WHAT CLINICIANS MUST NOT MISS

INTRODUCTION

Groin pain is a common but challenging presentation in sports and musculoskeletal medicine. Most cases are load-related, yet symptoms may also arise from the hip, pelvis, lumbar spine, abdomen, genitourinary tract, vascular system or peripheral nerves. This overlap creates diagnostic uncertainty, especially when the presentation resembles a familiar athletic groin disorder.

The Doha agreement improved terminology by grouping athletic groin pain as adductor-, iliopsoas-, inguinal- or pubic-related, with hip-related and other causes also recognised¹ This framework aids communication but is not a diagnostic endpoint: a patient can meet criteria for a recognised entity and still have another, potentially serious, pathology.

In high-performance sport, pressure to continue training can encourage symptom management before diagnostic uncertainty is resolved. Multiple abnormalities on examination or imaging are common; the likely pain generator must be judged against the history, examination, functional behaviour and imaging together^2,3.

Older labels such as “sportsman’s hernia” and “athletic pubalgia” have also added confusion and sometimes led to sequential procedures when symptoms persisted^4–7. Current practice favours integrated assessment, with surgery reserved for selected patients after a clear diagnostic formulation.

Red flags are warning features, not diagnoses. They should prompt clinicians to reconsider the differential diagnosis, decide whether continued loading is safe, and arrange targeted investigation or referral when indicated.

This article highlights features that should prevent premature closure and help sports physicians, doctors and physiotherapists recognise when apparently routine groin pain requires a different approach.

WHY DIAGNOSIS CAN BE DELAYED

Delay often reflects anchoring on an initially plausible musculoskeletal diagnosis. Later symptoms may then be interpreted as persistence rather than evidence to reopen the differential.

Overlapping innervation and referred pain from the lumbar spine, hip, pelvis, abdominal or genitourinary structures complicate localisation; peripheral neuropathies may not follow a single anatomical distribution^8,9.

Imaging may add uncertainty because adductor, pubic, hip and soft-tissue abnormalities are common in asymptomatic athletes^2,10. Pubic marrow oedema, labral changes, femoroacetabular morphology and degeneration may be causal or incidental¹¹.

Early radiographs may miss stress injury, infection or neoplasia, while an abnormal scan does not prove causation.

Keep the working diagnosis provisional. A mechanical disorder should show a coherent loading pattern, consistent examination findings and improvement with appropriate rehabilitation. Changing pain behaviour, systemic or neurological features, functional decline or unexpected non-response require reassessment.

RED FLAGS AND IMPORTANT ALTERNATIVE DIAGNOSES

Progressive, unexplained or systemic symptoms

First ask whether the pain behaviour fits a musculoskeletal disorder.

Progressive or constant pain, increasing rest pain, unexplained decline, fever, malaise, night sweats or weight loss should broaden the differential. New persistent night pain is concerning when accompanied by other features, although mechanical pain can also disturb sleep after heavy loading.

Disproportionate pain or failure to improve with appropriate rehabilitation also requires review.

Investigations should answer a specific question and may include blood count, inflammatory markers, renal/liver function, urinalysis and targeted imaging.

Malignancy

Although uncommon in athletes, pelvic or proximal femoral primary tumours and metastases can present as persistent, poorly localised groin or hip pain. Risk increases with age and a personal cancer history.

Features that should increase concern include:

• persistent or progressive non-mechanical pain, especially at rest or at night;
• weight loss, systemic symptoms or unexplained anaemia;
• a mass, focal bony tenderness or pathological fracture; and
• previous or current cancer.

MRI best assesses marrow and soft tissue; CT can clarify cortical destruction, mineralisation, fracture risk or staging. Follow suspected pathology and local referral pathways rather than repeatedly treating presumed soft-tissue disease.

Infection

Consider infection with systemic illness, disproportionate disability, marked functional loss or relevant risk factors. Hip septic arthritis and infection of the pubic symphysis or adjacent bone can mimic athletic groin disorders.

Pubic osteomyelitis and septic arthritis can resemble osteitis pubis, with groin, hip or perineal pain, fever, weight-bearing difficulty and symphyseal tenderness^12,13.

Risk factors include:

• recent surgery, pelvic/urological procedures, injections or instrumentation;
• recent infection or bacteraemia; and
• diabetes, immunosuppression or intravenous drug use.

Fever, rigors, escalating pain, inability to weight bear and severe pain with minor movement are red flags. Absence of fever does not exclude infection, particularly after antibiotics or with immunosuppression.

Inflammatory markers support but do not exclude infection. Use MRI for suspected osteomyelitis or deep infection; suspected hip septic arthritis needs urgent assessment and, where indicated, aspiration.

Bone stress injury and stress fracture

Bone stress injury may begin with non-specific symptoms. Femoral neck injury is high risk because displacement can cause avascular necrosis and lasting impairment^14,15.

Suspect it when running, jumping or weight-bearing pain follows a training increase, persists with unloading, or progresses to walking or rest pain.

Other relevant risk factors include:

• previous bone stress injury, low bone density or impaired bone health;
• low energy availability/REDs, menstrual or reproductive disturbance, or nutritional deficiency; and
• rapid training progression or medicines/conditions affecting bone.

The IOC recognises that problematic low energy availability impairs musculoskeletal health in female and male athletes and increases injury risk¹⁶.

Promptly investigate suspected high-risk sites. Early radiographs may be normal; MRI is preferred for persistent suspicion because it detects marrow change and defines injury extent^14,17.

Neurological causes

Neurological causes are less common but easily mislabelled as adductor or hip pain. Burning, shooting pain, paraesthesia, sensory change or weakness suggest peripheral nerve involvement^8,9.

Examine neurologically when symptoms are neuropathic, extend beyond the expected local distribution, or include weakness or sensory change.

Cauda equina syndrome

Cauda equina syndrome is uncommon but represents an emergency.

Red flags include:

• new urinary retention or major bladder/bowel dysfunction;
• saddle or perineal sensory loss; and
• bilateral symptoms or progressive severe leg weakness.

Suspected cauda equina syndrome requires emergency assessment and urgent MRI via local spinal pathways. Distinguish this progressive emergency from focal neuropathy or referred spinal pain.

Vascular causes

Vascular disease is uncommon in young athletes and may appear only at high workload.

External iliac artery endofibrosis, particularly in cyclists, causes reproducible exertional groin, thigh or buttock discomfort, weakness, paraesthesia or loss of power; resting examination may be normal^18,19.

A vascular assessment should be considered when symptoms are:

• symptoms recur at a specific exercise intensity with claudication or loss of power;
• pulses are altered or a bruit is present; or
• musculoskeletal findings do not explain the presentation.

A pulsatile groin mass or acute limb ischaemia requires urgent vascular assessment.

Urological and testicular pathology

Consider genitourinary causes. In male athletes, examine the abdomen, inguinal region and scrotum when indicated; differentials include epididymo-orchitis, torsion, tumour, ureteric calculus and prostatitis.

Acute severe testicular or groin pain with abnormal testicular position, nausea or vomiting is torsion until proven otherwise and requires emergency assessment; recurrent self-resolving episodes may indicate intermittent torsion.

Haematuria, dysuria, frequency, scrotal swelling, a mass or persistent testicular discomfort requires medical or urological assessment; do not assume a palpable or imaging abnormality is musculoskeletal when the history suggests a genitourinary source.

Gynaecological and pelvic pathology

In female athletes, take a menstrual and pelvic history when relevant. Pelvic pathology may cause groin, lower abdominal, hip or proximal thigh pain and can coexist with musculoskeletal disease.

Consider endometriosis, ovarian cyst or torsion, pelvic inflammatory disease, ectopic pregnancy and pelvic malignancy.

Cyclical symptoms, dysmenorrhoea, dyspareunia, abnormal bleeding, infertility, pelvic pressure or systemic features should prompt further assessment.

Acute severe pelvic or lower abdominal pain with pregnancy or possible pregnancy, haemodynamic instability, vomiting or peritoneal signs requires urgent medical assessment.

Not every female athlete needs gynaecological investigation, but a musculoskeletal diagnosis should not prevent targeted questioning when symptoms suggest pelvic pathology.

Abdominal and hernia-related pathology

The abdomen and abdominal wall should remain part of the differential diagnosis in persistent groin pain.

Inguinal-related groin pain is now understood more precisely than the historical term “sportsman's hernia” suggests. True hernias should be distinguished from disorders involving the abdominal wall and inguinal-related tissues^1,20.

More acute abdominal pathology requires a different approach. Severe colicky pain, vomiting, abdominal distension, peritonism, an irreducible hernia, haemodynamic instability or rapid clinical deterioration should not be managed as a routine sports injury.

Potential causes include:

• incarcerated or strangulated inguinal or femoral hernia;
• appendicitis;
• diverticular disease;
• inflammatory bowel disease;
• gastrointestinal malignancy; and
• other intra-abdominal pathology.

An abdominal examination is therefore appropriate when symptoms are poorly localised, associated with gastrointestinal symptoms or inconsistent with a straightforward musculoskeletal presentation.

Inflammatory and systemic disease

Inflammatory disease can present with hip, buttock or groin pain and may initially resemble a mechanical disorder.

Features that should increase suspicion include:

• prolonged morning stiffness;
• alternating buttock pain;
• pain that is not clearly related to mechanical loading;
• multiple peripheral joint symptoms;
• enthesitis at other sites;
• psoriasis;
• inflammatory bowel disease;
• uveitis; or
• a family history of spondyloarthritis.

Ankylosing spondylitis and other forms of spondyloarthritis may involve the hip and entheses. Reactive arthritis and rheumatoid arthritis may also enter the differential depending on the clinical presentation.

These patients do not necessarily require urgent referral, but the diagnosis should be considered early because management differs substantially from that of a local tendon or muscle disorder.

FAILURE OF EXPECTED RECOVERY AND COGNITIVE BIAS

Failure to improve is not, in itself, proof of serious pathology. Recovery times vary substantially between diagnoses, tissue types and athletes. Rehabilitation may also be complicated by continued exposure to high training loads, inadequate recovery or psychosocial factors.

However, failure to follow the expected trajectory should be treated as a diagnostic signal rather than simply a reason to continue the same treatment for longer.

A useful question at review is:

Does the patient's current presentation still behave as the diagnosis originally proposed?

If the answer is no, the differential diagnosis should be reopened.

Cognitive biases such as anchoring, confirmation bias and premature closure can contribute to diagnostic error²¹. Once an athlete has been labelled with “adductor tendinopathy”, “hip impingement” or “sports hernia”, subsequent findings may be interpreted through that framework even when the clinical picture has changed.

Several simple strategies can reduce this risk:

• schedule reassessment rather than leaving follow-up open-ended;
• document important positive and negative findings;
• define the expected trajectory at the outset;
• reconsider the differential diagnosis when progress is atypical;
• review imaging findings in the context of the clinical examination;
• seek an independent clinical opinion when diagnostic uncertainty persists.

A safety-netting discussion is particularly important when an athlete is being allowed to continue training despite some diagnostic uncertainty. The athlete should understand which symptoms require earlier review, while the clinical team should have a defined point at which the working diagnosis will be reconsidered.

A PRACTICAL CLINICAL APPROACH

The assessment of chronic groin pain should be structured but proportionate to the presentation.

The initial history should establish:

• onset and chronology;
• relationship to training and specific activities;
• progression or change in pain behaviour;
• night or resting pain;
• systemic symptoms;
• changes in training load;
• previous injuries and surgery;
• bone stress injury risk;
• menstrual and reproductive history where relevant;
• urinary, gastrointestinal and genital symptoms;
• neurological symptoms;
• vascular symptoms; and
• previous investigations and treatment response.

The physical examination should then be directed by the history but should generally consider the:

• adductor and pubic region;
• iliopsoas;
• hip joint;
• abdominal wall and inguinal region;
• lumbar spine;
• sacroiliac and pelvic region;
• neurological system;
• vascular system; and
• abdomen and genitourinary system where indicated.

The Doha classification remains useful for describing common clinical entities, but the clinician should first establish whether the presentation is safe to manage within a routine musculoskeletal pathway¹

When should rehabilitation be paused?

Continued rehabilitation may be inappropriate when there is:

• inability to weight bear or a sudden major reduction in function;
• suspected high-risk bone stress injury;
• rapidly progressive or unexplained pain;
• significant resting or night pain accompanied by other concerning features;
• systemic illness;
• new neurological deficit;
• bladder, bowel or saddle sensory disturbance;
• acute testicular or pelvic symptoms;
• a pulsatile mass or signs of vascular compromise;
• an irreducible groin swelling or acute abdominal symptoms; or
• a clinical trajectory that is fundamentally inconsistent with the working diagnosis.

The appropriate response is not necessarily immediate MRI. The correct investigation depends on the clinical question. MRI is particularly useful for occult bone, marrow, joint and soft-tissue pathology, while ultrasound may be more appropriate for some abdominal wall, tendon, scrotal or vascular questions. CT, laboratory testing and specialist investigations may be preferable when abdominal, vascular, infectious or oncological disease is suspected.

The key is to investigate the suspected pathology, rather than simply obtaining increasingly sophisticated imaging of the groin.

REASSESSMENT SHOULD BE DELIBERATE

Reassessment is one of the most effective safeguards against diagnostic error.

At each review, the clinician should ask whether the symptoms remain consistent with the original diagnosis. A change from activity-related pain to persistent rest pain, the development of neurological or visceral symptoms, progressive functional loss, or a widening discrepancy between clinical behaviour and imaging findings should prompt reconsideration.

This is particularly important in multidisciplinary sports settings. A physiotherapist who identifies unexplained night pain, systemic symptoms, neurological change, inability to progress loading or a significant change in symptom behaviour should feel able to pause rehabilitation and request medical review. Conversely, a normal early investigation should not end the diagnostic process if the athlete continues to deteriorate.

Clinical documentation should make the reasoning visible. Recording important negative findings is as valuable as recording positive findings because it establishes a baseline against which subsequent change can be recognised.

CONCLUSION

Most groin pain in athletes is not caused by serious disease. Nevertheless, the anatomical complexity of the region means that an apparently straightforward musculoskeletal presentation can occasionally represent bone stress injury, infection, malignancy, inflammatory disease, neurological pathology, vascular disease or visceral pathology.

The purpose of red-flag assessment is not to make clinicians suspicious of every athlete with groin pain. It is to identify presentations that do not behave as expected and to prevent a familiar sports diagnosis from prematurely closing the differential diagnosis.

The most useful warning signs are often patterns rather than isolated findings: progressive pain, increasing pain at rest, unexplained night symptoms, systemic features, disproportionate disability, neurological or visceral symptoms, relevant medical risk factors, abnormal investigations, or failure to follow an expected recovery trajectory.

For clinicians working in sports medicine, the safest approach is therefore not simply to ask, “What is the most likely diagnosis?” but also:

“Does the clinical behaviour fit that diagnosis, and what important diagnosis would I regret missing?”

Zafar Iqbal MD

Consultant in Sports and Exercise Medicine

London, UK

Contact: zaf@drzaf.co.uk

References

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Header Image by Waldemar Brandt (Cropped)