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
presence or absence of pain or hypersensitivity along any of the
distributions. Pain mapping, described in Chap. 21 , is another exam
tool to help isolate specific nerve dermatomes that are involved in
the pathology.
Radiographic Studies
While radiographic studies certainly play a role in the diagnosis and
potential management of groin pain, they are not needed for all patients.
In patients with symptomatic inguinal hernias that are palpable on physical
exam, radiographic studies are unnecessary, as they will add cost to
the workup without significantly changing management. However, for
the patient with symptoms suggestive of an inguinal hernia and a normal
physical examination, imaging studies may be extremely beneficial.
Ultrasonography, magnetic resonance imaging (MRI), computed tomography
(CT), and herniography under real-time fluoroscopy can all be
used to aid in the diagnosis of occult inguinal hernias. In a systematic
review and meta-analysis of imaging techniques in the diagnosis of
occult inguinal hernias, herniography was found to have a higher sensitivity
and specificity than both ultrasound and computed tomography
[ 27 ]. Herniography is an invasive procedure and not without its own
complications; thus, ultrasound has become popular for the diagnosis of
occult hernias in the United States. While ultrasound has a sensitivity of
86 % and a specificity of 77 % [ 27 ], it is operator dependent and requires
some institutional expertise [ 28 ]. Despite being less sensitive and specific
than other modalities, both CT and MRI of the groin can be performed
to assess for inguinal hernias. Of these two tests, the MRI has
less radiation exposure and a higher likelihood of discovering alternative
causes of groin pain.
For patients with histories consistent with sports injuries, osteitis
pubis, or hip joint injury, MRI of the groin and/or hip is likely to provide
the most high-yield information. Sports injuries have a variety of findings
seen on MRI. An MRI is dependent on the radiology read, and a
specializing sports injury MRI radiologist is often needed to get a thorough
enough dictation.
In skilled hands, patients with a true “sports hernia” can also be found
to have a protrusion of the transversalis fascia on dynamic ultrasound
[ 8 ]. Osteitis pubis can be diagnosed on MRI based on signs of inflammation
at the pubic symphysis [ 29 ]. Hip joint injury such as stress fractures,
labral tears, femoroacetabular impingement, and iliopsoas bursitis