Groin pain: A clinician’s guide to assessment

Assessment of groin pain can be a complex process for clinicians; with so many structures in such close proximity, it’s challenging to decipher which is the source of pain so we can help our clients achieve the best outcomes. It can become overwhelming thinking about the poor accuracy of the clinical tests meant to help rule in/out every possible cause – what are we supposed to prioritise in that first session? How do we differentiate between conditions? And most importantly, how do we know if we are going down the right track? Dr Andrea Mosler uses her clinical expertise to streamline this process in her Practical session on groin pain assessment and management.

If you want to learn exactly how top expert Dr Andrea Mosler assesses and manages groin pain, watch her full Practical HERE.

Below are some clinical tips from Andrea’s assessment Practical:

1- Categorise the pain source

While the categories of groin pain may be second nature to some, it seems appropriate to start off with a list of the categories for groin pain as outlined by the Doha agreement (1). Here they are:

1. Adductor-related groin pain
2. Iliopsoas-related groin pain
3. Inguinal-related groin pain
4. Pubic-related groin pain
5. Hip-related groin pain

This is a concise way to help to organise your differential diagnoses, and begin to utilise assessment to rule in/out certain categories.

2 – Thorough subjective assessment

As always, a thorough subjective assessment is integral in the successful management of any client. There are some specifics for groin pain you will want to glean from that initial appointment. Along with the area, type, depth and quality of pain, you want to know whether there are any other symptoms such as clicking, clunking or instability. Additionally, for those potential cam morphology clients, it is also important to learn about past history of activity/loading, particularly between the ages of 9-14 years old. Invariably, it is also vital to gain a good understanding of the intensity and nature of their current activity, and any sport-specific motions which are aggravating. Getting this information in the initial session will help to begin building a picture of your client’s issue and guide your clinical reasoning for the objective assessment.

3 – Palpation is important

Palpation around the hip and groin can be tricky. First of all, the adductor region is usually a tender area regardless of pathology, and differentiating between structures in that region can be challenging for those who don’t see a lot of groin-related pain. However, it is important – the Doha agreement uses tenderness on palpation to help rule in certain sources of pain (particularly adductor-related groin pain) (1), so it must be done, and it must be done well! In conjunction with your other findings, tenderness on palpation can add to the clinical picture. Contrarily, no tenderness on palpation can help to rule out certain categories of groin pain; that is of course if you palpate accurately.

If you need to brush up on your palpation skills, see the below snippet taken from Dr Andrea Mosler’s Practical in which she demonstrates how to palpate the iliopsoas tendon:

4 – Flexion-ADduction-Internal Rotation (FADIR) as a screening tool

The poor diagnostic accuracy of clinical tests for the hip and groin adds to the challenge of correctly differentiating the source of pain. A recent systematic review supports the usefulness of the FADIR test as a screening tool (2). The FADIR can be clinically useful to rule out the hip as a source of groin pain; that is, if the FADIR is negative, we can deduce the hip is probably not the source of pain. HOWEVER, if the FADIR is positive, this does not necessarily mean the hip is the culprit – the FADIR can compress a number of different tissues, such as the iliopsoas. Essentially, if you get a negative FADIR, then the hip may fall to the bottom of the priority list until proven otherwise, but if you get a positive FADIR, it’s time to do a little more digging.

5 – Eccentric testing is best

We all know how to do our resisted isometric testing for pain provocation. However, eccentric strength testing for hip musculature can be better to rule in/out certain sources of groin pain (3). On top of this, Dr Andrea Mosler notes it is also more useful for return to sport testing. So, this may be an important part of your early and ongoing assessment, particularly for those patients with longstanding pain. Watch the below excerpt taken from Dr Andrea Mosler’s Practical in which she demonstrates how to test the eccentric strength of the hip abductors:

6 – Assess lateral weight transfer

It is important to assess the client’s ability to transfer their weight laterally; interestingly, athletes with groin pain who play football (rugby, soccer etc.) have been shown to have altered pelvic control in the coronal plane as compared to healthy subjects (4). Testing can involve measuring lateral pelvic movement in a single leg stance, as well as in movements such as a single leg squat. Your client must be able to maintain good pelvic stability when moving laterally – if they’re unable to do this, it should become a rehab focus.

See Andrea assess lateral weight shift in single leg stance in this video taken from her Practical:

Wrapping up

The next time a client with groin pain walks through your door, hopefully these clinical tips enable you a bit more confidence in your ability to accurately identify the primary source of pain, so you can successfully manage your client’s rehabilitation.

We often wish we could be a fly on the wall to see how expert physios go about assessing and managing certain conditions, this is finally made possible by Physio Network’s expert Practical sessions! For an in-depth understanding of how an expert physio assesses groin pain, see Dr Andrea Mosler’s full Practical HERE.