Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

234
C.S. Moucha
trauma, often seen in younger athletes, will guide the workup differently
than pain not associated with a specific injury. A past medical history of
extensive alcohol abuse, steroid usage, and certain conditions such as
sickle cell anemia or lupus will guide the workup toward specific diagnoses.
Duration of symptoms, progression, and alleviating and exacerbating
factors need to be properly identified. Exact location and
radiating patterns of pain help distinguish intra-articular from extraarticular
musculoskeletal causes. Associated symptoms such as weakness,
numbness, and paresthesias are also important to identify, as they
can be associated with pathology of the spine.
This chapter reviews musculoskeletal causes of groin pain by dividing
them into three categories: intra-articular, extra- articular, and groin
pain after hip replacement. The focus will be predominantly on diagnosis.
Treatment of these conditions will not be discussed in much detail
as it is beyond the scope of this manual.
Extra-articular Causes of Groin Pain
A large majority of patients who present with hip pain do not actually
have intra-articular hip pathology. Determining whether the cause of
pain is intra-articular or extra-articular early on will help streamline the
diagnostic process. Patients with extra-articular causes of groin pain will
usually complain of pain on the side of the hip and/or in the buttock that
radiates into the groin.
Greater Trochanteric Pain Syndrome Greater trochanteric pain syndrome
(GTPS) encompasses several diagnoses that include trochanteric
bursitis and tendinosis (or even a degenerative tear) of the gluteus medius
or minimus muscles . While the direct source of pain is extra-articular, it
is not uncommon for patients to present with groin pain. Patients usually
have pain while driving or lying down on the affected side.
Gait examination may reveal a Trendelenburg gait , indicative of weak
abductor muscles, which should not be confused with an antalgic gait
(painful gait). A Trendelenburg gait is characterized by downward tilting
of the contralateral pelvis during stance on the weakened side. On physical
examination, we usually see direct tenderness to palpation over the greater
trochanter or just proximal to it. The Trendelenburg sign is found in
patients with weak or paralyzed hip abductor muscles (medius and/or
minimus). A positive Trendelenburg sign means that the affected hemipelvis
sags during one-legged stance . Most importantly, however, intra-