Key diagnostic factors

presence of risk factors (common)

• Key risk factors include previous groin injury, female gender, and training background.

acute pain related to trauma (common)

• May include bony and soft-tissue injury.

hx of sports-related or overuse injury (common)

• Mechanism of injury if known, level of physical activity, and/or recent changes to training programme should be discerned. Muscle strains and tendonitis frequently occur.
• More common in endurance athletes or military recruits. View image

positive anterior impingement test (common)

• Non-specific provocation test to elicit pain with maximal flexion, adduction, and internal rotation of the hip. Can be a sign of intra-articular pathology but also of several extra-articular problems.

pain on adduction against resistance (neutral hip flexion) (common)

• Pain at the proximal part of the adductors (most frequently at the insertion at the pubic bone) when adducting against resistance. Best done in a supine position with straight legs and neutral rotation. [10]

pain on palpation of adductor tendons (common)

• Palpation of the adductor tendons and their insertion into the pubic bone (the enthesis) can produce pain in traumatic lesions. Otherwise it is the enthesis (especially of the adductor longus and sometimes of the gracilis) that is painful. [10]

pain on palpation of iliopsoas (common)

• Palpation of the iliopsoas through the lower abdomen and/or the triangle between the sartorius muscle, the femoral artery, and the inguinal ligament may elicit pain. [10]

Other diagnostic factors

pain on passive range-of-motion testing of the hip joint (common)

• Groin pain, especially in maximal flexion and in maximal internal rotation, may indicate intra-articular or iliopsoas pathology.

snapping/clicking hip (uncommon)

• May be reproducible by patient.
• Usually pain-free and associated with extra-articular structure such as the iliotibial band or iliopsoas tendon.
• If associated with pain or mechanical symptoms (i.e., catching or locking), dynamic ultrasound can show the snapping structure in real time. Imaging with MRI arthrogram may be warranted to evaluate intra-articular structures.

positive Trendelenburg's test (uncommon)

• Inability to maintain level pelvis in stance phase on involved extremity due to hip abductor muscle inhibition related to musculoskeletal hip pathology. [13] View image

positive apprehension test (uncommon)

• Non-specific pain provocation test indicative of an intra-articular problem. The leg is extended over the side of the table in abduction and then externally rotated.

positive modified Thomas' test (uncommon)

• The patient sits on the end of the examining bed, and rolls back to a supine position, holding one knee to the chest while the other is hanging supported by the examiner from the end of the bed. The patient holds the knee close to the chest just enough to avoid excessive posterior tilt (lumbar lordosis flattened). The examiner then slowly lowers the free leg. The test is used in order to register whether the hip flexors and especially the iliopsoas are tight in the supine position (positive if the femur is above the horizontal of the table [psoas] and/or the knee extends [rectus femoris and psoas]) and whether stretching of the same muscles is painful and reproduces the known pain. [10]

pain on palpation of inguinal canal (uncommon)

• Elicited through the scrotum, preferably in the standing position. The external orifice and the inguinal canal is explored for pain. Any bulging with a Valsalva manoeuvre should also be noted.

pain on palpation of conjoined tendon at pubic tubercle (uncommon)

• Palpation of the conjoined tendons (falx inguinalis) of the oblique muscles at the pubic tubercle may elicit pain.

decreased strength and increased pain with hip flexion against resistance (90˚) (uncommon)

• Tests strength and functional pain of the iliopsoas with the hip in 90° flexion and the patient in the face-up position.

night pain/rest pain (uncommon)

• Atypical pain feature classically seen in patients with infectious or malignant process. View image May also signal end-stage osteoarthritis.