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

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C.S. Moucha
Lumbar Spine Disease Spine diseases, such as thoracolumbar discogenic
pain at multiple levels or L2–L4 nerve root impingement, can all
cause groin and thigh pain, with or without associated back pain [ 4 ]. The
mechanism is sometimes complex, as the pain can be radicular pain from
nerve root compression or pain from nerve endings on the herniated disc
itself. The existence of sensory nerve endings in the annulus fibrosus of
the human lumbar intervertebral disc has been described and well documented
[ 5 ]. Patients sometimes find it hard to understand how their groin
pain is originating from their back when they do not present with back
pain . Physical exam of the hip is usually normal. Limited spine flexion,
extension, and/or lateral bending are sometimes seen. Many of these
patients have very weak core musculature. The femoral nerve traction test
is done with the patient in a prone position with the knee flexed to 90° and
the hip fully extended; pain in the anterior thigh suggests a L2–L4 nerve
root impingement. One of the most common findings, however, appears
to be tight hamstring musculature. Tight hamstrings lead to hip flexion
contractures, a subtle crouched gait, and compensatory pressure on the
spine . Physical therapy focusing on core strengthening, hamstring stretching,
and lumbar stabilization is the first line of treatment. MRI of the spine
is sometimes needed, followed by selective spinal diagnostic and therapeutic
injections.
Osteitis Pubis Osteitis pubis is a noninfectious inflammatory process
of the pubic symphysis commonly seen in runners and in athletes
involved in cutting sports such as soccer and hockey. Previous trauma,
overuse, and vaginal delivery are all risk factors. Patients often present
with groin pain that is activity related. On physical exam they usually
have normal hip range of motion, nontender abductor muscles laterally,
and focal tenderness to palpation over the pubic symphysis. Weak core
musculature is often noted; pain with resisted hip adduction or passive
hip abduction may also be found. These latter physical exam findings
are often confirmed by tendinosis of the rectus abdominis and adductor
longus insertions on an MRI. Plain radiographs of the pelvis are usually
helpful as well, as they typically show widening of the symphysis with
blurring of the cortical margins and sometimes cysts. Physical therapy is
the first line of treatment followed by steroid injections. Surgical bony
resection with preservation of the rectus and pubic ligaments is rarely
done [ 6 ].
Pubic Ramus Fractures Fractures of the superior and/or inferior
pubic rami are commonly seen in elderly patients who have sustained a