosis distinct from that of chronic groin pain. Both musculoskeletal (Table 1) and nonmusculoskeletal (Table 2) sources of groin pain must be considered. Intra- and extra-articular pathologies are associated with different etiologies, and it is important to distinguish between the two. Intraarticular pathology is generally implied with anterior groin or inguinal pain, which is typically felt deep within the hip joint and which may radiate to the knee. Patients often indicate their pain with the C sign, that is, by cupping the hand over the hip in the shape of the letter C (Figure 1). The ipsilateral index finger is positioned over the groin area on the affected side, with the thumb placed proximal to the greater trochanter.6-8 Patients also may report pain with weight bearing and during activities that require pivoting or twisting, such as golf, baseball, racquet sports, and martial arts.9 The presence of mechanical symptoms (eg, catching, locking) is suggestive of labral tears

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Table 1 Groin Pain Differential Diagnosis: Musculoskeletal Disorders Intra-articular Acetabular labral tears Osteonecrosis of the femoral head Chondrolysis Femoroacetabular impingement Femoral neck stress fracture Instability Legg-Calv-Perthes disease Oncologic processes Osteoarthritis Osteochondritis dissecans Septic arthritis Slipped capital femoral epiphysis Synovitis Extra-articular Apophyseal avulsion fracture Facet joint abnormalities Iliofemoral ligament sprain Lumbar radiculopathy Pubic ramus stress fracture Muscle strain: adductors/sartorius, rectus femoris, iliopsoas, or rectus abdominis Nerve entrapment: genitofemoral (L1, L2, L3), iliohypogastric (T12, L1), ilioinguinal (T12, L1), lateral femoral cutaneous (meralgia paresthetica, ventral rami [L2 L4]), obturator, or pudendal Osteitis pubis Psoas muscle abscess Sacroiliac joint disorders Snapping hip syndrome Sports hernia/pubalgia (eg, hockey player syndrome) Trochanteric bursitis

Table 2 Groin Pain Differential Diagnosis: Nonmusculoskeletal Disorders Intra-abdominal Acute Abdominal aortic aneurysm Appendicitis Diverticulitis Lymphadenitis Chronic Diverticulosis Inammatory bowel disease Inguinal or femoral hernia Tumors Genitourinary Acute Adnexa torsion Ectopic pregnancy Nephrolithiasis Orchitis Ovarian cysts Pelvic inammatory disease Round ligament pain Round ligament torsion Urinary tract infection Chronic Endometriosis Prostatitis Testicular cancer

or loose bodies as the principal diagnosis.7,8 Noting these symptoms early in the diagnostic process may not only help narrow the differential diagnosis but may also help streamline the remaining workup and expedite treatment. In contrast, pain that is relayed to the buttocks or posterior trochanteric region (Figure 2) or that is felt below the knee often indicates an extra-articular source of groin pain (Figure 3). Two such cases are spinal and sacroiliac (SI) joint pathology; associated symptoms include weakness, paresthesias, numbness, back pain, and neurogenic claudication. Symptoms are often worsened with sneezing or coughing and may vary

with posture.7,10 Upper lumbar radiculopathy (L1 through L3) often manifests as groin pain without distal radiation.11 Patients should also be asked about known congenital disorders, childhood use of orthoses, and childhood surgeries that may suggest conditions such as hip dysplasia, slipped capital femoral epiphysis, or LeggCalv-Perthes disease.12 History of alcohol abuse, excessive steroid use, coagulopathy, blood dyscrasia, malignancy, systemic inflammatory disease, HIV, hyperlipidemia, and decompression sickness should raise the suspicion of osteonecrosis.7,13 Past medical history also should include questions about nonmusculo-

skeletal sources of groin pain. A surgical history, including orthopaedic, gastrointestinal, genitourinary, gynecologic, and vascular procedures can assist with the differential diagnosis (Figure 4). For example, nerve entrapments and postoperative neuralgias are frequent and often overlooked causes of hip pain. Postoperative neuralgias resulting from suture entrap-

Dr. Suarez or an immediate family member is a member of a speakers bureau or has made paid presentations on behalf of Pacira Pharmaceuticals and serves as a paid consultant to OrthAlign. Dr. Mutnal or an immediate family member has stock or stock options held in Genentech. Dr. Patel or an immediate family member serves as a paid consultant to Stryker and has stock or stock options held in OtisMed. Dr. Barsoum or an immediate family member has received royalties from Exactech, Stryker, and Zimmer; is a member of a speakers bureau or has made paid presentations on behalf of Stryker; serves as a paid consultant to Stryker; has stock or stock options held in Custom Orthopaedic Solutions, iVHR, and OtisMed; and has received research or institutional support from Active Implants, Cool Systems, DJO, Orthovita, Stryker, and Zimmer. None of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Ely, Dr. Figueroa, and Ms. Klika.

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Comprehensive Approach to the Evaluation of Groin Pain

ment or nerve trauma can occur as early as 1 week after surgery.14 Neuralgias can present months to years after surgery due to scar tissue entrapment and/or neuroma development.14 The pain usually follows a
Figure 1

nerve distribution pattern (Figure 5) and is described as burning or lancing with occasional impaired sensation.14 Scar location provides clues to
Figure 2

the possible etiology and nerve involved. Neural groin pain is most commonly seen following herniorrhaphy and hysterectomy proce-

Photograph of the C sign. Patients with intra-articular hip pathology often localize the area of pain by cupping the thumb and index nger in the shape of the letter C above the affected area. Figure 3

Algorithm for the differential diagnosis of groin pain involving the thigh and buttocks and for groin pain that radiates distally. SI = sacroiliac

Algorithm for the differential diagnosis of groin pain radiating to the knee. ROM = range of motion, TOH = transient osteoporosis of the hip

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Figure 4

Algorithm for the differential diagnosis of groin pain related to the abdomen and as manifested with localized burning/ dysesthesias. AAA = abdominal aortic aneurysm, IBD = irritable bowel disease, PID = pelvic inammatory disease

dures, although it is also noted following vasectomy, appendectomy, soft-tissue tumor surgery, and iliac bone grafting.14 For example, numerous low transverse Pfannenstiel incisions are performed each year worldwide, and chronic neuropathic pain is observed in 12.3% to 33% of these patients.15 Nonmusculoskeletal sources of groin pain also should be considered during the initial history and patients referred to the appropriate specialist. Constipation, abdominal pain, changes in bowel or bladder habits, history of inflammatory bowel disease, and weight loss point toward gastrointestinal disease.7 Inguinal masses; pain with straining, lifting, sneezing, or coughing; and prior hernia surgeries may indicate inguinal or femoral hernia.16 Suprapubic pain accompanied by dysuria, urgency, and frequency suggests a urinary tract infection, a condition that nearly half of all women will experience at least once in their lifetime17 (Figure 6). Severe flank tenderness
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Figure 5

Cutaneous innervation of the lower abdomen.

radiating to the groin along with hematuria suggests nephrolithiasis.18 Epididymitis, orchitis, and testicular

torsion can present acutely with groin pain.19,20 Various gynecologic processes may

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Figure 6

Figure 7

Algorithm for the differential diagnosis of isolated groin pain. Algorithm for the differential diagnosis of suprapubic groin pain and radiating ank pain.

cause groin pain; endometriosis is present in approximately one third of cases.21 Typically, this is associated with the menstrual cycle, and dyspareunia and dyschezia are commonly reported. In pregnant females, the round ligament can be a source of groin pain, typically presenting during the second and third trimester of pregnancy. Pain is localized to the right lower quadrant of the abdomen and is described as sharp and shooting, with radiation to the groin.21 Ectopic pregnancy, painful ovarian cysts, ovarian cyst ruptures, pelvic inflammatory disease, and ovarian torsion are other sources of acute groin pain. Occupational and recreational history should be explored, including prior history of trauma. Many types of sports have been associated with an increased risk of developing early hip osteoarthritis (OA), which can cause groin pain in the young, active patient. These include endurance sports, which require continuous repetitive loading of the weightbearing joints; mixed sports (eg, soccer, ice hockey, basketball), which involve frequent high-impact joint loading along with cartilage sheer stresses; and power sports (eg, power lifting), in which extreme forces are

applied across the hip joint.22 Avulsion fractures are commonly seen in adolescents who participate in sports that involve kicking, rapid acceleration/deceleration, and jumping (eg, soccer, rugby, ice hockey, gymnastics, sprinting). Girls and women involved in endurance sports have a higher propensity for sustaining hip and pelvic stress fractures; therefore, the clinician must have a high index of suspicion for these injuries which, if overlooked, can cause poor results.16 Sports hernia, which is also known as athletic pubalgia, sportsman hernia, and hockey hernia, is a common sports-related groin injury (Figure 7). The etiology, diagnosis, and optimal treatment of sports hernias are somewhat controversial.16,23,24 This injury is thought to result from vigorous, repetitive twisting and turning activities, with the highest incidence among athletes who participate in ice hockey, soccer, rugby, tennis, and field hockey.16,23,24 These patients typically present with insidious, unilateral, deep groin pain that is exacerbated by sudden movements, coughing, sneezing, sit-ups, sprinting, and kicking. A key discriminator for sports hernia is pain that disappears completely with inactivity but reappears on resumption of activity.16,23,24 Hockey player syndrome, or slap shot gut, is a variant of sports hernia that is unique to elite ice

hockey athletes. Over time, the forceful extension and rotation of the hip of the nonshooting side that occurs during a slap shot is thought to cause tearing of the external oblique aponeurosis. Symptoms are usually worse in the morning, during the first few strides of skating, and when taking a slap shot. Pain can radiate to the hip, back, and, in males, the scrotum; the latter presentation is thought to be due to concomitant inguinal nerve entrapment.16,23 Evaluation and diagnosis of groin pain can be difficult because numerous pathologies have similar presentations. A comprehensive medical history will help guide the differential diagnosis and a focused physical examination, as well as prevent unnecessary diagnostic testing.

Physical Examination
A complete hip examination should be performed to identify or exclude hip and other musculoskeletal pathology (Tables 3 and 4). Many tests exist to help distinguish between intra-articular and extra-articular sources of groin pain, and the orthopaedic surgeon should know how to properly perform these maneuvers and understand their biomechanical rationale to maximize their usefulness. A recent meta-analysis found, however, that no single test was meaningfully discriminatory for a particular hip pathology and that most maneuvers have poor sensitivity and specificity due to interrelating pathomechanics that can result in groin pain.28 The physical examination is governed by the clinical picture and is unique to each patient. That is, no single protocol will suffice for all patients. A history-guided physical examination, including inspection, palpation, range of motion (ROM), and strength, along with provocative

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Table 3 Musculoskeletal Examination of the Patient With Groin Pain: Intra-articular Pathology Test Dynamic external rotary impingement3,4,25 Examination Procedure Supine position with the contralateral leg held in exion beyond 90. The examined hip is brought to 90 of exion and passively taken through a wide arc of abduction and external rotation. Supine position with the contralateral leg held in exion beyond 90. The examined hip is brought to 90 of exion and passively taken through a wide arc of adduction and internal rotation. Lateral or supine position. The hip is brought into exion, adduction, and internal rotation. Supine position. The leg is actively abducted to 30, and the examiner applies passive axial traction (ie, pulls the leg away from the body). Supine position. Strike heel rmly. Supine position. The leg is internally and externally rotated. Pain Results Diagnosis FAI/labral pathology

Dynamic internal rotary impingement3,4,25

Pain

FAI/labral pathology

Flexion adduction internal rotation3,4,25,26 Foveal distraction3

Pain

FAI/labral pathology

Relief of pain

Nonspecic intra-articular source

Heel strike4,26 Log roll (passive supine rotation)3,26

Pain Guarding, laxity, or pain

McCarthy4,25,26

Stincheld3,4

Supine position. The hip is moved from max- Pain in specic position imal exion, adduction, and internal rotation to full extension. The hip is moved from maximal exion, abduction, and external rotation with movement to full extension. Supine position. The leg is actively raised to Pain or weakness 30. The examiner exerts passive downward force on the leg.

Femoral neck stress fracture Intra-articular pathology suggestive of inammation (eg, synovitis, sepsis) Acetabular labral tear

Intra-articular pathology (eg, arthritis, synovitis, femoral neck fracture). Iliopsoas tendinitis.

FAI = femoroacetabular impingement

testing, should provide the necessary framework for conducting a thorough yet efficient hip examination. Patients may be examined in the upright, sitting, supine, or lateral decubitus position. Tests are individualized to each patient.

Standing Examination
Diagnostic information regarding gait, posture, and mobility can be gathered as the patient enters the consultation room, sits, and transfers to the examination table. On initial inspection the physician should make note of asymmetry, masses, or muscle atrophy. Particular attention
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should be paid to pelvic obliquity, gait, and functional ROM to aid in further characterizing the underlying pathologic process. With the patient standing and facing the examiner, pelvic obliquity can be estimated based on the angle created between an imagined line tangent to the superior margins of both iliac crests and the horizontal.6,7 Obliquity may result from spinal deformity or limb-length discrepancy (LLD); a full-length standing AP radiograph or CT scan is required to accurately calculate the LLD.7 A less accurate way to clinically determine the LLD involves measuring the dis-

tance between the anterior superior iliac spine (ASIS) and the distal aspect of the ipsilateral medial malleoli.9,25 Viewing the patient from behind, the examiner should note asymmetries or angular/rotational abnormalities suggestive of spinal deformity; the Adams forward bend test is most useful for detecting thoracic imbalances.25 In the absence of scoliosis or true LLD, pelvic obliquity may result from hip flexion contracture. These contractures can cause a functional LLD that incites a compensatory change in pelvic tilt.7 To adequately assess gait, the examiner should observe at least six to

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Table 4 Musculoskeletal Examination of the Patient With Groin Pain: Extra-articular Pathology Test Arch and twist maneuver12 Examination Procedure Results Diagnosis Suggestive of nerve entrapment Rectus femoris contracture Ipsilateral sacroiliac joint pathology Iliopsoas pathology

Ely4-6 FABER (ie, Patrick)3-6,25,26

Femoral nerve traction27 Gaenslen4

Stand and hyperextend the trunk while rotat- Twisting away from the ing toward and away from the symptomatic affected side recreates inguinal site symptoms Prone position. The knee is passively exed. Involuntary compensatory hip exion Supine position with the hip exed, abPosterior hip pain ducted, and externally rotated The ipsilateral knee is exed so that the lat- Groin pain eral ankle rests on the contralateral thigh just proximal to the patella (gure-of-4 position) The contralateral AIIS is stabilized, and the Lateral hip pain knee is lowered to the table Prone position, with the knee exed to 90 Pain in the anterior or and the hip fully extended lateral thigh Supine position with both knees exed and Pain one thigh extended over the edge of the table

Ober3-6,25,26

Pubic symphysis stress tests4,5

Single-leg stance phase (ie, Trendelenburg)3-6,25,26 Thomas25,26

Lateral position with the knee exed to 90. The hip is brought into maximal extension and the leg is adducted. Recreate shearing force with one hand at the superior border of the pubis and the other hand at the contralateral inferior border. Press two hands together or recreate compression force by directing downward force on the iliac crest. Standing, with the feet shoulder width apart. The hip and knee are exed to 45 and the position is held for 6 seconds. Both hips are exed at the same time and one leg is brought back down to the table

Unable to adduct past the midline Pain

Femoroacetabular impingement L2L4 nerve root impingement Chronic inammation of the lumbar vertebrae and SI joint (eg, spondyloarthritis, arthritis, sciatica) IT band contractures or tight hip abductors Pelvic pathology

Pelvic shift or decrease >2 cm Thigh cannot reach the table

Weak contralateral abductors/poor neural loop of proprioception Hip exor contraction

AIIS = anterior inferior iliac spine; FABER = exion, abduction and external rotation; IT = iliotibial; SI = sacroiliac

eight full stride lengths.6 Notable parameters include stride length, stance phase, foot progression angle, pelvic rotation, and abnormal gait patterns. Gait pattern can provide clues regarding the underlying pathology. Antalgic gait is characterized by a shortened stance phase involving the affected side. This gait pattern counteracts groin or hip pain that worsens with weight bearing and is commonly associated with acute trauma and early OA. The Trendelenburg

gait is typified by dropping of the contralateral hemipelvis during the ipsilateral single-leg stance phase due to hip abductor insufficiency on the affected side.7 This pattern is usually seen with long-standing hip OA and other chronic disorders such as superior gluteal nerve palsy and lumbar radiculopathy. During the stance phase, both of these gait abnormalities include a trunk lurch toward the affected side, which brings the center of gravity closer to that side, thereby

lowering the joint reactive forces and abductor moment arm. The pelvic wink gait involves excessive axial rotation toward the affected hip to obtain terminal hip extension, aided by extension and rotation of the lumbar spine. This gait pattern is associated with internal hip pathology or secondary hip flexion contracture, particularly when combined with lumbar lordosis or a forward-stooping posture.6,9,25 Although they are ordinarily suggestive of intra-articular

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Figure 8

Photograph demonstrating evaluation of internal rotation of the right hip with the patient seated.

hip pathology, these gait abnormalities also can stem from extraarticular disease.6,7,9,10

distinguishing hip pathology from spine pathology. A seated straight leg test can be done by passively extending the knee to full extension. A positive examination elicits radicular pain by stretching an entrapped nerve root. Patellar (L2 through L4) and Achilles (S1 to S2) deep tendon reflexes should also be tested.6,9,25 Hamstring tightness, which often is related to sciatica, is tested by passively extending the knee while the patient remains in a sitting and upright position. A compensatory ipsilateral hip and trunk extension that occurs during knee extension, requiring the patient to place both hands on the table for support, is indicative of clinically relevant tightness.7

Seated Examination
Proper assessment of hip joint mobility is a chief component of the physical examination. Decreased ROM is a common, nonspecific consequence of numerous intra-articular hip disorders. Passive ROM (ie, abduction, adduction, flexion, extension, internal rotation, external rotation) can be assessed with the patient seated, supine, or prone. Rotational measurements are obtained in the seated position because the pelvis and hip (at approximately 90 of flexion) are relatively stabilized. The normal range for internal hip rotation is 20 to 35 (Figure 8) and for external hip rotation is 30 to 45.7,9,25 Internal rotation is important for normal hip function, and 10 internal rotation should be present at terminal hip extension.9,25 Decreased internal rotation can be the first sign of intraarticular disease processes (eg, OA, joint effusion) and can also be related to contracture.6,9,25 Brown et al26 reported that the presence of a limp, groin pain, and limited internal rotation were found to be highly predictive of intra-articular hip pathology. This triad was also useful for
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Supine Examination
Most of the groin-centric examination is performed with the patient supine. Internal and external ROM are assessed by passively rotating the entire extremity to its rotational end points.8 Pain is elicited in the presence of intra-articular hip inflammation, effusion, or fracture. Hip flexion, extension, abduction, and adduction are measured, as well. Normal values for hip abduction, adduction, and flexion are 45, 20 to 30, and 120, respectively.25 For improved accuracy during abduction and adduction testing, the examiner should rest one hand on the ipsilateral ASIS to stabilize the pelvis. Flexion contractures are assessed using the Thomas test, which is positive when the affected hip cannot reach full extension when the contralateral hip is fully flexed.6,7,25 On the Stinchfield test, pain with active hip flexion to 20 or 30, with or without resistance, is suggestive of intra-articular or iliopsoas pathology27 (Figure 9). For the Patrick (ie, FABER [flexion, abduction, and external rotation]) test, the extremity of interest is

placed in the figure-of-4 position and the examiner applies downward force while stabilizing the pelvis (Figure 10). The location of elicited pain (ie, SI joint, lumbar spine, and/or groin) corresponds to the source of the pathology.6-9,25,29 With the patient positioned supine, palpation can be performed to localize areas of tenderness. Relevant bony prominences include the bilateral anterior superior and inferior iliac spines, pelvic rami and symphysis pubis, SI joints, iliac crests, and proximal femora, including the greater trochanters.7,8,29 In cases of suspected muscle strain, the origins should be palpated for tenderness.25,29 Adductor muscle strain is the most common cause of groin pain in kicking athletes.30 Symptoms are localized to the medial thigh and anterior groin.12 The classic physical examination triad includes tenderness to palpation and pain with resisted adduction and passive abduction.16 A rectus femoris strain can result from overuse; symptoms typically include pain with resisted hip flexion and/or knee extension.16,24 Iliopsoas strain typically occurs in patients who lift weights, run uphill, or perform sit-ups. Pain is reproduced with hip hyperextension or with resisted hip flexion at 90.16 A rectus abdominis strain results in pain with resisted trunk flexion, along with localized tenderness to palpation that is accentuated with muscle contraction.16 The standard abdominal examination is best performed with the patient supine, to allow for inspection and palpation for fascial as well as femoral and inguinal hernias. The inguinal region should be palpated for hernias. The conjoined tendon and pubic tubercle should be palpated when sports hernia is suspected. Osteitis pubis is a common source of groin pain that presents with pain and tenderness involving the pubic

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Figure 9

Figure 10

Photograph of the Stincheld test, which is performed with the patient supine. The examiner applies downward pressure as the patient actively elevates the leg to 30.

Photograph of the Patrick (ie, FABER) test. With the patient positioned supine, the affected lower extremity is placed in the gure-of-4 position, and the examiner stabilizes the pelvis while applying downward force on the ipsilateral knee.

symphysis, adjacent rami, and tendinous attachments that can radiate to the inner thigh or lower abdomen. Pain can be reproduced with palpation as well as resisted hip adduction with the hip and knee in 90 of flexion.7,25 Knowledge of the surrounding neuroanatomy is necessary to evaluate all possible points of pathology in patients with suspected nerve entrapment or neuralgia. Meralgia paresthetica is a common cause of groin pain that involves entrapment of the lateral femoral cutaneous nerve as it travels beneath the inguinal ligament.14 In patients with this condition, deep palpation 1 cm medial and inferior to the ASIS may produce dysesthesias about the proximal anterolateral thigh. Tenderness proximal to the deep inguinal ring is typical of iliohypogastric nerve entrapment, whereas tenderness at or just inferomedial to the ASIS signifies ilioinguinal nerve entrapment.14 Prior surgery involving these nerve distributions should raise concern for postoperative neuralgia and may warrant neurology consultation.14 Vascular disease can also manifest as groin pain, so it is important to

evaluate femoral and abdominal pulses. Infrequently, a femoral artery aneurysm can present with swelling and pain about the hip; sudden onset of scrotal or groin pain and pulsatile abdominal mass are worrisome for an abdominal aortic aneurysm.10

Lateral Decubitus Position

After measuring hip flexion and extension, the patient is placed in the lateral decubitus position. The Ober test, which assesses iliotibial band contracture, is performed with the unaffected side facing down. The examiner stands behind the patient and, with the patients knee in 90 of flexion, abducts and extends the hip as far as is comfortable. The leg is then allowed to slowly adduct, taking care to keep the pelvis stable and the hip in neutral rotation (Figure 11). The test is positive when the knee does not reach the midline.6,7,9,25,29 Extending the knee while performing the same maneuver (ie, modified Ober test) evaluates for tensor fascia latae contracture. Maintaining knee flexion, which re-

moves the tensor fascia latae contribution with the hip at zero degrees of flexion, tests the gluteus medius; and extending the knee with the hip flexed to 90 tests the gluteus maximus.6,9,29 The flexion adduction internal rotation (FADDIR) test is also performed with the patient in the lateral position. This test is useful for assessing femoroacetabular impingement (Figure 12). The FADDIR test maintains the normal dynamic pelvic inclination without affecting lumbar lordosis. As the hip is brought into flexion, adduction, and internal rotation, the patients symptoms and the degree of impingement are recorded.6,29 Sprains of the pubic symphysis and SI ligaments are assessed using the approximation test (ie, transverse posterior stress test or compression test). The examiner applies downward force on the iliac crest, which results in compression on the pubic symphysis (Figure 13). Posterior pain may be suggestive of posterior SI joint sprain, whereas anterior pain may be indicative of pubic symphysis inflammation, as seen in osteitis pubis.7,8 No single position is ideal for testing the strength of all the major muscle groups. Pain with strength testing is noteworthy because it can provide clues to musculotendinous sources of pain. Hip abductor strength can be assessed with the single-leg stance phase test (ie, Trendelenburg test); weakness is suspected if the patient cannot maintain a level pelvis while standing on one leg.6,7,9,25,29 The hip flexors can be tested in the supine and sitting positions as the patient lifts the extremity and the examiner applies resistance.7-9,25,29 Similarly, adduction is tested with the patient supine, and extension can be tested in either the lateral or the prone position.7,25,29

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Figure 11

Figure 12

Figure 13

Photograph of the Ober test. With the patient in the lateral decubitus position and the knee exed 90, the hip is maximally extended and the leg adducted.

Photograph of the exion adduction internal rotation (FADDIR) test. With the patient in the lateral decubitus position, the hip is brought into exion, adduction, and internal rotation to elicit pain.

Photograph of the approximation test. With the patient in the lateral decubitus position, the examiner applies downward force on the iliac crest, resulting in compression of the pubic symphysis.

Laboratory Evaluation and Diagnostic Imaging

Laboratory studies should be ordered as the clinical picture dictates. If there is concern for an infectious process, a complete blood count with differential, erythrocyte sedimentation rate, and C-reactive protein level are obtained. Rheumatoid factor and human leukocyte antigen B27 should be added if inflammatory arthritis or spondyloarthropathies are suspected.7 Conventional radiography is typically the primary imaging modality for evaluating groin pain; the standard views are AP and frog-leg lateral radiographs of the pelvis and the involved hip. The AP pelvic view enables comparison with the unaffected side. The AP view aids in assessing acetabular version, whereas the lateral views are used to assess abnormal head-neck offset and anterior femoral head coverage.2 Conventional radiographs can identify osseous intra- and extra-articular abnormalities such as bone malignancies,
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hip dysplasia, OA, advanced osteonecrosis, loose bodies, and fractures. When indicated, standing AP views can help visualize more subtle abnormalities such as early degenerative joint disease and functional pelvic obliquity. Restricted internal rotation is predictive for radiographic OA in persons with groin pain.31 Osteitis pubis can also be evaluated radiographically and often presents with symmetric bone resorption, sclerosis, and symphyseal widening on the AP pelvic radiograph.2,16 More sophisticated views, such as the single leg stance (ie, flamingo) radiograph, can be used to evaluate pelvic instability. Vertical pubic translation >2 mm is considered to be pathologic, although as much as 5 mm of physiologic motion has been seen in asymptomatic patients.32-34 MRI is a sensitive imaging modality in the evaluation of hip pathology. MRI should be obtained when soft-tissue abnormalities, subtle degenerative changes, bone marrow abnormalities, or fractures are suspected and the diagnosis remains questionable (Table 5). It is sensitive

for identifying stress fractures, nondisplaced fractures, early-phase OA and osteonecrosis, transient osteoporosis of the hip, labral pathology, osteomyelitis, oncologic processes, musculotendinous injuries, and other inflammatory processes.2 In addition, abnormal head-neck offset and bony deformity can be characterized on MRI; for example, the alpha angle or anterior offset angle, which locates where the femoral head becomes aspheric, can be measured in the setting of cam impingement. MRI is the method of choice to evaluate labral and cartilage abnormalities, but MR arthrography can provide additional utility compared with conventional MRI.35 The injection of intra-articular contrast distends the capsule and outlines the labrum, thereby making labral tears more obvious. One recent European meta-analysis found MR arthrography to be superior to and to exhibit less variability than conventional MRI in detecting labral tears (87% versus 66% sensitivity and 64% ver-

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Table 5 Advanced Imaging Recommendations for Evaluating Groin Pain Imaging Type CT Suspected Diagnosis Femoroacetabular impingement Fracture Loose bodies Chondral injury Labral tear Osteonecrosis Bone and/or soft-tissue malignancy Lumbar spinal disease Osteomyelitis Sports hernia Stress fracture Transient osteoporosis of the hip Tendinopathy/tendinitis Sports hernia

Magnetic resonance arthrography MRI

Ultrasonography

sus 79% specificity, respectively).35 Hyaline cartilage abnormalities can also be detected with lower accuracies.36,37 The addition of local anesthetic to the directly injected contrast can help distinguish intra-articular from extra-articular sources of pain.8 Advancements in routine, nonarthrographic MRI may soon obviate the need for magnetic resonance arthrography, which would be ideal because the latter is more costly and requires radiation exposure.38 One study demonstrated equivalency between 3-Tesla MRI and 1.5-Tesla magnetic resonance arthrography in the detection of acetabular labral tears.39 Generally considered the modality of choice for detailing bony anatomy about the hip, CT has largely been replaced by MRI and MR arthrography for evaluating hip- and groinrelated pathology. CT is still the primary tool for assessing joint congruity after hip dislocation and reduction as well as for identifying loose bodies.8,40 In the setting of femoroacetabular impingement, CT can be used to assess femoral head-neck offset and deformities. CT is used to characterize implant fixation and bone

quality after hip arthroplasty and in situations in which MRI is contraindicated (eg, implanted metallic devices, claustrophobic patients).41 No single imaging modality has demonstrated satisfactory sensitivity and specificity for diagnosing socalled sports hernia. Albers et al42 found that MRI was able to show subtle abnormalities in the layers of the abdominal wall as well as stress-related edema in the pubic bones. Dynamic ultrasonography has emerged as a second imaging modality for diagnosing sports hernias. The patient bears down during the procedure, and a bulge at the superficial inguinal ring indicates a positive result.43 Herniography, which involves obtaining radiographs following the injection of dye into the peritoneal cavity, has gained popularity in Europe despite its questionable safety and efficacy.5,22,44,45 Electromyography and nerve conduction velocity studies can be useful for investigating potential nerve entrapment in the presence of symptoms lasting longer than 2 weeks.46 For example, denervation changes in the adductor muscles are seen with

obturator nerve entrapment.14 These studies can also assist in the evaluation of lumbar radiculopathy. However, nerve conduction velocity studies are not recommended for evaluating predominantly sensory nerves about the groin.14 The utility of diagnostic injections in the evaluation of groin pain should not be overlooked. A positive response to an intra-articular anesthetic injection suggests an intraarticular source of pain.11 A negative response should prompt exploration of extra-articular causes. The SI joint, iliopsoas tendon sheath, symphysis pubis, lumbar spine, and peripheral nerves are all potentially amenable to diagnostic injection, which also can be therapeutic. We have found ultrasonography to be useful in the application of this technique around the hip joint, specifically for intra-articular, iliopsoas tendon sheath, trochanteric bursa, and peripheral nerve injections. Loos et al15 used nerve blocks effectively to establish the diagnosis of inguinal neuralgia after low transverse Pfannenstiel incision, which then guided treatment.

Summary
Groin pain is a common complaint encountered by orthopaedic surgeons. Correct diagnosis is challenging due to a relative lack of discriminating factors and symptoms that span numerous medical specialties. Consequently, the clinician must be knowledgeable about possible underlying pathologies and proficient in carrying out examination maneuvers and diagnostic techniques. A detailed medical history and tailored physical examination promote prudent selection of additional diagnostic testing and/or procurement of necessary referrals, thereby facilitating prompt diagnosis and management.

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Juan C. Suarez, MD, et al

12. Zacher JG, Gursche A: Hip pain. Best Pract Res Clin Rheumatol 2003;17(1): 71-85. Petrigliano FA, Lieberman JR: Osteonecrosis of the hip: Novel approaches to evaluation and treatment. Clin Orthop Relat Res 2007;465:53-62. Rassner L: Lumbar plexus nerve entrapment syndromes as a cause of groin pain in athletes. Curr Sports Med Rep 2011;10(2):115-120. Loos MJ, Scheltinga MR, Roumen RM: Surgical management of inguinal neuralgia after a low transverse Pfannenstiel incision. Ann Surg 2008; 248(5):880-885. Lacroix VJ: A complete approach to groin pain. Phys Sportsmed 2000;28(1): 66-86. Mehnert-Kay SA: Diagnosis and management of uncomplicated urinary tract infections. Am Fam Physician 2005;72(3):451-456. Wasserstein AG: Nephrolithiasis: Acute management and prevention. Dis Mon 1998;44(5):196-213. Trojian TH, Lishnak TS, Heiman D: Epididymitis and orchitis: An overview. Am Fam Physician 2009;79(7):583-587. Ringdahl ET, Teague L: Testicular torsion. Am Fam Physician 2006;74(10): 1739-1743. Apte G, Nelson P, Brisme JM, Dedrick G, Justiz R III, Sizer PS Jr: Chronic female pelvic pain: Part 1. Clinical pathoanatomy and examination of the pelvic region. Pain Pract 2012;12(2):88110. Kujala UM, Kaprio J, Sarna S: Osteoarthritis of weight bearing joints of lower limbs in former lite male athletes. BMJ 1994;308(6923):231-234. Farber AJ, Wilckens JH: Sports hernia: Diagnosis and therapeutic approach. J Am Acad Orthop Surg 2007;15(8): 507-514. OKane JW: Anterior hip pain. Am Fam Physician 1999;60(6):1687-1696. Braly BA, Beall DP, Martin HD: Clinical examination of the athletic hip. Clin Sports Med 2006;25(2):199-210, vii. Brown MD, Gomez-Marin O, Brookfield KF, Li PS: Differential diagnosis of hip disease versus spine disease. Clin Orthop Relat Res 2004;(419):280-284. Larsen E, Johansen J: Snapping hip. Acta Orthop Scand 1986;57(2):168-170. Reiman MP, Goode AP, Hegedus EJ, Cook CE, Wright AA: Diagnostic accuracy of clinical tests of the hip: A systematic review with meta-analysis. Br 40. 38. 37. 34. 30. J Sports Med 2012; Nov 7 [Epub ahead of print]. 29. Martin HD, Kelly BT, Leunig M, et al: The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists. Arthroscopy 2010;26(2):161172. Mora SA, Mandelbaum BR, Szalai LJ, et al: Extraarticular sources of hip pain, in Byrd JWT, ed: Operative Hip Arthroscopy, ed 2. New York, NY, Thieme, 2005, pp 70-99. Birrell F, Croft P, Cooper C, Hosie G, Macfarlane G, Silman A; PCR Hip Study Group: Predicting radiographic hip osteoarthritis from range of movement. Rheumatology (Oxford) 2001;40(5): 506-512. Siegel JT, Templeman DC, Tornetta P III: Single-leg-stance radiographs in the diagnosis of pelvic instability. J Bone Joint Surg Am 2008;90(10):2119-2125. Garras DN, Carothers JT, Olson SA: Single-leg-stance (flamingo) radiographs to assess pelvic instability: How much motion is normal? J Bone Joint Surg Am 2008;90(10):2114-2118. Chamberlain WE: The symphysis pubis in the roentgen examination of the sacroiliac joint. AJR Am J Roentgenol 1930;24:621-625. Smith TO, Hilton G, Toms AP, Donell ST, Hing CB: The diagnostic accuracy of acetabular labral tears using magnetic resonance imaging and magnetic resonance arthrography: A metaanalysis. Eur Radiol 2011;21(4):863874. Keeney JA, Peelle MW, Jackson J, Rubin D, Maloney WJ, Clohisy JC: Magnetic resonance arthrography versus arthroscopy in the evaluation of articular hip pathology. Clin Orthop Relat Res 2004;(429):163-169. Perdikakis E, Karachalios T, Katonis P, Karantanas A: Comparison of MRarthrography and MDCT-arthrography for detection of labral and articular cartilage hip pathology. Skeletal Radiol 2011;40(11):1441-1447. Rakhra KS: Magnetic resonance imaging of acetabular labral tears. J Bone Joint Surg Am 2011;93(suppl 2):28-34. Sundberg TP, Toomayan GA, Major NM: Evaluation of the acetabular labrum at 3.0-T MR imaging compared with 1.5-T MR arthrography: Preliminary experience. Radiology 2006; 238(2):706-711. Scopp JM, Moorman CT III: The assessment of athletic hip injury. Clin Sports Med 2001;20(4):647-659. Burgess RM, Rushton A, Wright C,

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