Clinical examination of musculoskeletal groin pain: a simple protocol for hernia surgeons (Groin-MAP)

Patients with groin pain are often referred to hernia surgeons because of imaging-detected inguinal abnormalities, even when no hernia is palpable. Many of these patients have musculoskeletal pathology that would not benefit from surgical intervention. This project aimed to develop a rapid, evidence-informed musculoskeletal screening protocol for use as an adjunct to routine hernia assessment.

The protocol was developed in four phases: (1) Structured PubMed search for clinical examination tests relevant to each of the entities defined by the 2016 Doha agreement classification system; (2) QUADAS-2 appraisal and extraction of individual tests based on reliability, diagnostic accuracy, and prevalence; (3) consultation with a sports physiotherapist and a high-volume hernia surgeon; and (4) protocol synthesis.

From seven eligible studies, 79 techniques were considered. Thirteen fulfilled our criteria for diagnostic utility and were refined into a six-item protocol. This was titled the Groin Musculoskeletal Assessment Protocol (Groin-MAP). The Groin-MAP screens for adductor-, pubic-, iliopsoas-, and hip-related groin pain. The protocol prioritises low-intra-abdominal-pressure manoeuvres and can be completed in approximately 100 s during simulated testing.

Groin-MAP is a fast and simple musculoskeletal screening adjunct to routine hernia assessment. It requires no equipment or pre-requisite knowledge and clearly explains each test and the positioning of the patient and clinician. Prospective validation will be required to determine its diagnostic performance and impact on clinical decision making.