Groin pain

[Dr. Ice]

do any of you guys have experience treating groin pain?

I have a few patients referred to me by my ortho collegues, some of which are s/p hip arthroplasty with persistent groin/lateral thigh/buttock pain. The physical exam is pretty non-focal. The pain seems to be reproduced with palpation over the greater troch/PSIS area. No real radicular pattern. ROM of the hip is limited but does not reproduce symptoms.

I tried upper lumbar epidural, greater troch inection/SIJ injection, referred for ultrasound guided gluteus medius/piriformis/greater troch injection...all with no relief. Patient(s) not interested in med management or more PT.

Any ideas?

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[SleepIsGood]

Do Iliohypogastric nerve/ ilioing nerve blocks.

That doesnt work, go block the DRGs of T12, L1.

If by "groin' you are referring to the anterior groin area( dont know why PSIS would be tender)...

this is assuming you have ruled out a 'radiculopathy' and the MRI is clean.

 

[Ligament]

Agree with Sleep. I see a good amount of groin pain and usually have success with above procedures.

 

[clubdeac]

Agree with Sleep. However, there is a paper (or a few) out on blocking and then pulsing the sensory branches of the obturator and femoral nerves for persistent hip pain after THA or for patients who aren't candidates for THA due to other comorbidities. It explains how to do it. I've had a couple patients I wanted to try it on but just haven't gotten around to it. If I can find the paper I'll post it.

 

[Tenesma]

a lot of THA patients have weird hip/groin/buttock pains for months after their THA --- i usually tell them to wait about a year and things will adjust.... i think a lof of it is mechanical as they adjust.

 

[Dr. Ice]

a lot of THA patients have weird hip/groin/buttock pains for months after their THA --- i usually tell them to wait about a year and things will adjust.... i think a lof of it is mechanical as they adjust.

so what about in the mean time if they arent interested in anything procedural?

 

[ziggyziggy]

Looking for input from heavyweights here for mgmt of Groin pain (Neuralgia, no hip pathology) . What modalities do you have good success with after pt has not benefited from TFESI, short relief from PNB ? I had done pulsed RFA with good relief for 3-4 months but did not get paid. So, I have stopped doing pulsed DRF RF. Any success with SCS vs peripheral stim? Which one will you choose first?

 

[willabeast]

what imaging studies were performed?

 

[ziggyziggy]

Not talking about a single patient. But my patients are predominantly post surgery (multiple hernia repair , orchidectomy etc) and are coming to me from Ortho, Urology and surgery clinic for mgmt. They had hip imaging, CT abdo, hip injections without much success.

 

[ziggyziggy]

Found this, If someone wants a refresher on the topic:

 

[willabeast]

"coming to me from Ortho, Urology and surgery clinic for mgmt". it seems to me all these patients have different Dx. also - some of these will have been operated on and developed a new pain, some will have been operated on and the procedure failed to help their old pain. and then you have the ones with a new pain and also still have their pre-op pain. you also mention "Patient(s) not interested in med management or more PT." sometimes this is what got them in the situation they are now in.
i really do think step #1 is obtaining a provisional differential diagnosis. i suspect i have not helped you much. i used to work with a pelvic pain specialist (an ob-gyn who did a pain fellowship) who Dx a neuralgia s/p emergency hysterectomy. her Rx was do do a pulsed RF on the ilioinguinal/iliohypogastric and genito-femoral nerves every 4 months or so (when it wore off). since the patient was in my service area i got stuck doing this, which i did for years until i retired. i eventually got pretty good at finding the nerves with my probe (i used a 5 mm #22 gauge) but i always thought it was a very labor intensive procedure that i never would have come up with myself.
patient worked full time and had very good relief, and never was on meds of any kind for pain.

 

[Ducttape]

Use ultrasound? It should take no more than a minute to find the nerve. This nerve and intercostal are the only nerves I pulse, and I believe I get good results... At least, I have 4-5 "regulars"...


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[willabeast]

Use ultrasound? It should take no more than a minute to find the nerve. This nerve and intercostal are the only nerves I pulse, and I believe I get good results... At least, I have 4-5 "regulars"...


Sent from my iPhone using SDN mobile

i used ultrasound for about 6 months, then i got faster without it.

 

[melancholy]

Found this, If someone wants a refresher on the topic:

i like how the final part of the treatment algorithm in the slide show lists alternative therapies and specifically puts "pain clinics" in there.

groin pain after hernia repairs and such with short to moderate term relief with steroid injections seemed to be one of our main indications in fellowship to trial peripheral nerve stim.

I do think that willabeast has a point about the ddx given where all these various patients are coming from. there are a few less common things that sometimes can cause groin pain (for example, femoral acetabular impingement, referred pain from SI joint, iliopsoas bursitis, etc.). Imaging can only take you so far though. Let the needle be your guide...

 

[jonnylingo]

Iliopsoas tendinitis/bursitis. US guided injection for diagnostic/therapeutic purposes.

 

[clubdeac]

L1/2 DRG stim.... all day baby

 

[101N]

do any of you guys have experience treating groin pain?

I have a few patients referred to me by my ortho collegues, some of which are s/p hip arthroplasty with persistent groin/lateral thigh/buttock pain. The physical exam is pretty non-focal. The pain seems to be reproduced with palpation over the greater troch/PSIS area. No real radicular pattern. ROM of the hip is limited but does not reproduce symptoms.

I tried upper lumbar epidural, greater troch inection/SIJ injection, referred for ultrasound guided gluteus medius/piriformis/greater troch injection...all with no relief. Patient(s) not interested in med management or more PT.

Any ideas?

Are these young patients s/p arthroscopy for labral tears or older pt's s/p THA's?

 

[ziggyziggy]

Are these young patients s/p arthroscopy for labral tears or older pt's s/p THA's?

so 1st pt, 60's female with multiple abdominal surgery (colon resection, panniculectomy with h/o poor healing and infection, hernia repair). Nothing on hip. Got good relief from SNRB and then 3-4 m relief from pulsed DRG but insurance rejected the claim for DRG. Since then has tried TFESI with not much success. - Will your consider SCS or peripheral stim on her?

 

[101N]

Chronic regional pain with no anatomic correlate. Nope, no stim.

 

[ampaphb]

Chronic regional pain with no anatomic correlate. Nope, no stim.

So you ignore the positive response pulsing the DRG because you can't see the pathology on MRI?

You are aware that CRPS type 1 is distinguished from type 2 because there is no distinct nerve injury? Or are the 90% of CRPS patients who have been diagnosed with type 1 not deserving of care? Or are their diagnoses part of your paranoid delusion of the vast IPM conspiracy?

Wait, let me guess - it's all central sensitization, and should be treated with CBT?

 

[101N]

Yep, chip shot claim rejection. No objective pathology, regional pain. Done.

 

[ampaphb]

I was an arrogant narcissist in my 20s, when I saw the world in black and white, and thought I knew everything. When I grew up, and recognized that lots of things are inbetween (shades of gray), I learned to defer to others (in this case, the IASP), who have a greater breath of knowledge than I posess. I hope you reach that level of maturity sometime soon.