Femoral hernia deserves particular attention — it passes through the femoral canal below and lateral to the pubic tubercle (inguinal hernias are above and medial). Femoral hernias occur predominantly in women (3:1 female:male) and have a strangulation rate of up to 40% within 2 years of presentation — far higher than the 2–5% annual strangulation risk of inguinal hernias. For this reason, all femoral hernias should be referred for elective surgical repair (rather than watchful waiting, which is an option for asymptomatic inguinal hernias). The femoral ring is narrow and rigid — once bowel enters, it is very easily obstructed. The classic teaching is: any groin lump in a woman that is below and lateral to the pubic tubercle is a femoral hernia until proven otherwise. Inguinal hernias in women are less common but do occur — direct inguinal hernias are almost exclusively a male condition; indirect inguinal hernias can affect women.

The cough impulse test for hernia is the key examination technique — place the fingertips firmly over the suspected hernia defect (inguinal canal or femoral canal) and ask the patient to cough. A transmitted impulse (movement felt against the fingers with coughing) confirms a hernia. In thin patients, an inguinal hernia is often visible — a bulge appearing at the inguinal region when the patient stands or strains that disappears when lying flat is virtually diagnostic. The distinction between inguinal and femoral hernia is made by the anatomical relationship to the pubic tubercle: inguinal hernias emerge from above and medial to the pubic tubercle; femoral hernias emerge from below and lateral. This can be difficult clinically — USS inguinal region confirms the diagnosis and identifies the specific type and any complications. All hernia patients with pain or change in symptoms should be referred to general surgery for assessment.

Avascular necrosis (AVN) of the femoral head is the most important diagnosis not to miss in groin pain in younger patients — it is caused by impaired blood supply to the femoral head (arterial end vessels, no collateral supply). It presents as progressive groin pain and is irreversible if not treated early. Risk factors: systemic steroids (most common iatrogenic cause — even short courses), alcohol excess (40 units/week+), sickle cell disease, caisson disease (decompression sickness), post-trauma (fractured neck of femur disrupts blood supply), radiation, HIV medications. Early-stage (before femoral head collapse): core decompression surgery can preserve the joint. Late-stage (collapse): total hip replacement. GPs who prescribe long-term steroids should be aware of AVN as a complication and have a low threshold for MRI hip in patients with groin pain on steroids, even if X-ray is normal.

Femoroacetabular impingement (FAI) is an increasingly recognised cause of groin pain in young adults (20–40 years) — it is caused by abnormal bony morphology at the hip joint (cam deformity of the femoral head or pincer deformity of the acetabulum) causing abnormal contact during hip motion, particularly flexion and internal rotation. FAI causes labral tears and progressive hip OA if untreated. The FADIR test (flexion-adduction-internal rotation) reproduces anterior groin pain in FAI — it is sensitive (90%) but not specific. MRI arthrogram is the gold standard investigation for labral pathology. Hip arthroscopy (labral repair + femoroplasty) achieves good outcomes in appropriately selected patients. GPs who see young athletes with chronic anterior groin pain and limited internal rotation on examination should refer to orthopaedics for FAI assessment rather than attributing the pain to muscle strain.

The management of asymptomatic inguinal hernia in adults has changed significantly — the NICE guideline and the UK Hernia Audit now support watchful waiting (non-surgical management) for asymptomatic or minimally symptomatic inguinal hernias in men, as the risk of strangulation is approximately 2% per year and surgery carries its own risks (mesh complications, chronic groin pain, recurrence). However, symptomatic hernias (dragging, pain, interference with activity) should be referred for surgical repair. All femoral hernias (both symptomatic and asymptomatic) should be referred, as their strangulation risk is disproportionately high. Round ligament pain in pregnancy is a benign cause of groin pain (stretching of the round ligament of the uterus as the uterus enlarges) — it is a stabbing unilateral groin pain, worse with rapid movement or coughing, and is entirely benign. However, a groin lump in pregnancy should be assessed to exclude a hernia, which becomes more prominent as intra-abdominal pressure increases.

Meralgia paraesthetica (lateral femoral cutaneous nerve entrapment) is frequently unrecognised in primary care — patients describe burning, tingling, or numbness of the anterolateral thigh, which they may initially attribute to a back or hip problem. The key clinical feature is that the symptoms are purely sensory (no motor deficit — the LFCN is purely sensory) and are confined to the distribution of the LFCN (anterolateral thigh, not involving the knee or lower leg). Examination shows reduced sensation in the LFCN territory with a positive Tinel's sign at the ASIS. The most common treatable causes are obesity (weight distribution shifts the inguinal ligament, compressing the nerve) and external compression (tight waistband, carpenter's belt, military belt). Weight loss of 5–10 kg often resolves symptoms completely. Physiotherapy and postural correction are useful adjuncts. LFCN injection under USS guidance has a 75% short-term success rate for refractory cases.

Chronic inguinodynia (post-herniorrhaphy chronic groin pain) affects 10–15% of all hernia repairs and is a significant under-recognised complication. It is more common after open repair than laparoscopic repair due to the risk of ilioinguinal nerve injury during open dissection. The three nerves at risk during inguinal hernia repair are: ilioinguinal (sensory — medial thigh, scrotum/labia majora), iliohypogastric (sensory — lower abdomen), and genitofemoral (sensory — anterior scrotum, upper medial thigh; motor — cremaster). GPs should discuss inguinodynia risk with patients as part of pre-operative counselling, as many patients are surprised by chronic post-operative pain and mistakenly attribute it to a failed repair. Management mirrors other neuropathic pain conditions: amitriptyline, gabapentin, targeted nerve block, and pain psychology.

The Copenhagen adductor exercise programme (a simple body-weight adductor strengthening exercise performed in pairs) was shown in the Copenhagen Groin Injury Study (2019) to reduce adductor muscle injuries in male football players by 45% over a season when performed regularly. It is now part of FIFA 11+ warm-up programme and is recommended by UEFA for professional football. GPs can recommend it to athletes recovering from groin strains — it is freely available on YouTube and requires no equipment. Strengthening the adductor muscles specifically (rather than generic stretching, which has no evidence) is the cornerstone of secondary prevention of adductor injuries. This represents one of the most cost-effective sports medicine interventions available in primary care.

Written safety-netting for hernia patients is a medicolegal obligation — every patient with a known groin hernia (whether managed conservatively or awaiting surgery) should be given clear written instructions about the signs of strangulation: sudden new severe pain in the hernia, the hernia becoming hard and irreducible, nausea, vomiting, and abdominal distension. They should be instructed to call 999 or go directly to A&E if these develop. This instruction must be documented in the clinical record. The average UK GP practice has 50–100 patients on waiting lists for hernia repair at any time — each of these patients is at risk of strangulation during the wait. GPs who fail to provide strangulation safety-netting information face significant medicolegal exposure if a patient presents late with strangulation having not been warned of the signs.