The physical examination should begin with vital signs, including accurate height and weight . Overweight and obese patients have a lower incidence of inguinal hernia formation compared to normal weight individuals [14, 15]. Routine physical examination of the thorax and abdomen should be performed, but the majority of the physical exam should be focused on the groin and the hip. The back, pelvis, groin, and upper thigh should be completely exposed in order to facilitate a thorough examination.

Examination should begin in the upright position with inspection. Palpation of the spine and paraspinal muscles should be done. Unilateral inguinal hernias will often be apparent as an asymmetric bulge in the inguinal area that may or may not extend into the scrotum in males. Most other pathologies will have no obvious findings on inspection alone. Palpation of the groin should also begin in the upright or standing position. Many inguinal hernias can be palpated simply by placing the hand over the inguinal canal and reducing any hernia contents into their intra-abdominal position. The patient is then asked to cough or to perform the Valsalva maneuver, and the hernia contents should slide past one’s fingers. If a hernia cannot be appreciated, the index finger can be placed into the inguinal canal by invaginating the scrotum in male patients. With a finger placed deep in the canal, hernias can again be appreciated with Valsalva or cough . Additionally, the inguinal occlusion test can be performed to determine if the hernia is direct or indirect [16]. With this maneuver, the hernia contents are reduced and manual pressure is applied over the presumed site of the deep inguinal ring. The patient then performs a Valsalva maneuver, and one can observe if the hernia appears with continued compression (direct) or only after release of the internal ring (indirect). While this maneuver may help to differentiate the types of inguinal hernia, its accuracy is relatively low and is not likely to alter the surgical intervention [17, 18]. If no hernia is appreciated, then the groin is similarly examined with the patient lying supine. If hernias still cannot be recognized, then ancillary imaging may be necessary or an alternative diagnosis should be entertained.

Patients with sports injuries, often suspected by the patient’s history, should undergo a sequential exam of the back, hip, and groin [19, 20]. For a general surgeon, the exams will in most cases be basic, but even a basic exam will help direct referral or image ordering. The spine and back should be palpated along the thoracic, lumbar, and sacral vertebrae. The paraspinal muscles should also be palpated, and the rare entity of thoracolumbar syndrome should be ruled out when this entity is suspected. The hip should then be examined with some simple maneuvers that examine hip rotation, extension, and flexion. The rest of the exam should focus on the groin, where a firm understanding of the musculoskeletal anatomy will help greatly in figuring out the precise cause of the athletic pubalgia. The rectus muscle insertion on the pubis should be examined with palpation and a sit-up or crunch maneuver while palpating the conjoint tendon Fig. 4.2 [11]. Reproducible pain in this area suggests rectus sheath or conjoined tendon pathology. The pubic tubercle should be palpated and pain with direct pressure can suggest osteitis pubis [21]. Finally, the leg muscles , specifically the adductors and abductors, can be examined by asking the patient to adduct and abduct against resistance and noting any reproducible symptoms [20]. The hip flexors (iliopsoas and rectus femoris) can also be tested at this point with leg flexion against resistance. If all is normal, yet the patient only has tenderness over the internal ring region of the canal without a palpable hernia, a “sports hernia” can then be suspected.

There are a wide variety of physical exam maneuvers that can be employed to assess for hip joint injury as the cause of groin pain (Table 4.2) [1, 10, 22–25]. Range of motion, strength, and provocative maneuvers may all be necessary; however, the majority of these clinical tests have not been found to be of substantial quality to dictate clinical decision making [26]. The majority of these maneuvers are outside the scope of practice for most general surgeons, and if hip pathology is suspected, then early referral to Sports Medicine or Orthopedic Surgery is warranted, as radiographic studies will likely be necessary to make a firm diagnosis.