Groin Pain (non-traumatic)

Psoas Abscess

Signs & Symptoms

  • Pain confined to psoas fascia but may extend to the back, buttock, hip, pelvic, groin, upper thigh, or knee
  • Pain located in the anterior hip in the area of the medial thigh or femoral triangle, sometimes occurring with abdominal pain 
  • Psoas spasm causing a functional hip flexion contracture
  • Leg pulled into internal rotation
  • Positive psoas sign (pain elicited by stretching the psoas muscle by extending the hip)
  • “Hectic” fever pattern (up and down)
  • Night sweats
  • Loss of appetite or other GI symptoms
  • Palpable, tender mass in inguinal area
  • Positive iliopsoas or obturator test
  • Antalgic gait
  • Weight loss
  • Malaise

Risk Factors

  • Diverticulitis
  • Crohn’s disease
  • Appendicitis
  • Pelvic inflammatory disease
  • Diabetes mellitus
  • Any source of infection such as dental, renal, infective spondylitis, osteomyelitis, or sacroiliac joint infection
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Special Tests

Obturator muscle test
Patient performs AAROM flexing to 90 degrees at the hip and knee in supine. PT holds ankle and rotates the leg internally and externally. A positive test for muscle affected by peritoneal infection or inflammation reproduces right lower quadrant abdominal or pelvic pain.   

Blumberg’s sign
Place hand on the abdomen in an area away from suspected area of local inflammation and then palpate deeply and slowly. The palpating hand is then quickly removed. Pain induced or increased by quick withdrawal results from rapid movement of inflamed peritoneum which is called rebound tenderness. When this is present the patient will have pain or increased pain on the side of the inflammation when the palpatory pressure is released.  
Heel tap (video)
Gently pick up patient’s leg on the involved side and tap the heel. A positive test would be right lower quadrant pain due to peritoneal inflammation.
Hop test (video)
Have patient hop on one leg. A positive test would be if the patient clutches their side unable to complete the movement.
Iliopsoas muscle test (video)
Patient performs ALSR in supine and PT applies resistance to the distal thigh as the patient tries to hold the leg up. Alternately, have the patient turn onto their side and PT extends the uppermost leg at the hip. A positive test is increased abdominal, flank, or pelvic pain on either maneuver, suggesting irritation of the psoas muscle by an inflamed appendix or peritoneum
Palpate iliopsoas muscle (video)
Patient should be supine with hips and knees flexed to 90 degrees. PT slowly presses fingers into abdomen approximately one third the distance from the ASIS toward the umbilicus. It may be necessary to ask the patient to initiate slight hip flexion to help isolate the muscle and avoid palpating the bowel. A positive sign for an iliopsoas abscess is reproducing or causing lower quadrant, pelvic, or abdominal pain.

When to refer:

If the patient is showing positive signs of a psoas abscess, they should be immediately referred to a physician.

Red Flags

References

  1. Ferri, F. F. (1999). Ferri's clinical advisor : instant diagnosis and treatment. St. Louis, Mosbyv.
  2. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis: Suanders Elsevier; 2007.
  3. Mallick IH, Thoufeeq MH, Rajendran T P.  Iliopsoas abscesses. Postgrad Med J 2004; 80: 459-462.

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