Screening the Lower Quadrant: Buttock, Hip, Groin, Thigh, and Leg

Chapter 16

Screening the Lower Quadrant

Buttock, Hip, Groin, Thigh, and Leg

The causes of lower quadrant pain or dysfunction vary widely; presentation of symptoms is equally wide ranging. Vascular conditions (e.g., arterial insufficiency, abdominal aneurysm), infectious or inflammatory conditions, gastrointestinal (GI) disease, and gynecologic and male reproductive systems may cause symptoms in the lower quadrant and lower extremity,1 including the pelvis, buttock, hip, groin, thigh, and knee. Some overlap may occur, but unique differences exist.

Cancer may present as primary hip, groin, or leg pain or symptoms. Primary cancer can metastasize to the low back, pelvis, and sacrum, thus referring pain to the hip and groin. Primary cancer may also metastasize to the hip, causing hip or groin pain and symptoms.

Pain may be referred from other locations such as the scrotum, kidneys, abdominal wall, abdomen, peritoneum, or retroperitoneal region. Lower quadrant pain may be referred through conditions that affect nearby anatomic structures, such as the spine, spinal nerve roots, or peripheral nerves, and overlying soft tissue structures (e.g., hernia, bursitis, fasciitis).1a

One of the keys to accurate and quick screening is knowledge of the types of conditions, illnesses, and systemic disorders that can refer pain to the lower quadrant, especially the hip and groin. Much of the information related to screening of the back (see Chapter 14), sacrum, sacroiliac (SI), and pelvis (see Chapter 15) also applies to the hip and groin.

Using the Screening Model to Evaluate the Lower Quadrant

When screening is called for, the therapist looks at the client’s personal and family history, clinical presentation, and associated signs and symptoms. Knowledge of problems that can affect the lower quadrant, along with the likely history, pain patterns, and associated signs and symptoms, shows us the steps to follow in screening.

Most often, the screening process takes place through a series of special questions. A few special tests may be used as well. Recognition of red flag signs and symptoms of systemic or viscerogenic problems can direct the client toward the necessary medical attention early in the disease process. In many cases, early detection and treatment may result in improved outcomes.

Past Medical History

Some of the more common histories associated with lower extremity, hip, or groin pain of a visceral nature are listed in Box 16-1. A previous history of cancer, such as prostate cancer (men), any reproductive cancers (women), or breast cancer, is a red flag as these cancers may be associated with metastases to the hip.

Past history of joint replacement (especially hip arthroplasty) combined with recent infection of any kind and new onset of hip, groin, or knee pain is suspicious. Postoperatively, orthopedic pins may migrate, referring pain from the hip to the back, tibia, or ankle. Loose components, improper implant size, muscular imbalance, and infection that occur any time after joint arthroplasty may cause lower quadrant pain or symptoms (Case Example 16-1).

Case Example 16-1   Screening After Total Hip Replacement

A 74-year-old retired homemaker had a total hip replacement (THR) 2 days ago. She remains an inpatient with complications related to congestive heart failure. She has a previous medical history of gallbladder removal 20 years ago, total hysterectomy 30 years ago, and surgically induced menopause with subsequent onset of hypertension.

Her medications include intravenous furosemide (Lasix), digoxin, and potassium replacement.

During the initial physical therapy intervention, the client reported muscle cramping and headache but was able to complete the entire exercise protocol. Blood pressure was 100/76 mm Hg (measured in the right arm while lying in bed). Systolic measurement dropped to 90 mm Hg when the client moved from supine to standing. Pulse rate was 56 bpm with a pattern of irregular beats. Pulse rate did not change with postural change. Platelet count was 98,000 cells/mm3 when it was measured yesterday.

How would you screen a client with this history and current comorbidities?

What signs and symptoms should be reported to the medical staff?

Nurses will be closely monitoring the patient’s signs and symptoms. Read the medical record to stay up with what everyone else knows or has observed about the patient. Read the physician’s notes to see whether medical intervention has been ordered.

Report anything observed but not already recorded in the chart such as muscle cramping, headache, irregular heartbeat with bradycardia, low pulse, and orthostatic hypotension.

Bradycardia is one of the first signs of digitalis toxicity. In some hospitals, a pulse less than 60 bpm in an adult would indicate that the next dose of digoxin should be withheld and the physician contacted. The protocol may be different from institution to institution.

The therapist is advised to report the following:

There have been reports of hip, groin, and/or pelvic pain and/or mass associated with wear debris from hip arthroplasty. Polyethylene wear debris can also cause deep vein thrombosis, lower extremity edema, ureteral or bladder compression, or sciatic neuropathy.2

Risk Factors

Each condition, illness, or disease that can cause referred pain to the buttock, hip, thigh, groin, or lower extremity has its own unique risk factors. Many of the items listed as past medical history are risk factors. For example, femoral artery catheterization used to monitor ongoing hemodynamic status (arterial line; status post burn injuries, and/or individuals in the intensive care unit [ICU]) or used for individuals with poor upper extremity intravenous access can cause retroperitoneal hematoma formation or septic arthritis and subsequent hip pain.

Most known risk factors for systemically induced problems have been discussed in the individual chapters on each specific condition. For example, arterial insufficiency as a cause of low back, hip, buttock, or leg pain is presented as part of the discussion of peripheral vascular disease in Chapter 6 and again in Chapter 14 because it relates just to low back pain. Likewise, known risk factors for bone cancer or metastases as a cause of hip, groin, or lower extremity pain are presented in Chapter 13.

Many conditions with overlap symptoms (e.g., back and hip pain, pelvic and groin pain) are presented throughout this third text section (Systemic Origins of Neuromusculoskeletal Pain and Dysfunction) as part of the discussion of back pain (see Chapter 14) or pelvic pain (see Chapter 15).

Awareness of risk factors for various problems can help alert the therapist early to the need for medical intervention, as well as for direct education and prevention efforts. Many risk factors for disease are modifiable. Exercise often plays a key role in prevention and treatment of pathologic conditions. Recognizing red flags in the history and clinical presentation and knowing when to refer versus when to treat are topics of focus in this chapter.

Clinical Presentation

If no neuromuscular or musculoskeletal cause of the client’s symptoms can be identified, then the therapist must consider the following:

Hip and Buttock

The physical therapist is well acquainted with hip or buttock pain (Table 16-1) as a result of regional neuromuscular or musculoskeletal disorders. The therapist must be aware that disorders affecting the organs within the pelvic and abdominal cavities can also refer pain to the hip region, mimicking a primary musculoskeletal lesion. A careful history and physical examination usually differentiate these entities from true hip disease.4

Pain Pattern: True hip pain, whether from a neuromusculoskeletal or systemic cause (Table 16-2), is usually felt posteriorly deep within the buttock or anteriorly in the groin, sometimes with radiating pain down the anterior thigh. Pain perceived on the outer (lateral) side or posterior aspect of the hip is usually not caused by an intraarticular problem but more likely results from a trigger point, bursitis, knee, SI, or back problem.

With true hip joint disease, pain will occur with active or passive motion of the hip joint; this pain increases with weight bearing.5 Often, an antalgic gait pattern is observed as the individual leans away from the affected hip and shortens the swing phase to avoid weight bearing.

When the underlying problem is related to soft tissue (e.g., abductor weakness) rather than to the joint as the source of symptoms, the client may lean toward the affected side to compensate for the downward rotation of the pelvis.6 With soft tissue involvement of the bursa or tendons (e.g., gluteus medius, gluteus minimus) pain may radiate from the buttock, greater trochanter, and/or lateral thigh down the leg to the level of insertion of the iliotibial tract on the proximal tibia.79

Pain with medial rotation and decreased hip medial range of motion is associated with hip osteoarthritis.10 Cyriax’s “Sign of the Buttock” (Box 16-2) can help differentiate between hip and lumbar spine disease.1113 The presence of any of these signs may be an indication of osteomyelitis, neoplasm (upper femur, ilium), fracture (sacrum), abscess, or other infection.12

Neuromusculoskeletal Presentation: Identifying the hip as the source of a client’s symptoms may be difficult because pain originating in the hip may not localize to the hip but rather may present as low back, buttock, groin, SI, anterior thigh, or even knee or ankle pain (Fig. 16-1).

On the other hand, regional pain from the low back, SI, sacrum, or knee can be referred to the hip. SI pain that localizes to the base of the spine may be accompanied by radicular pain extending across the buttock and down the leg. It can also cross the lateral hip area. Additionally, SI joint dysfunction can cause groin pain and, with referred pain to the hip, may be accompanied by an ipsilateral decrease in hip joint internal rotation of 15 degrees or more, thereby confusing the clinical picture even further.14,15

Overlying soft tissue structure disorders such as femoral hernia, bursitis, or fasciitis; muscle impairments such as weakness, loss of flexibility, hypertonus or hypotonus, strain, sprain, or tears; and peripheral nerve injury or entrapment, including meralgia paresthetica, can also cause localized hip (and/or groin) pain.

Hip pain referred from the upper lumbar vertebrae can radiate into the anterior aspect of the thigh, whereas hip pain from the lower lumbar vertebrae and sacrum is usually felt in the gluteal region, with radiation down the back or outer aspect of the thigh (Fig. 16-2).

The client with pain caused by component instability following total hip arthroplasty may report hip or groin pain with activity, pain at rest, or both. Clinically, a history of “start up” pain may indicate a loose component. After 5 or 10 steps, the groin pain subsides. Pain may increase again after a moderate amount of walking. Groin or thigh pain is most common with micromotion at the bone–prosthesis interface or other loose component, periosteal irritation, or an undersized femoral stem.16-18

The client reports a dull aching pain in the thigh with no history of systemic illness or recent trauma. Often, the pain is localized to the site of the prosthetic stem tip. The client points to a specific spot along the anterolateral thigh. Pain on initiation of activity that resolves with continued activity should raise suspicion of a loose prosthesis. Persistent pain that is not relieved with rest and continues through the night suggests infection, requiring medical referral.16,19

Systemic Presentation: A noncapsular pattern of restricted hip motion (e.g., limited hip extension, adduction, lateral rotation) may be a sign of pathology other than a joint problem associated with osteoarthritis, potentially a serious underlying disease (Case Example 16-2). The pattern of movement restriction most common with a capsular pattern for the hip is limitation of hip medial rotation, flexion, abduction, and, sometimes, slight limitation of hip extension. Empty end feel can be an indicator of potentially serious disease such as infection or neoplasm. Empty end feel is described as limiting pain before the end range of motion is reached but with no resistance perceived by the examiner.12

Case Example 16-2

Noncapsular Hip Pattern

A 46-year-old male long-distance runner developed sudden onset of right hip pain. He was given a diagnosis of trochanteric bursitis (now called greater trochanteric pain syndrome [GTPS]) by an orthopedic physician and was referred to physical therapy.

Objective Findings

The major criteria for a medical diagnosis of trochanteric bursitis (GTPS) consist of marked tenderness to deep palpation of the greater trochanter and relief of pain after peritrochanteric injection with a local anesthetic and corticosteroid.

The absence of greater trochanter tenderness and the presence of a noncapsular pattern of restriction of the hip were not consistent with the given diagnosis. Local injection was not administered. If an injection had been given, trochanteric bursitis/GTPS may have been eliminated from the list of possible diagnoses.

Objective findings are not consistent with trochanteric bursitis/GTPS. What do you do now?

More tests, of course, and more questions! Is there any history of cancer or prostate problems? Take his vital signs. Can he squat? Clear the hip. Conduct a Review of Systems to look for a pattern in the past medical history, clinical presentation, and any associated signs and symptoms.

Look for a pattern of symptoms that suggests a particular visceral system. Hip pain can be caused by gastrointestinal (GI), vascular, infectious, or cancerous causes. Ask a few screening questions directed at each of these systems. For example:

Result: Red flags included:

The results of the physical therapy examination warranted further medical evaluation, and the client was returned to the physician with a recommendation for imaging studies. Magnetic resonance imaging (MRI) results indicated a nondisplaced, complete fracture of the femoral neck from prostate cancer that had metastasized to the bone.

Data from Jones DL, Erhard RE: Differential diagnosis with serious pathology: A case report, Phys Ther 76:S89-S90, 1996.

Whenever assessing hip joint pain for a systemic or viscerogenic cause, the therapist should look at hip rotation in the neutral position and perform the log-rolling test. With the client in the supine position, the examiner supports the client’s heels in the examiner’s hands and passively rolls the feet in and out. Decreased range of motion (usually accompanied by pain) is positive for an intraarticular source of symptoms. If normal hip rotation is present in this position but the motion reproduces hip pain, then an extraarticular cause should be considered.

Log-rolling of the hip back and forth, though not sensitive, is generally considered to be the most specific examination maneuver for intraarticular hip pathology because it rotates the femoral head back and forth in relation to the acetabulum and capsule, not stressing any of the surrounding extraarticular structures.20 The test does not identify the specific disease present but identifies the source of the symptoms as intraarticular.

Keep in mind that if normal rotations are present but painful, the problem may still be musculoskeletal in origin (e.g., SI, early sign of arthritic changes in the hip joint). Full motion is also possible in the early stages of avascular necrosis and sickle cell anemia. The log-rolling test should be combined with Patrick’s or Faber’s (flexion, abduction, and external rotation) test, long-axis distraction, compressive hip loading, and the scour (quadrant) test to determine whether the hip is a possible source of symptoms.

The presence of GI symptoms (e.g., nausea, vomiting, diarrhea, constipation, abdominal bloating or cramping) or urologic symptoms (e.g., urinary frequency, nocturia, dysuria, or flank pain) along with hip pain is cause to take a closer look. Palpable reproduction of painful symptoms is generally considered extraarticular.21

Negative radiographs of the hip may not rule out bone lesions. When intervention by the physical therapist does not yield relief of symptoms (or only temporary relief), further imaging studies may be needed. A careful review of risk factors and clinical presentation will guide this decision.22


The physical therapist may see a client with an isolated groin problem, especially in the sports or military populations (Case Example 16-3), but more often, the individual has low back, pelvic, hip, knee, or SI problems with a secondary complaint of groin pain. Possible systemic and/or visceral causes of groin pain are wide ranging, whether appearing as an isolated symptom or in combination with pelvic, hip, low back, or thigh pain (Table 16-3 and Case Example 16-4).

Case Example 16-3

Groin Pain in a 13-Year-Old Skateboarder

Referral: A 13-year-old boy presented with a 2-week history of left groin pain. He reported a skateboarding accident as the cause of the symptoms. He was coming down a flight of stairs, hit the last step by mistake, and caught his foot on the stair railing. His leg was forced into wide abduction and external rotation. No (heard or felt) pop or snap was perceived at the time of injury.

The client continued skateboarding but experienced increasing pain 2 hours later. At that time, he could “hardly walk” and has had trouble walking without limping ever since. He tried getting back to skateboarding but was stopped by sharp pain in the groin. No other symptoms were reported (no saddle anesthesia, no numbness and tingling, no bladder changes, no constitutional symptoms).

Clinical Presentation: An antalgic gait was observed as the boy avoided putting full weight through the hip during the stance phase. Trendelenburg gait or Trendelenburg test was not positive. He could not do a squat test because of pain. He could not put enough weight on the left leg to try heel walking or toe walking.

Generalized pain occurred along the inner thigh and was described as “tenderness.” The child cannot internally rotate the hip past midline. Abduction was limited to 30 degrees with painful empty end feel. During active hip flexion, the hip automatically flexes, abducts, and externally rotates. Pain increases with active assisted or passive hip flexion when one is trying to keep the hip in neutral alignment.

Associated Signs and Symptoms: When asked about symptoms of any kind anywhere else in his body, the boy replied, “No.” When offered a list of possible symptoms, these were all negative. He did admit to being slightly constipated because of the pain. Vital signs were all within normal limits.

Is referral indicated in the absence of any signs or symptoms of viscerogenic or systemic disease?

Some red flags are identified here, even though they do not point to a viscerogenic or systemic origin. Trauma, young age, and failure to complete a squat screening test for orthopedic clearance of the hip, knee, and ankle all suggest the need for medical referral before physical therapy intervention is initiated.

Turn to Table 16-3. As you look at the left column of Systemic Causes, what clinical presentation and signs and symptoms might be expected with each of these conditions? Does the current clinical presentation fit any of these?

Now look at the musculoskeletal causes of groin pain (right column, Table 16-3). Are past medical history, risk factors, or clinical presentation consistent for any of these problems? For example, pain in the hip or groin area in anyone who is not skeletally mature raises the suspicion of an orthopedic injury. Abduction and external rotation forces on the hip can produce a slipped capital femoral epiphysis (SCFE).

This is the case here, which required imaging studies for diagnosis. Anteroposterior x-rays were negative, but a lateral view showed slippage to confirm SCFE.

Data from Learch T, Resnick D: Groin pain in a 13-year-old skateboarder, J Musculoskel Med 20:513-515, 2003.

Case Example 16-4

Soft Tissue Sarcoma

A 38-year-old female patient was referred to physical therapy by a primary care clinic physician assistant with a diagnosis of “groin strain.” The client denied any injury or trauma. Little to no pain was reported, but a feeling of “fullness” in the left proximal thigh was described. She was unable to cross her legs when sitting because of this fullness. No other constitutional symptoms or associated symptoms were noted.

When asked, “How long have you had this?” the client thought it had been present for the past 3 months. When asked, “Has it changed since you first noticed it?” she stated that she thought it was getting larger.

Examination: There was an obvious area of edema or tissue mass identified in the proximal medial left thigh. No tenderness, bruising, erythema, or skin temperature changes were reported. The area in question had a boggy feel on palpation. Lower extremity range of motion and manual muscle testing were within normal limits.

Screening and Differential Diagnosis: Look at Table 16-3. As you review the possible systemic and musculoskeletal causes of groin pain, what additional questions and tests or measures must be asked/carried out to complete your screening examination?

On the Systemic Side

• Spinal cord tumors—No temperature changes, dermatomal changes, or associated bowel and bladder changes; no further testing required at this time

• Hodgkin’s disease/lymphoma/leukemia—Ask about previous history of cancer, family history of cancer; palpate lymph nodes (quick screen of lymph nodes above and below the groin and careful examination of inguinal lymph nodes)

• Urinary tract involvement—No history of recent fever, chills, difficulty urinating, or urinary tract infection; no blood in the urine; no further questions at this time

• Ascites—No apparent abdominal ascites, no history of alcoholism; check for asterixis, liver palms (palmar erythema); ask about symptoms of carpal tunnel syndrome, look for spider angiomas during inspection, and observe nail beds for any changes (nails of Terry)

• Hemophilia—It is a long shot, but ask about personal/family history

• Abdominal aortic aneurysm (AAA)—Ask about bounding pulse sensation in the abdomen; palpate aortic pulse width (see Fig. 4-55); ask about the presence of chest or back pain at any time, especially with exertion

• Gynecologic—Ask about a history of pelvic pain, pelvic inflammatory disease, or sexually transmitted infection

• Appendicitis—Perform McBurney’s test, Blumberg’s sign, and iliopsoas and obturator tests (see Chapter 8 for descriptions)

On the Musculoskeletal Side

• Muscle strain—As already tested, no loss of motion or strength; no pain with resisted movement; no history of trauma or overuse. Red flag: Clinical presentation is not consistent with the medical diagnosis.

• Internal oblique avulsion/stress reaction or fracture—As above

• Pubalgia—As above; no painful symptoms reported, no pain on palpation

• Sexual assault/domestic violence—Even though the client denies trauma, consider a screening interview for nonaccidental trauma (see Chapter 2 or Appendix B-3); absence of erythema, skin bruising, or other skin changes makes this type of trauma unlikely

• Total hip arthropathy—Negative history

• Avascular necrosis—Not likely, given the clinical presentation; ask about a history of long-term use of immunosuppressants (corticosteroids for Crohn’s disease, sarcoidosis, autoimmune disorders)

• Trigger points (TrPs)—Atypical presentation for a trigger point; check for latent TrPs of the adductors, iliopsoas, vastus medialis, and sartorius

Special Questions to Ask: Take a final look at Special Questions to Ask in this chapter. Have you missed anything? Left anything out?

Result: On the basis of lack of objective findings and red flags of mass increasing in size and clinical presentation inconsistent with medical diagnosis, the therapist consulted with an orthopedic surgeon in the same health care facility. The orthopedic surgeon ordered x-rays, which were normal, and advised a short period of observation before ordering magnetic resonance imaging (MRI).

After 3 weeks, no changes were observed, and an MRI was ordered. The MRI showed a soft tissue tumor, later diagnosed on biopsy as a stage IIIB high-grade soft tissue sarcoma.

The client underwent multiple surgical procedures, including removal of the medial compartment musculature and limb salvage with an eventual hemiarthroplasty. Physical therapy included gait training, regaining safe hip active range of motion, an aquatic rehabilitation program, use of an underwater treadmill, and both open and closed kinetic chain strengthening.

Adapted from Baxter RE: Identification of neoplasm mimicking musculoskeletal pathology: A case report involving groin symptoms. Poster presented at Combined Sections Meeting, 2004, New Orleans, LA. Used with permission.

Palpating the groin area is usually necessary in making a differential diagnosis. This can be a sensitive issue, and the therapist is advised to have a third person in the examination area. This person should be the same gender as the client. The therapist should explain the examination procedure and obtain the client’s permission.

During examination of the groin, the physical therapist may palpate enlarged lymph nodes, or the client may indicate these nodes to the examiner. Painless, progressive enlargements of lymph nodes or lymph nodes that are aberrant or suspicious for any reason, especially if present in more than one area or in the presence of a past medical history of cancer, are an indication of the need for medical referral.

Changes in lymph nodes without a previous history of cancer continue to represent a yellow or red flag. Tender, movable inguinal lymph nodes may be a sign of food intolerance or allergies or an indication that the body is fighting off an infectious process. The therapist should use his or her best clinical judgment in deciding what to do but should always err on the side of caution. When doubt arises, one should contact the physician and communicate any concerns, observations, or questions.

Neuromusculoskeletal Presentation: Neuromuscular or musculoskeletal causes of groin pain should also be considered (Case Example 16-5).23,24 Keep in mind that intraarticular pathology of the hip can manifest as groin pain owing to the innervation of the hip capsule. Extraarticular hip conditions radiate to the lateral or posterior aspects of the hip.25

Case Example 16-5

Groin Pain—Musculoskeletal Cause

A 44-year-old male patient came to physical therapy with a 7-year history of right groin pain. X-rays, bone scan, and arthrogram of the hip were negative. At the time of initial examination, the client was taking morphine for pain that was described as constant, severe, and sharp and that was rated 8 out of 10 on the Numeric Rating Scale (NRS; see Chapter 3). Sitting and driving made the symptoms worse, and he was unable to work as a mechanic because prolonged squatting was required. Lying supine relieved the pain.

Physical examination revealed extreme hip medial rotation associated with active hip flexion, abduction, and knee extension; each of these movements reproduced his symptoms. Passive range of motion of the right hip was painful and was limited to 95 degrees of flexion and 0 degrees of lateral rotation.

Visual inspection during movement and palpation of the greater trochanter indicated that the proximal femur had medially rotated and moved anteriorly during hip flexion. Through application of a posteroinferior glide over the proximal femur during hip flexion, groin pain was decreased and motion increased. The client was able to moderate his symptoms by avoiding hip medial rotation during hip and knee movements.

Consider: Are any red flags present? Is further screening indicated to rule out systemic origin of symptoms? If yes, what questions or tests might you consider carrying out?

Red Flags: Age (over 40); constant, intense pain

Further Screening Required: The length of time that symptoms have been present without accompanying signs and symptoms of a urologic or gastrointestinal (GI) nature (7 years) is not typical of systemic origin of musculoskeletal symptoms.

The fact that no aggravating and relieving factors are known further rules out a viscerogenic cause of pain. It would be appropriate to ask the Special Questions for Men at the end of Chapter 14 (see also Appendix B-24).

It is always a good idea to ask one final question: Are any other symptoms of any kind anywhere else in your body? Special tests might include the heel strike test (fracture), translational rotation tests for stress reaction (fracture), iliopsoas and obturator tests (abscess; see Chapter 8), and trigger point assessment.

Result: The client was treated for femoral anterior glide with medial rotation (movement impairment diagnosis).23 Training to teach the client to modify hip medial rotation during sustained postures and functional activities was a key component of the intervention. Exercises were given to strengthen the right iliopsoas muscle, hip lateral rotator muscles, and posterior gluteus medius muscle.

The client was pain-free and off pain medications 2 months later after 6 treatment sessions. He was able to return to full-time work.

Comment: Knowledge of red-flag signs and symptoms, risk factors for various systemic conditions and illnesses, associated signs and symptoms of viscerogenic pain, and typical clinical presentations for neuromuscular and musculoskeletal problems can guide the therapist in quickly sizing up a situation and deciding whether or not further screening is warranted.

In this case, the therapist can see that only a few screening questions are in order. The application of any additional special tests depends on the client’s answers to screening questions. The client’s immediate response to intervention is another way to verify a correct physical therapy diagnosis. Failure to progress with intervention is a red flag that indicates the need for reevaluation.

Data from Bloom NJ, Sahrmann SA: Groin pain caused by movement system impairments: A case report. Poster presented at Combined Sections Meeting, 2004, New Orleans, LA.. Used with permission.

Groin pain is a common complaint in sports that involve kicking and rapid change of direction (e.g., soccer, hockey). The most common musculoskeletal cause of groin pain is strain of the adductor muscles, most often involving the adductor longus. The history includes a specific trauma, repetitive motion, or injury, which occurs primarily at the junction of the muscle fibers and the extended tendon of origin. Acutely, this injury causes unilateral or bilateral pain during or after activity, with local palpation of the adductor longus origin, and during passive stretching or active contraction; eccentric activation may be even more painful.26,27 Acute injury may be followed in several days by ecchymosis.

Chronic groin or inguinal pain in the active athletic, sports, or military groups is often referred to as athletic pubalgia. Athletic pubalgia is sometimes used interchangeably to describe a sports or athletic hernia, which is a tear in the muscles of the inner thigh, lower abdomen, and/or the fascia.28 The term sports hernia may be a bit misleading because experts in this area do not consider this condition the same as a true inguinal or femoral hernia.29

Symptoms associated with athletic pubalgia are often described as deep groin or lower abdominal pain with exertion (usually unilateral). There may be a localized sharp burning sensation in the lower abdomen and/or inguinal region. Symptoms are relieved with rest but aggravated by activity, especially sport-related activities. As the condition progresses, symptoms may radiate to the adductor region, testes (male), and labia (female).30,31

Labral tears of the acetabulum can also cause groin pain. There may be a history of trauma but acetabular labral tears can occur without trauma. The clinical presentation can vary and include night pain, activity-related pain, positive Trendelenburg sign, and positive impingement sign (pain reproduced with hip flexion, adduction, and internal rotation). In young, active individuals with a primary complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected and investigated further.32

Femoroacetabular impingement presents as groin pain in young adults. Onset is gradual and progressive with intermittent groin pain after prolonged walking, prolonged sitting, or athletic activities that stress the hip. The impingement test (internal hip rotation and adduction while the hip is flexed) is always positive. Referral for a medical orthopedic examination and imaging studies may be warranted.33

Another common problem in the young athlete or long distance runner is osteitis pubis. Repetitive stress of the adductor group can cause inflammation at the musculotendinous attachment on the pubic bone, contributing to sclerosis and bony changes.34

Osteitis pubis with inflammation and sclerosis of the pubic symphysis can cause both acute and chronic groin pain. Individuals affected most often include competitive sports athletes involved in running, leaping and landing with force, repetitive kicking motions, or training on concrete, uneven, or other hard surfaces. Osteitis pubis can also occur as a result of leg length differences, faulty foot and body mechanics, or muscular imbalances and during pregnancy. Tenderness on palpation of the pubic symphysis helps identify this condition.26 Onset of midline pain that radiates to the groin is typical. Pain is reproduced by palpation of the pubis (anterior), passive hip abduction, and resisted hip adduction. Articular lesions involving the pubis symphysis can also lead to pubalgia.35

Insertional injuries of the upper attachment of the rectus abdominis muscle over the anteroinferior pubis (just lateral to the pubic symphysis) can lead to tendinopathy presenting as pubalgia. Without magnetic resonance imaging (MRI), insertional abdominis pathology cannot be differentiated from adductor pathology as the abdominis pubic attachment and the thigh adductor tendon blend to form one unit.35

Chronic, unresolved groin pain in the athletic population also has been linked with altered neuromotor control.36 The therapist may need to evaluate groin pain from a motor control point of view. See further discussion of stress reaction/fractures in the section on Trauma as a Cause of Hip, Groin, or Lower Quadrant Pain in this chapter.

Older adults are more likely to experience hip, buttock, or groin pain associated with arthritis, lumbar stenosis, insufficiency fractures, or hip arthroplasty. Arthritis is characterized by radiating pain to the knee, but not below, with decreased hip range of motion. Gait disturbances may be seen as arthritis progresses.17 Insufficiency fracture of the pubic rami can also cause hip/groin pain, resulting in a reluctance to bear weight on the affected side along with an antalgic gait.37

Hip and groin pain secondary to lumbar stenosis can manifest as low back pain that radiates to the lower extremities. The pain begins and gets worse with ambulation. Standing and walking may also increase symptoms when the lumbar spine assumes a more lordotic position and the ligamentum flavus folds in on itself, pinching the foramina closed. The client who has stenosis bends forward or sits to avoid painful symptoms. Clients who have a total hip arthroplasty for hip pain may have continued groin and buttock pain, secondary to sciatica or lumbar spinal stenosis.17


Once again, we cannot emphasize enough the importance of conducting a thorough physical examination to rule out systemic or viscerogenic disease as the source of thigh pain; client history and lower quadrant screening examination should be performed (see Box 4-16).

Anterior thigh pain is more common (Table 16-4), but posterior thigh pain may occur, with ruptured abdominal aortic aneurysm. Local anterior or posterior thigh pain of systemic origin generally occurs as a deep aching generated by soft tissue irritation or bone involvement. Radicular pain is usually a sharp, stabbing pain that projects in dermatomal distributions caused by compression of the dorsal nerve roots.

Neuromusculoskeletal Presentation: The lower lumbar vertebrae and sacrum can refer pain to the gluteal and hip region, with pain radiating down the posterior or posterolateral thigh. Pain down the lateral aspect of the thigh to the knee may also be caused by inflammation of the tensor fascia lata with iliotibial band syndrome.5 A similar pattern has been reported in association with irritability, injury, or disease of the thoracolumbar transitional segments,38,39 and at least one case of synovial cell sarcoma presenting as iliotibial band syndrome has been reported.40

Anterior thigh pain is commonly disk related, resulting from L3-L4 disk herniation and occurring most often in older clients with a previous history of lumbar spine surgery. The clinical presentation varies among affected individuals, but thigh pain alone is most common (Case Example 16-6).

Case Example 16-6   Buttock Pain Post Prostatectomy

A 62-year-old male patient was examined by a physical therapist for a chief complaint of severe left buttock and lateral thigh pain. No injury or trauma was reported; the client noticed low back pain 3 days ago. He lifted a couple of sand bags but did not think that was the cause of his pain. He has seen the chiropractor twice this week and felt that the electrical stimulation he had on one visit “usually does it” (helped relieve the pain). Pain relief was of a very short-term nature and had no lasting effects.

Past Medical History: Prostatectomy 4 years ago for cancer followed by 36 radiation treatments. The bowel was resected, and the patient received a stoma at that time.

Current Health Report: Prostate-specific antigen has increased from 0 to 0.4 in a stepwise fashion over the past year. The patient has not seen his oncologist for any follow-up “for quite some time.” At this time, the client is not taking any medications except for over-the-counter pain relievers. Supplements include calcium and fish oil.

Clinical Presentation

Pain Pattern: Pain is reported as “constant,” but it “has its highs and lows.” The client prefers lying on his left (involved) side. He cannot sit for longer than 1 minute without onset of radicular symptoms.

Physical Examination: Visual inspection showed flattened lumbar spine. What appeared to be atrophy was seen in the right gluteal; this was confirmed with comparative palpation. Pelvic landmarks were slightly elevated (L higher than R). Lumbar range of motion was limited in all planes with remarkably minimal flexion, which the patient said was normal for him. No centralization of pain occurred with side glides or with repeated extension in standing.

Vascular Examination: No signs of peripheral vascular disease (PVD) were noted in the lower extremities. Blood pressure was not assessed.

Neurologic Screening Examination: Hyperreflexive patellar deep tendon reflexes (DTRs) on the right (L3); this was difficult to assess: He may have been notably hyporeflexive on the left. Achilles deep tendon reflexes (S1) appeared equal, with grading of 2/4 bilaterally. Clonus, Babinski’s, and Oppenheim’s were negative. Manual muscle testing (MMT) showed fatiguing weakness on the left at L2 (hip flexors), L3 (quadriceps), L5 (extensor hallucis longus and gluteus medius), and S1 (hamstring). No loss of light touch sensation was observed.

Associated Signs and Symptoms: No nausea or vomiting was reported. No recent significant weight loss or gain occurred. No changes in bowel or bladder function were described. The patient reported feeling chills of late, intermittently, which he says are caused by the bouts of severe pain. He showed no diaphoresis during the physical therapist’s examination.

Red Flags

Result: The therapist applied some direct intervention for pain relief (positioning, Pain Reflex Release Technique (PRRT), trigger point release) with no immediate relief of painful symptoms. The therapist explained his concerns regarding the red-flag symptoms and advised the client to make an appointment with his oncologist for further evaluation. The client was instructed to call the therapist with the name and number for the oncologist, so his findings could be relayed to her.

The client left a message on the therapist’s answering machine (received the next morning) that he was “going to the ER: I’ve got to do something about the pain.”

The client followed up midday to state that he had gone to the emergency department. Diagnostic tests were ordered, and MRI revealed a herniated nucleus pulposus (HNP) of the L3/4 disk with effacement on the L3 nerve root. The L5/S1 disk was also reportedly herniated, although this did not affect the adjacent nerve root. The client is to see a neurosurgeon next week.

Use of the extreme lateral interbody fusion (XLIF) technique has been linked with thigh weakness and/or numbness postoperatively as a possible consequence of trauma to the psoas muscle or femoral nerve during the approach. Symptoms are temporary and appear to resolve with soft tissue healing following surgery.41

Back and thigh pain, a positive reverse straight leg raise (SLR) test, and depressed knee reflex are described more often in clients with disk herniation at the L3-L4 level than in clients with L4-L5 and L5-S1 levels.42,43 A positive reverse SLR is defined as pain traveling down the ipsilateral leg when the person is prone and the leg is extended at the hip and the knee. A positive test is caused by tension on the femoral nerve and its roots.44

Objective neurologic findings, such as hyperreflexia or hyporeflexia, decreased sensation to light touch or pinprick, and decreased motor strength, can occur with soft tissue problems such as bursitis. However, clients with true nerve root irritation experience pain extending into the lower leg and foot. Clients with bursitis exhibit a positive “jump” sign when pressure is applied over the greater trochanter; no jump sign is seen with nerve root irritation.7

A common neuromuscular cause of anterior or anterolateral thigh pain is lateral femoral cutaneous nerve (LFCN) neuralgia. Entrapment or compression of the LFCN causes pain or dysesthesia, or both, in the anterolateral thigh—a condition called meralgia paresthetica. Compression of the LFCN may occur at the level of the L2 and L3 roots through upper lumbar disk herniation or tumor in the second lumbar vertebra. LFCN neuropathy may occur after spine surgery to repair nerve damage that occurred during harvesting of the iliac bone graft or that resulted from pressure on the pelvis from prone positioning or with use of the Relton-Hall frame.45

Other causes of injury to the LFCN include positioning during hip arthroplasty (at risk: obese individuals)46; abnormal posture; chronic muscle spasm; tight-fitting braces, corsets, or pants; and thigh injury.47 For clients with hip arthroplasty, implant loosening, fracture, or subsidence (sinking down into the bone) can cause thigh pain as the first symptom of instability.19 Both passive and active range of motion should be evaluated to assess implant stability. X-rays are needed to look at component position, bone–prosthesis interface, and signs of fracture or infection.16

Systemic Presentation: The pain pattern for anterior thigh pain produced by systemic causes is often the same as that presented for pain resulting from neuromusculoskeletal causes. The therapist must rely on clues from the history and the presence of associated signs and symptoms to help guide the decision-making process.

For example, obstruction, infection, inflammation, or compression of the ureters may cause a pattern of low back and flank pain that radiates anteriorly to the ipsilateral lower abdomen and upper thigh. The client usually has a past history of similar problems or additional urologic symptoms such as pain with urination, urinary frequency, low-grade fever, sweats, or blood in the urine. Murphy’s percussion test (see Fig. 4-54) may be positive when the kidney is involved.

The same pain pattern can occur with lower thoracic disk herniation. However, instead of urologic signs and symptoms, the therapist should look for a history of back pain and trauma and the presence of neurologic signs and symptoms accompanying diskogenic lesions.

Retroperitoneal or intraabdominal tumor or abscess may also cause anterior thigh pain. A past history of reproductive or abdominal cancer or the presence of any condition listed in Box 16-3 is a red flag.

Thigh pain has been reported as a prodromal symptom of unilateral low-energy subtrochanteric and femoral shaft (diaphyseal) stress reactions and fractures in a small number of people on long-term bisphosphonate therapy.48

Knee and Lower Leg

Pain in the lower leg is most often caused by injury, inflammation, tumor (malignant or benign), altered peripheral circulation, deep venous thrombosis (DVT), or neurologic impairment (Table 16-5). Assessment of limb pain follows the series of pain-related questions presented in Fig. 3-6. The therapist can use the information in Boxes 4-13 and 4-16 to conduct a screening examination.

Neuromusculoskeletal Presentation: In addition to screening for medical problems, the therapist must remember to clear the joint above and below the area of symptoms or dysfunction. True knee pain or symptoms are often described as mechanical (local pain and tenderness with locking or giving way of the lower leg) or loading (poorly localized pain with weight bearing).

There are many musculoskeletal or neuromuscular conditions well known to the therapist as a potential cause of generalized knee pain, including muscle spasm, strain, or tear; patellofemoral pain syndrome; tendinitis; ligamentous disruption, meniscal tear, or osteochondral lesion; stress fracture49; and nerve entrapment.50,51

Degenerative joint disease of the hip52 or other hip pathology can masquerade as knee pain in adults.53 Neurologic problems, including spinal stenosis, complex regional pain syndrome (Type 1), neurogenic claudication, and lumbar radiculopathy are common disorders that can produce knee pain. Isolated knee pain involving SI dysfunction has also been reported.54

Pain and impaired function from a variety of intraarticular or extraarticular etiologies can also develop following a total knee arthroplasty.55 Client history and clinical examination will help establish the diagnosis. Assessment of trigger points (TrPs) is also essential as pain referral to the knee from TrPs in the lower quadrant is well recognized but sometimes forgotten.56,57

Many therapists over the years have shared with us stories of clients treated for knee pain with a total knee replacement only to discover later (when the knee pain was unchanged) that the problem was really extraarticular (i.e., coming from the back or hip). On the flip side, it is not as likely but is still possible that hip pain can be caused by knee disease. Individual case reports of hip fracture presenting as isolated knee pain have been published58 (Case Example 16-7).

Case Example 16-7   Total Knee Arthroplasty

A 78-year-old woman went to the emergency department over a weekend for knee pain. She reported a knee joint replacement 6 months ago because of arthritis. X-ray examination showed that the knee implant was intact with no complications (i.e., no infection, fracture, or loose components). She was advised to contact her orthopedic surgeon the following Monday for a follow-up visit. The woman decided instead to see the physical therapist who was involved with her postoperative rehabilitation.

The physical therapist’s interview and examination revealed the following information. No pain was perceived or reported anywhere except in the knee. The pain pattern was constant (always present) but was made worse by weight-bearing activities. The knee was not warm, red, or swollen. No other associated signs and symptoms or constitutional symptoms were present, and vital signs were within normal limits for her age range.

Range of motion was better than at the time of previous discharge, but painful symptoms were elicited with a gross manual muscle screening examination. After a test of muscle strength, the woman was experiencing intense pain and was unable to put any weight on the painful leg.

The physical therapist insisted that the woman contact her physician immediately and arranged by phone for an emergency appointment that same day.

Result: Orthopedic examination and pelvic and hip x-ray films showed a hip fracture that required immediate total hip replacement the same day. The knee can be a site for referred pain from other areas of the musculoskeletal system, especially when symptoms are monoarticular. Systemic origin (or medical conditions causing) symptoms is more likely when multiple joints are involved or migrating arthralgias are present.

No history or accompanying signs and symptoms suggested a systemic origin of knee pain, but the pain on weight bearing made worse after muscle testing was a red-flag symptom for bone involvement. Hip fractures or other hip disease can masquerade as knee pain.

Prompt diagnosis of hip fracture is important in preventing complications. This therapist chose the conservative approach with medical referral rather than proceeding with physical therapy intervention. Sometimes, the “treat-and-see” approach to symptom assessment works well, but if any red flags are identified, a physician referral is advised.

Mar 20, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Screening the Lower Quadrant: Buttock, Hip, Groin, Thigh, and Leg
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