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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J.A. Greenberg
inguinal area that may or may not extend into the scrotum in males.
Most other pathologies will have no obvious findings on inspection
alone. Palpation of the groin should also begin in the upright or standing
position. Many inguinal hernias can be palpated simply by placing the
hand over the inguinal canal and reducing any hernia contents into their
intra-abdominal position. The patient is then asked to cough or to perform
the Valsalva maneuver, and the hernia contents should slide past
one’s fingers. If a hernia cannot be appreciated, the index finger can be
placed into the inguinal canal by invaginating the scrotum in male
patients. With a finger placed deep in the canal, hernias can again be
appreciated with Valsalva or cough . Additionally, the inguinal occlusion
test can be performed to determine if the hernia is direct or indirect [ 16 ].
With this maneuver, the hernia contents are reduced and manual pressure
is applied over the presumed site of the deep inguinal ring. The patient
then performs a Valsalva maneuver, and one can observe if the hernia
appears with continued compression (direct) or only after release of the
internal ring (indirect). While this maneuver may help to differentiate
the types of inguinal hernia, its accuracy is relatively low and is not
likely to alter the surgical intervention [ 17 , 18 ]. If no hernia is appreciated,
then the groin is similarly examined with the patient lying supine.
If hernias still cannot be recognized, then ancillary imaging may be
necessary or an alternative diagnosis should be entertained.
Patients with sports injuries, often suspected by the patient’s history,
should undergo a sequential exam of the back, hip, and groin [ 19 , 20 ].
For a general surgeon, the exams will in most cases be basic, but even a
basic exam will help direct referral or image ordering. The spine and
back should be palpated along the thoracic, lumbar, and sacral vertebrae.
The paraspinal muscles should also be palpated, and the rare entity of
thoracolumbar syndrome should be ruled out when this entity is suspected.
The hip should then be examined with some simple maneuvers
that examine hip rotation, extension, and flexion. The rest of the exam
should focus on the groin, where a firm understanding of the musculoskeletal
anatomy will help greatly in figuring out the precise cause of the
athletic pubalgia. The rectus muscle insertion on the pubis should be
examined with palpation and a sit-up or crunch maneuver while palpating
the conjoint tendon Fig. 4.2 [ 11 ]. Reproducible pain in this area
suggests rectus sheath or conjoined tendon pathology. The pubic tubercle
should be palpated and pain with direct pressure can suggest osteitis
pubis [ 21 ]. Finally, the leg muscles , specifically the adductors and
abductors, can be examined by asking the patient to adduct and abduct
against resistance and noting any reproducible symptoms [ 20 ]. The hip