Groin Exam
for the general surgeon:
chief complaint – groin pain
Brian Jacob, MD
Big Sky, MT 2018

Dr. Brian Jacob Disclosures
• Equity
• International Hernia Collaboration, INC
• LifeBond™
• ViaSurgical
• Consultant
• Medtronic
• Intuitive
• Ethicon
• Verb
• Board Member
• SAGES
• AHS
Brian Jacob 2018
• Thanks to
• Bard, Intuitive, Yuri,
Columbia University
• *Upcoming meetings*
• AHS – Miami, Florida (March
12-15)
• SAGES – Seattle, WA
(April 11 – 15)
• IHC 2018 - New Delhi, India
…(May 3 to 5)
• RAW – Ghent, Belgium
• May 23 to 25

Chief complaint:
•Groin pain
Inguinal Hernia No Inguinal Hernia
Brian Jacob 2018

Chief complaint: History
•Groin pain
Inguinal Hernia
No Inguinal Hernia
•Where is it located, exactly?
•When did it start?
•Why did it start?
•Constant or intermittent?
•What makes it worse or better?
•Does it radiate / to where?
•Severity (vas score 1 – 10)Brian Jacob 2018

Chief complaint: History
•Groin pain
Inguinal Hernia
No Inguinal Hernia
•When did it start?
•Why did it start?
•Constant or intermittent?
•What makes it worse or better?
•Does it radiate?
•Severity (vas score 1 – 10)
Sport / Exertion
injury?
If patient recognizes
a single event…
Brian Jacob 2018

Injury or athletic pubalgia:
History documentation – let’s be consistent
• Sport
• S (starting event)
• P (pain description, mapping, photo)
• O (objective exam)
• R (radiology)
• T (treatment intervention)
Brian Jacob 2018

Chief complaint: Exam
•Groin pain
Inguinal Hernia
No Inguinal Hernia
•Back
•Hip
•Abdomen
•Groin/ hernias / pubic tubercle
•Legs
•Photograph
Brian Jacob 2018

Exam: Back
• Palpate
• Flexion
• Extension
• Rule out obvious disc disease
•SI dysfunction
•TLS ?
• Thoraco-lumbar syndrome
Brian Jacob 2018

Exam: Back
SI dysfunction (lower back and groin)
http://www.hughston.com/
Brian Jacob 2018

Exam: Back
TLS (T12-L1) syndrome
Brian Jacob 2018

Exam: Hip
(for the hernia surgeon)
•Flexion
•Extension
•Rotation
•C-sign
•FABER exam
• Flexion/external
rotation/abduction
1) FAI (femoral – acetabular impingement)
2) Intraarticular Tear of the Labrum
Brian Jacob 2018

Flexion, Abduction, External Rotation
Thank you Eduardo Parra-Davila
Brian Jacob 2018

Brian Jacob 2018

Brian Jacob 2018

Labral Tear
Brian Jacob 2018

Femoral Acetabular Impingement
Brian Jacob 2018

MRI : hip
arthrogram
Brian Jacob 2018

Exam: Intra-Abdominal
• Right side
• Appendicitis (chronic relapsing)
• Epiploica Appendigitis
• Adhesions
• Hidden hernias
• Fallopian tubes, Ovaries
• Endometriosis
• Sigmoid or Ascending
diverticulitis
• Left side
• Adhesions
• Epiploica appendigitis
• Hidden hernias
• Fallopian tubes, Ovaries
• Endometriosis
• Sigmoid diverticulitis
Brian Jacob 2018

Exam: Groins / legs
(inguinal canals and pubic tubercles)
• Internal rings (inguinal hernia exam)
• Standing with Valsalva, and laying down
• Round ligament or spermatic cord
• Vulva or testicles
• Rectus insertions
• (sit-up maneuver or leg lifts)(reproducible symptoms or not?)
• Pubic tubercles and symphysis (tender or not?)
• Hip flexors, Aponeurotic plate, and adductor longus insertions
• Adductor squeeze maneuver
• Palpation between adductor tendons and rectus insertions
• Hip flexors (iliopsoas tendons) with straight leg raises
Brian Jacob 2018

“conjoint tendinopathy”
• Lower part of the tranversus abdominis as it inserts into the crest of the pubis
and pectineal line
• Pain at internal ring
• No hernia bulge
Rectus insertions:
Brian Jacob 2018

Rectus sheeth avulsion or tear
• Lower part of the rectus tears or avulses off the pubic
tubercle
• Pain at insertion site
• medial
• Acute or chronic
• No hernia bulge
Rectus insertions:
Brian Jacob 2018

Pubic Tubercle: the most underappreciated joint
drandyfranklynmiller.com Brian Jacob 2018

Rectus, AdductorsMuscles
Brian Jacob 2018

Bones Pubic tubercles, symphysis, acetabulum
Brian Jacob 2018

Groin pain is not so simple: need MRI to help
• Iliopsoas
• Rectus
• Pubic bone
• Adductors
http://www.clinicalsportsmedicine.com/
Brian Jacob 2018

Exam:
Rectus insertions, iliopsoas, and adductors
Brian Jacob 2018
Thank you Eduardo Parra-Davila

MRI: What can be the problem?
•Main buckets : athletic pubalgia
• Osteitis
• Rectus sheeth insertion
• Aponeurotic plate
• Adductor longus tendon origin
• Inguinal ligament
• Weak floor with tension or pressure
on nerves or fascia
• (sportsman groin)
MRI pelvis: Athletic Pubalgia Protocol at Mount Sinai, NYC
Brian Jacob 2018

Osteitis
• MRI axial
Brian Jacob 2018

MRI: No osteitis
Brian Jacob 2018

MRI: confirmed osteitis
Brian Jacob 2018

Osteitis: which is yes vs no?
Brian Jacob 2018

MRI: Aponeurotic plate avulsion
Saggital mri view of left pubic tubercle
Brian Jacob 2018

MRI: coronal view
left adductor longus tear
• Look for the fluid
• (white on these images)
Brian Jacob 2018

Positive MRI Management options
•Acute injury: to surgery
•Chronic injury: to physical therapy first
•6 to 12 weeks of gradual rehab
•Need to find one or two you like to refer
to
•NOT just a work out….
Brian Jacob 2018

Repair options for acute injuries: surgery
•Prefer no mesh
•Rectus sheeth avulsion
•Reattach with 0 ethibonds
•Aponeurotic plate avulsion
•Reattach with 0 ethibonds
•Adductor pain or tear or avulsion
•Leave alone or tenotomy at level near pubic bone
Brian Jacob 2018

http://ernestschilders.com/
“sportsman groin”
(by exclusion of any other disruption sprain, injury,
or hernia)
Brian Jacob 2018

Dynamic Ultrasound
http://www.aspetar.com/
Brian Jacob 2018

Repair options for weak floor (sportsman groin):
•Diagnosis made with sonogram or MRI with Valsalva
•Repair can be open or MIS with mesh
•Concept is to release pressure on nerves and tissue,
but in the end do a hernia repair
• Lloyd release (TEP with medial release, mesh)
• Moshe release (TEP with mid release, mesh)
• Muscaleck (open release with primary repair)
• Myers, Brunt, others (open releases with primary
reconstruction, no mesh)
Brian Jacob 2018

Nerves: Neuroanatomy (open)
• Iliohypogastric nerve
• Ilioinguinal nerve
• Distal genital branch of the
genitofemoral nerve
• Femoral branch of the GF nerve
• Vas deferens (paravasal fibers)
Brian Jacob 2018

Brian Jacob 2018

Chief complaint: History
•Groin pain
No Inguinal Hernia
•When did it start?
•Why did it start?
•Constant or intermittent?
•What makes it worse or better?
•Does it radiate?
•Severity (vas score 1 – 10)
Inguinal Hernia
Brian Jacob 2018

Groin Pain with History of an inguinal hernia or a repair:
Diagnostic Evaluation
• Review All Operative Reports
• Focused history and physical exam (with photo)
• xray, Ultrasound
• CT with marker
•MRI with marker or AP protocol
• Never , never assume a recurrence or a hernia is
the cause of the pain until a thorough work up is
completed
•Mapping is strongly encouraged
•Nociceptive vs neuropathic pain
Brian Jacob 2018

• Nociceptive:
• inflammation, meshoma, in one spot
• Neuropathic:
• nerve injury, scarring, radiating
• Combination
• Overlap of symptoms / signs
• Psychological, social, genetic factors
Ways to document type of
Chronic Pain
Brian Jacob 2018

A word about mapping with previous hernia history
• I always draw on patients in exam room, and right before surgery.

Nerve Injury: Pain Mapping
Brian Jacob 2018

Cases: Right groin pain for 6 years
Localized,
nonradiating,
constant
Brian Jacob 2017

Ct scan was normal
Intraoperative exploration:
(what did we find in OR??)
Hidden right inguinal hernia in a male
Brian Jacob 2017

5 years of right groin pain. No previous surgery.
Exam, Ct, and MRI all negative
Brian Jacob 2017

Hidden right inguinal hernia in a female
Brian Jacob 2017

Colon resection 5 years ago. No hernias.
Chronic nociceptive pain.
Brian Jacob 2017

Suture granuloma
Brian Jacob 2017

2 years of nociceptive left groin pain
No previous surgery
Started after a work out
Brian Jacob 2017

2 years of nociceptive left groin pain
after open plug and patch
Brian Jacob 2017

14 years of both nociceptive and neuropathic
Brian Jacob 2017

Brian Jacob 2017
Scrotum and testicle NO Pain

Brian Jacob 2017

Open right groin
Staples and mesh found b/t external oblique + internal oblique
Staples seem to be from inside to out (look closely)
Pubic tubercle
(right)

Brian Jacob 2017
WWYD ?

Brian Jacob 2017
Neuropathic pain after open hernia repair
Pain management injections working
Holding off on surgery

Brian Jacob 2017

Hidden inguinal hernias can really be hidden
Brian Jacob 2017

Inguinodynia: tack
Brian Jacob 2017

Inguinodynia: old mesh
Brian Jacob 2017

Inguinodynia: recurrence
Brian Jacob 2017

Inguinodynia: missed femoral hernia
after open plug and patch
Brian Jacob 2017

Let’s Review
• History (work from back to hip to groin to leg)(then to abdomen and gyn)
• Review of previous Op reports
• Exam with mapping, put photo into EMR
• Imaging (CT scan with marker or MRI)(or both)
• Rule out back and hip issues
• Label as nociceptive or neuropathic or both
• Decide if pt needs injections, PT before offering surgery
• Surgery catered to patient’s history and the above
Brian Jacob 2017

Thank you