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

17. The Orthopedic Perspective on Groin Pain…
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low- energy fall. These patients present with acute groin pain that was
not present prior to trauma. They usually have painless hip rotation
but focal tenderness over the bony pelvis lateral to the pubic symphysis.
It is common for these patients to report having had recent hip radiographs
that were normal. Unfortunately, the pelvis has rarely been
evaluated. Hip radiographs often do not show rami fractures; it is
imperative to obtain an AP of the pelvis when evaluating groin pain.
Treatment of these fractures is most commonly nonoperative with unrestricted
weight bearing.
Iliopsoas Pathology The two most common iliopsoas pathologies
seen by orthopedic surgeons are snapping (coxa saltans interna) and
tendinitis. Internal snapping of the iliopsoas tendon is actually an extraarticular
process. Patients usually present with an audible snap and
anterior groin pain. As the hip is extended, the iliopsoas tendon travels
from lateral to medial catches at the iliopectineal eminence or on the
femoral head. On occasion, the snapping can be palpated directly in
the groin. Dynamic ultrasound may be useful in the diagnosis. MRI is
sometimes indicated, as it can show resultant hip labral tea [ 7 ]. Iliopsoas
tendinitis is a relatively rare entity in patients with native hips and seen
most commonly in patients involved in activities that require repetitive
hip flexion (rowing, uphill running, and ballet). Patients generally present
with anterior hip pain that radiates to the knee and sometimes with
knee pain alone. The most common physical exam findings are painless
hip rotation, pain with resisted hip flexion, and pain with passive hip
extension. Initial treatment of both coxa saltans interna and iliopsoas
tendinitis is always stretching (best done in a luge position) and, when
necessary, steroid injections [ 8 ]. Open and arthroscopic releases of the
iliopsoas tendon have been reported, but complications such as symptomatic
intra-abdominal fluid extravasation [ 9 ] and anterior hip instability
[ 10 ] have been reported. Exclusion of the other potentially life-threatening
pathologies with which abdominal surgeons are very familiar, such
as an iliopsoas abscess, is clearly important.
Intra-articular Causes of Groin Pain
Anterior groin pain that radiates deep into the hip and sometimes radiates
into the groin should always raise the suspicion of an intra-articular
process. In the now classic C sign (Fig. 17.2 ) suggestive of intra-articular
hip pathology, patients will place their hand over the affected hip with the