Groin
pain
A wide variety of pathologies can present with pain in the groin. The
surgeon requires a systematic and methodical approach to the diagnosis based on
a sound knowledge of the complex anatomy in the region. The history of pain
should give clues as to whether the origin is visceral (more constant) or
somatic (exercise related). Each surgeon will develop their own system but it is
reasonable to separate the pathologies on the basis of the tissue involved.
Muscles
A large number of muscles takes their origin from or traverse the region
of the groin. Inflammation of these musculotendinous origins or partial tears
will produce activity-related pain. The principles of assessment are carefully
to localise the point of maximal tenderness and then test the muscles in that
area with an isometric contraction. Muscles that frequently cause problems are
the proximal insertion of rectus femoris just distal to the anterosuperior iliac
spine, the adductor
Visceral pain from pelvic organs may produce groin pain and a careful
history will have elicited symptoms of systemic upset. Appendicitis, prostatitis,
urinary tract infection and gynaecological disorders should always he borne in
mind and dealt with appropriately.
Nerve
entrapment
Lumbar spine disease causing entrapment of the higher lumbar nerve roots
may produce pain radiating round the buttock to the groin. Less commonly the
ilio-inguinal (in the inguinal canal) and lateral cutaneous nerve of the thigh
(distal to the anterosuperior iliac spine) may be trapped as they pass through
the deep fascia.
Hernia
Male athletes who play sports that involve a lot of twisting and turning
are prone to developing the ‘sportsman’s hernia’. This is really a direct
‘prehernia’ in that no bulge can be demonstrated either clinically or even
with specialist scanning techniques. The hernia is a fatigue failure of the
transversalis fascia which only becomes symptomatic because of the repeated
stresses placed on it by the athlete. The diagnosis is based on the history and
tenderness at the deep inguinal ring. This sign is elicited by invaginating the
scrotum with the little finger until the tip can be placed directly over the
deep inguinal ring. The examination is uncomfortable and so comparison with the
normal side is required. Repair is performed in the standard manner either using
a mesh or by reefing the conjoined tendon to the inguinal ligament.
Bone
and joint
Osteoarthritis of the hip classically presents with groin pain, and the
diagnosis should not be excluded because of normal radiographs. Plain
radiographs will usually demonstrate a stress fracture of the femoral neck but
if there is still doubt then bone scintigraphy or an MRI will establish the
diagnosis.
Osteitis
pubis is a well-recognised but poorly understood condition. Pain and tenderness
are vaguely localised to the anterior pubic bones and intervening symphysis.
Plain radiographs may demonstrate changes of fragmentation of the margin of the
pubic bones and patchy sclerosis within the symphysis. The aetiology of this
condition is unknown; certainly no pathogenic organisms have ever been
demonstrated
within biopsies. Treatment is frustrating for both surgeon and athlete as it may
require a prolonged period of nonweight-bearing activity. Fusion of the pubic
symphysis should be avoided as the results are very poor.