Spine diseases, such as thoracolumbar discogenic pain at multiple levels or L2–L4 nerve root impingement, can all cause groin and thigh pain, with or without associated back pain [4]. The mechanism is sometimes complex, as the pain can be radicular pain from nerve root compression or pain from nerve endings on the herniated disc itself. The existence of sensory nerve endings in the annulus fibrosus of the human lumbar intervertebral disc has been described and well documented [5]. Patients sometimes find it hard to understand how their groin pain is originating from their back when they do not present with back pain. Physical exam of the hip is usually normal. Limited spine flexion, extension, and/or lateral bending are sometimes seen. Many of these patients have very weak core musculature. The femoral nerve traction test is done with the patient in a prone position with the knee flexed to 90° and the hip fully extended; pain in the anterior thigh suggests a L2–L4 nerve root impingement. One of the most common findings, however, appears to be tight hamstring musculature. Tight hamstrings lead to hip flexion contractures, a subtle crouched gait, and compensatory pressure on the spine. Physical therapy focusing on core strengthening, hamstring stretching, and lumbar stabilization is the first line of treatment. MRI of the spine is sometimes needed, followed by selective spinal diagnostic and therapeutic injections.

  Osteitis pubis is a noninfectious inflammatory process of the pubic symphysis commonly seen in runners and in athletes involved in cutting sports such as soccer and hockey. Previous trauma, overuse, and vaginal delivery are all risk factors. Patients often present with groin pain that is activity related. On physical exam they usually have normal hip range of motion, nontender abductor muscles laterally, and focal tenderness to palpation over the pubic symphysis. Weak core musculature is often noted; pain with resisted hip adduction or passive hip abduction may also be found. These latter physical exam findings are often confirmed by tendinosis of the rectus abdominis and adductor longus insertions on an MRI. Plain radiographs of the pelvis are usually helpful as well, as they typically show widening of the symphysis with blurring of the cortical margins and sometimes cysts. Physical therapy is the first line of treatment followed by steroid injections. Surgical bony resection with preservation of the rectus and pubic ligaments is rarely done [6].

  Fractures of the superior and/or inferior pubic rami are commonly seen in elderly patients who have sustained a low-energy fall. These patients present with acute groin pain that was not present prior to trauma. They usually have painless hip rotation but focal tenderness over the bony pelvis lateral to the pubic symphysis. It is common for these patients to report having had recent hip radiographs that were normal. Unfortunately, the pelvis has rarely been evaluated. Hip radiographs often do not show rami fractures; it is imperative to obtain an AP of the pelvis when evaluating groin pain. Treatment of these fractures is most commonly nonoperative with unrestricted weight bearing.

  The two most common iliopsoas pathologies seen by orthopedic surgeons are snapping (coxa saltans interna) and tendinitis. Internal snapping of the iliopsoas tendon is actually an extra-articular process. Patients usually present with an audible snap and anterior groin pain. As the hip is extended, the iliopsoas tendon travels from lateral to medial catches at the iliopectineal eminence or on the femoral head. On occasion, the snapping can be palpated directly in the groin. Dynamic ultrasound may be useful in the diagnosis. MRI is sometimes indicated, as it can show resultant hip labral tea [7]. Iliopsoas tendinitis is a relatively rare entity in patients with native hips and seen most commonly in patients involved in activities that require repetitive hip flexion (rowing, uphill running, and ballet). Patients generally present with anterior hip pain that radiates to the knee and sometimes with knee pain alone. The most common physical exam findings are painless hip rotation, pain with resisted hip flexion, and pain with passive hip extension. Initial treatment of both coxa saltans interna and iliopsoas tendinitis is always stretching (best done in a luge position) and, when necessary, steroid injections [8]. Open and arthroscopic releases of the iliopsoas tendon have been reported, but complications such as symptomatic intra-abdominal fluid extravasation [9] and anterior hip instability [10] have been reported. Exclusion of the other potentially life-threatening pathologies with which abdominal surgeons are very familiar, such as an iliopsoas abscess, is clearly important.