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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commonly seen in the femoral head, is also a common reason for groin
pain, especially in patients with risk factors such as steroid use, alcohol
abuse, coagulopathies, sickle cell disease, Gaucher’s disease, and
decompression sickness. When radiographs are normal and suspicion
is high, patients should undergo an MRI of the hip. Depending on the
stage of avascular necrosis, treatment includes protected weight
bearing, bisphosphonate treatment, electrical stimulation, electromagnetic
fields, core decompression, bone grafting, autologous mesenchymal
cells, osteotomies, and arthroplasty procedures [ 14 ].
Hip Synovitis and Septic Arthritis Transient synovitis of the hip is a
short-lived acute inflammatory process usually seen in boys aged 2–10
following an upper respiratory tract infection. Generally a diagnosis of
exclusion, it must be differentiated from a septic hip, which is also
commonly seen in this patient population. Patients present with groin
pain and sometimes difficulty putting weight on the limb. In addition to
the aforementioned tests for intra- articular pathology, these patients will
have pain with log rolling of the hip while in extension. Kocher et al.
have provided useful ways of differentiating between these two entities
[ 15 ]. Patients with transient synovitis require close observation, while
those with septic arthritis most commonly require arthroscopic or open
irrigation and debridement of the hip joint.
Femoroacetabular Impingement Femoroacetabular impingement (FAI)
occurs when anatomic variations in hip anatomy lead to impingement
between the acetabulum and the femoral head–neck junction. FAI is
believed by many to be a common pathway to hip arthritis, especially in
younger patients. Impingement is generally classified into Cam impingement
and Pincer impingement. CAM impingement is due to prominence of
the anterosuperior head–neck junction or diminished head–neck offset.
Pincer impingement is secondary to acetabular over coverage of the
femoral head for a variety of reasons such as coxa profunda or acetabular
retroversion. FAI may lead to chronic groin pain, especially in younger
adults who often go on to have symptomatic arthritis. FAI is also a probable
predisposing factor to labral tears , most of which, even in the face of
trauma, would probably rarely occur otherwise. Patients with FAI may
have some of the classic signs of intra-articular hip pathology and
also report pain with tests such as the anterior impingement test or
FADIR (flexion adduction internal rotation). Sophisticated radiographs
and MR arthrography are some of the methods of choice in further