KayLeigh McIlhenny: A 21-Year-Old Female With Right Groin Pain Following a Cheerleading Accident

Learning Objectives

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Learn the common causes of groin pain (pubalgia).
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Develop an understanding of the innervation of the groin and pelvis.
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Develop an understanding of the anatomy of the adductor tendons.
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Develop an understanding of the causes of adductor tendinitis.
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Learn the clinical presentation of adductor tendinitis.
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Learn how to use physical examination to identify adductor tendinitis.
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Develop an understanding of the treatment options for adductor tendinitis.
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Learn the appropriate testing options to help diagnose adductor tendinitis.
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Learn to identify red flags in patients who present with groin pain.
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Develop an understanding of the role of interventional pain management in the treatment of adductor tendinitis.

KayLeigh McIlhenny

KayLeigh McIlhenny is a 21-year-old cheerleader with the chief complaint of, “I pulled my groin.” KayLeigh went on to say that she got hurt at the ‘Bama game when she was thrown up into the air and did splits. She felt a sudden, sharp tearing sensation in her right groin and had to be helped off the field. “The good news,” KayLeigh said, “is that we won!” The bad news is that she was really having a hard time getting better in spite of massage, acupuncture, aromatherapy, and a lidocaine patch. She said that the pain pills the team doctor gave her seized up her bowels, so she quit taking them.

I asked KayLeigh if she ever had anything like this before, and she shook her head no. She also denied any current urinary or gynecologic symptoms, hematuria, or fever or chills. She also denied a history of kidney stones. Her last menstrual period was about 10 days ago. KayLeigh was using oral contraceptives, but volunteered that the groin pain made sex pretty much impossible. I asked what she was currently doing to manage the pain and she said that “nothing really works.” I asked her to rate her pain on a scale of 1 to 10, with 10 being the worst pain she ever had, and she said the pain was a 7 or 8. “Doctor, I have to get back to normal. Cheerleading is my life. The pain is interfering with just about everything. I can’t cheerlead, I have a hard time getting dressed, no exercise, no sex—everything. I just really need to get my life back.”

I asked KayLeigh to point with one finger to show me where it hurt the most. She pointed to insertions of the adductor tendons at the pubic ramus. She said, “Doc, the pain is right here. This spot right on the bone is really killing on me.”

On physical examination, KayLeigh was afebrile. Her respirations were 16. Her pulse was 72 and regular. Her blood pressure (BP) was normal at 118/68. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination was negative. Her abdominal examination revealed no abnormal mass or organomegaly, and no groin mass or hernia was identified. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Her lower extremity neurologic examination was completely normal. The Waldman knee squeeze test was markedly positive ( Fig. 11.1 ).

I asked KayLeigh to lie back on the examination table and let her legs drop apart. She cautiously began abducting her hips and didn’t get very far when she cried out in pain. I asked her where it hurt and she again pointed to the origin of the adductor tendons. Visual inspection of the area revealed no ecchymosis. I asked KayLeigh if I could palpate the spot that she identified, and after a moment’s hesitation she nodded yes and said, “Sure, just be gentle. It really is sensitive.” I said, “No problem. Why don’t you hold my hand, and you do the pushing and I’ll do the feeling, and together we’ll figure out what is going on.” She said she liked that idea and relaxed. I had KayLeigh guide my index finger to the spot that was causing the trouble. The spot was right over the origin of the adductor tendons as they inserted on the ischium. I asked KayLeigh to push my finger a little harder and she said, “No way! It already hurts too much.” I said, “KayLeigh, I think I know what’s going on. How about getting up and walking down the hall for me?” She carefully sat up and slid off the exam table. As she started down the hall, I immediately noticed that she walked cautiously, guarding her right hip.

Key Clinical Points—What’s Important and What’s Not

The History

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A history of recent onset right groin pain following a cheerleading injury
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No history of gynecologic or urinary tract symptoms related to the pain
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No history of kidney stones
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No history of hematuria
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Difficulty in ambulating without reproducing the groin pain
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Difficulty in carrying out activities of daily living
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Pain is localized to the origin of the right adductor tendons
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No fever or chills

The Physical Examination

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The patient is afebrile
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Normal visual inspection of the origin of the right adductor tendons with no ecchymosis
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Palpation of the right adductor tendons elicits pain
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Patient has cautious gait with guarding of the right hip
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The lower extremity neurologic examination is within normal limits

Other Findings of Note

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Normal BP
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Normal HEENT examination
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Normal cardiopulmonary examination
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Normal abdominal examination
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No peripheral edema
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No groin mass or inguinal hernia
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No CVA tenderness

What Tests Would You Like to Order?

The following tests were ordered:

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X-ray of the pelvis with special attention to the adductor tendons
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Ultrasound of the pelvis with special attention to the adductor tendons
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Magnetic resonance imaging (MRI) of the pelvis with special attention to the adductor tendons

Test Results

Plain radiograph of the pelvis demonstrates an avulsion fracture of the ischium ( Fig. 11.2 ). Ultrasound imaging reveals tearing of the adductor tendon near its proximal insertion ( Fig. 11.3 ). MRI of the pelvis reveals hyperintense signal abnormality on coronal and axial fat-saturated T2-weighted images at the origin of the right adductor longus tendon ( Fig. 11.4 ).