Clinical examination for athletes with inguinal-related groin pain: interexaminer reliability

Key points

1. 01Interexaminer reliability of inguinal palpation pain tests was fair to moderate (kappa 0.35-0.49); combining tests improved agreement to moderate-substantial (kappa 0.54-0.65)
2. 02Abdominal resistance tests showed fair to substantial reliability (kappa 0.35-0.72), generally outperforming individual palpation tests
3. 03In athletes with defined inguinal-related groin pain, scrotal invagination palpation during Valsalva was the most prevalent positive test (79%)
4. 04Abdominal resistance tests were positive in only 21%-49% of confirmed cases, so a negative test does not rule out the condition
5. 05No single perfect clinical test exists; a full examination battery is needed for classification

How it was conducted

Design

Prospective interexaminer reliability study

Participants

44 male athletes aged 18-40 with longstanding groin pain (61 symptomatic sides), recruited at Aspetar Hospital, Doha, Qatar, March 2019 to October 2020

Examiners

Two blinded examiners (general surgeon with 24 years experience; physiotherapist with 11 years experience), each independently performing standardised examination

Tests assessed

Abdominal palpation without and with scrotal invagination, and four resisted abdominal tests at 0 degrees and 45 degrees hip flexion

Primary outcome

Interexaminer reliability using Cohen's Kappa (kappa); secondary outcome was prevalence of positive tests in inguinal-related groin pain

What they found

• Inguinal palpation pain tests: kappa 0.35-0.49 (fair to moderate) for individual sites; kappa 0.54-0.65 (moderate to substantial) for any inguinal palpation pain combined
• Posterior wall structure (firm/soft): kappa 0.01 (slight); posterior wall bulging: kappa 0.29 (fair); external ring size: kappa 0.56 (moderate)
• Abdominal resistance tests: kappa range 0.35 (oblique sit-up 45 degrees, affected shoulder) to 0.72 (straight sit-up 45 degrees), fair to substantial
• Examiner A classified defined inguinal-related groin pain in 41/61 (67%) symptomatic sides; examiner B in 37/61 (61%)
• In defined inguinal-related groin pain: any inguinal palpation during invagination positive in 94% of sides; any transabdominal palpation positive in approximately 80% of sides
• Most prevalent positive abdominal resistance test was cross-test with contralateral shoulder resistance (49% of defined inguinal-related groin pain sides)
• Oblique sit-up 45 degrees (affected shoulder) was least prevalent positive resistance test (21% of defined inguinal-related groin pain sides)
• 6%-24% of palpation tests caused pain that was not recognisable injury pain according to athletes, highlighting overdiagnosis risk

Limitations

• Both examiners were experienced specialists at a tertiary groin clinic, limiting generalisability to less experienced clinicians in general practice
• No gold or reference standard exists for inguinal-related groin pain, making diagnostic accuracy analysis (sensitivity/specificity) inappropriate
• Study included only male athletes from a tertiary centre, likely introducing selection bias with a higher-than-expected prevalence of inguinal-related groin pain
• Results cannot be generalised to female or transgender athletes due to anatomical differences in the inguinal canal

Why it matters

For patients

Athletes with groin pain in the inguinal region should expect a thorough hands-on examination combining palpation and resisted movements, as no single test is enough to confirm or exclude the diagnosis.

For clinicians

Use a full battery of abdominal palpation (including scrotal invagination when feasible) and resisted abdominal tests; clustered palpation tests offer better agreement than individual ones, and asking specifically whether provoked pain replicates the athlete's injury pain is essential to avoid overdiagnosis.

For readers

This is the first study quantifying how consistently two experienced examiners agree on these tests; results highlight moderate-at-best agreement for individual tests and the need for standardised multi-test protocols in clinical and research settings.