I agree that if you have it "minorly" you can work around it. In hindsight I believe I had it since the late 80's and it nagged me on/off since I finally had the bif tear.
I have a copy of Meyers latest paper if anyone wants to see it. For some reason i can not copy and paste it on here. Please let me know if i am doing something wrong or i can e-mail it to anyone that wants to see it. It is written very recently and shows how it has progressed since the invention of his new MRI technique. He also fields questions from other prominent physicians.
A very interesting read. He also describes his original exclusionary criteria when he first started the surgery.
Surf, I definitely needed the surgery as my life was actually HELL....I think each person knows their own body the best. If i were in the "in between" area i would schedule to see Meyers and see what diagnosis he makes. The MRI's are unbelievable clarity. I could see tears and edema before he even pointed them out. He is not a pushy surgeon. HE will merely suggest he can help you as he did me. He told me I had significant tears.
However, they never truly know until they open you. He said my tear was HUGE (larger than he thought)...my pectineus tear was not as complete as he thought yet had more scarring and shortness....and same with the longus. I was alos quite amazed he injects the steroid directly into the inflammed muscles during surgery. This makes perfect sense because I was reading here that many guys had the stiffness/inflammation at week4-8 and went in for a steroid shot. I think this way he is proactive and hits the muscle exactly where it needs to be hit.
When i first realized I had an adductor problem I was injected with lidocaine by dr. marcus in NYC and although he was good he had to bury that needle deep in me repeatedly to get the pectineus and when a muscle is tight it hurts even more. So I thank Meyers for that.
I am on day 3 and I made it through the nite without pain pills. I am sleeping on a recliner because when i awake i have a tendency to immediately roll out of bed. I am very sore on adduction so I am trying to avoid any of that.
Today I am trying for 2 miles at once walking. NO treadmill walking yet because I do not want to have to keep up with anything. I prefer being able to stop if I need to.
The worst pain so far has been the toilet sitting which is getting better to. It is funny how we do not realize how much we use our pelvis to do the smallest things. My first night in bed it hurt to take a deep breath. Not bad, but it was noticable and i could not imagine sneezing....thank goodness i didn't.
Experience With “Sports Hernia” Spanning Two Decades
William C. Meyers, MD,* Alex McKechnie, PT,† Marc J. Philippon, MD,‡ Marcia A. Horner,*
Adam C. Zoga, MD,§ and Octavia N. Devon, MD*
Objective and Background: Athletic pubalgia (AP) is a leading
cause of athlete loss from competitive sports. Commonly misnamed
“sports hernia,” AP is a set of pelvic injuries involving the abdominal
and pelvic musculature outside the ball-and-socket hip joint and
on both sides of the pubic symphysis. Prospective studies show that
timely intervention and appropriate repair of selected injuries results
in greater than 95% success.
Methods: The senior author reviewed his experience with 8490 patients
and 5460 operations, looking primarily at the changes in patient
characteristics over the last 2 decades and at some of the advances.
Results: Female proportion, age, numbers of sports, and soft tissue
structures involved have all increased as have the number of syndromes
identified and number of operations. MRI has improved
greatly for both the diagnosis of hip and nonhip pathology in the
pelvis. Increased understanding has led also to new rehabilitation
and performance protocols.
Conclusions: Better understanding and recognition of the injuries
has led to more satisfactory care and returned many athletes to
successful careers, which has had a major impact on modern sport.
(Ann Surg 2008;248: 656–665)
Hip and pelvic injuries have shortened the careers of many
athletes. These patients have a variety of types of pain,
usually related to exertion. The differential diagnosis of
pelvic pain is, of course, exhaustingly wide, and the gamut of
injuries in this patient group is extensive.1–3 A common way
to think about the musculoskeletal injuries of the anterior
pelvis is to consider injuries that occur either inside or outside
of the “ball-and-socket” hip joint.4–6 Accurate diagnosis of
the athlete with pelvic pain remains challenging, but recent
progress has shed considerable light on this topic and the care
of these patients has improved.
Over the past 2 decades, the senior author has accumulated
a large experience with these injuries. During this
period of time, we have seen improvements in recognition of
the injuries, identification of the various injury types, diagnosis,
and treatment. In this paper, we shall review some of
these developments as well as the theoretical bases behind
them. We shall look primarily at the characteristics of the
overall population of patients that have been treated, tracing
some of the changes that have occurred over the past 2
decades. We shall also provide some overall results of treatment.
The latter has been the subject of a number of other
papers2,6,7 and we are not ready to report our most recent
results, but an overall perspective with respect to this large
patient series seems appropriate.
The term “sports hernia” conveys 2 huge assumptions
about the above injuries: (1) that the cause of the above set of
injuries has something to do with occult hernias, and (2) that
the above injuries can be lumped into one explanation and be
treated the same way. Hopefully, there will be an appreciation
from reading this manuscript that those assumptions have
little basis; and that understanding these injuries leads to
predictably successful management that is actually quite
different from hernia repair.
Current understanding has been previously described.3,6
Basically, we think in terms of there being 2 types of joints in
the pelvis: the ball-and-socket hip joint, and the “pubic bone”
joint, not the pubic symphyseal joint. In the second joint, we
think in terms of the entire right and left pubic symphyses
together acting as the center of activity for a lot of soft tissue
structures that are normally symmetrically distributed, in
terms of both anatomy and forces, around that bone.
METHODS
Patient Population
This series involves patients seen at 3 different academic
institutions and in locker-rooms and training facilities
of various sports teams and on visits to other patient care
institutions from 1986 through January 2008. Many patients
were included in a large prospective data-base, but others were
retrieved from outpatient and inpatient files, operative logs,
billing records, or other documentations of patient contact.
Patients whose medical records or imaging studies were
reviewed only and who were never directly examined were
excluded from this study. Because of the large number of
different sources, the same detail was not available on all
patients and several gaps in any patient information were
identified. Therefore, comparisons from one decade to another
were made with select groups of patients with comparable
detail. The select groups necessarily include patients
from previously published series, which shall be referenced.
From the *Department of Surgery, Drexel University College of Medicine,
Philadelphia, PA; †Los Angeles Lakers, Los Angeles, CA; ‡Steadman-
Hawkins Clinic, Vail, CO; and §Department of Radiology, Thomas
Jefferson University, Philadelphia, PA.
Reprints: William C. Meyers, Department of Surgery, Drexel University
College of Medicine, 245 North 15th St, Room 7150, Mail Stop 413,
Philadelphia, PA 19102. E-mail:
wmeyers@drexelmed.edu
.
Copyright © 2008 by Lippincott Williams & Wilkins
ISSN: 0003-4932/08/24804-0656
DOI: 10.1097/SLA.0b013e318187a770
656 Annals of Surgery • Volume 248, Number 4, October 2008
Similarly, during the latter years of the study, more specific
detail was available on patients because of increased understanding
of the various afflictions and improved imaging
tests. Therefore, many comparisons could not be made to
earlier time periods when there was less understanding of the
pathologies. The overall results do not reflect more recently
recognized syndromes.
Clinical Considerations
Diagnosis of the various clinical entities were made by
a combination of history and physical examination, and in
more recent years supported by new magnetic resonance
imaging techniques. The surgical procedures included various
types of reattachments and/or releases of soft tissues that
normally attach or cross the pubic symphyses.
The precise procedures depended on the specific injuries
and are based on an understanding of the anatomy
described previously.1,3,6 Basically, the injuries are presumed
to cause instability of the pubic joint, and the procedures are
designed to either tighten and broaden the attachments of
various structures that normally attach to the pubic symphysis
and/or loosen the attachments or other supporting structures
via selective epimysiotomy (like fasciotomy) or detachment.
The operations depend on an intimate understanding of the
pubic symphyis and surrounding structures including the
aponeurotic plate and variations of muscular anatomy.
We have not completed the 2-year results of treatment
for the past 2 years of patients because not enough time has
elapsed. We believe that the last 2 years represent an important
patient cohort because this is when we have been able to
correlate the specific diagnoses with MRI findings.
Because of that limitation, we have chosen to list our
longer term results in terms of return-to-play data. We define
“return-to-play” as an athlete’s actual returning to full competitive
play. This definition does not include the athlete’s or
close associate’s assessment as to whether this level of play was
satisfactory. By nature, return-to-play only provides one point in
time as the assessment point. As published previously,2 we
believe that the player’s assessments at various time points up to
2 years are far superior to return-to-play data.
Various rehabilitation and training protocols have
evolved during the time frame of the study in conjunction
with the various professional and collegiate teams via on-site
consulting and care of specific patients. Protocols are counted
when these were officially introduced as part of the team’s
protocol(s) within 6 months of consultation.
Other Definitions
For clarity, we used the following definitions. Athletic
pubalgia or “sports hernia” refers to the musculoskeleton of
the pelvis outside the hip joint and arranged symmetrically
around and including the pubic symphyses, but not including
the sacrum or spine. We used the term athletic pubalgia
synonymously with sports hernia. Hip joint refers to the
ball-and-socket joint consisting of the acetabulum, ligamentum
teres, articular and labral cartilage, head and neck of the
femur, and other soft tissue enclosed within this space, for
example, synovium. “Pubic joint” refers to the motion within
the pelvis but outside the hip joint that involves symmetrically
the soft tissues around the pubis and has at its center of
activity both sides of the pubic symphysis.
The term athlete refers to patients currently or recently
participating in competitive athletic activity as a livelihood or
integral way of life. The patients themselves determined
their highest level of competition and level of education
and primary sport. For the database, all athletes had to
choose one sport as their primary, so in this analysis, true,
multiple sport athletes were represented by single data
points. In other words, multiple sport athletes are present
but not identifiable within these data.
Pelvic MRI
During the latter part of the series, MRI became an
integral part of the evaluation of these patients. Whenever
possible, we used a new technique7 of pelvic MRI that
correlates well with demonstrable injury. Additionally, this
MRI technique uses both surface coil and a send-receive body
coil, as well as oblique planes to maximize sensitivity and
specificity for osseous and musculotendinous pathology of
the pelvis. This objective way of demonstrating the injuries
provides convincing evidence of the multiplicity of injuries
and the overlap of hip injuries with the pelvic soft
tissue injuries of athletic pubalgia. Differentiating hip
problems was extremely important to the diagnosis of
these patients. MR arthrography with sensorcaine was
important to this differentiation.
Perioperative Sequelae
Postoperative sequelae, defined by undesirable findings
leading to patient complaints within 6 weeks of surgery, were
recorded for the entire series. For these purposes, followup
was 100% at 7 days and 7 weeks after the surgery. As a best
estimate of infection rate, we chose to use the National
Surgical Quality Improvement Program (NSQIP) criteria and
methodology for all of 2007. These data came from a combination
of the nurse reviewer who kept track of all patients,
not just those required by NSQIP, plus a clinical assistant.
Prolonged length of stay was defined as greater than 24-hour
hospitalization. All patients had LMA, general or local anesthesia
with an intended 23-hour stay, although many patients
were discharged the same day as surgery.
RESULTS
Overall Experience
In total during this time period, the senior author saw
8490 patients (Fig. 1). Five thousand two hundred and eighteen
of those patients underwent surgery, resulting in 5460
operations. The surgery involved 26 different procedures and
121 different combinations of procedures. The increase in
number of types and combination of operations has been
primarily a function of the last 10 years compared with the
earlier decade, because of increased understanding of the
various syndromes that afflict these patients.
One can see from the graph (Fig. 1) that the number of
patients seen per week has on the average increased from 2 to
25. The number increased from 2 to 5 over the first 7 years,
to 8 over the next 7 years, and most pronouncedly from 8 to
Annals of Surgery • Volume 248, Number 4, October 2008 “Sports Hernia” Spanning Two Decades
© 2008 Lippincott Williams & Wilkins 657
25 over the most recent 5 years. Likewise, the number of
surgical procedures per week increased within a similar
pattern over the same time period: 1 to 3, 6, and 15.
From the graph, one can notice that in the first 5 years,
the percentage of patients who underwent operations was
initially low (24.5%), then increased for the next 10 years to
83.2%, and then lowered again for the past 5 years to 60.0%.
During the initial phases of recognition of these injuries, there
was more uncertainty with respect to the pathophysiology and
results of surgery. Initially, patients were carefully selected.
A number of patients were excluded such as all patients with
osteitis pubis (Fig. 2) and patients whose symptoms changed
from side to side without apparent reason.
As we understood the pathophysiology and results
better, patients with osteitis and other conditions consistent
with the increased understanding were included in the surgical
group. Many patients, in fact, who had been previously
excluded, were ultimately called back for surgery. During the
past 5 years, we are seeing a larger variety of patients
including more patients with primary hip problems and older
patients who do not seem optimal surgical candidates.
Gender and Age
The male/female ratio of the patients has undergone a
dramatic change. In the first decade of recognition of the injuries,
females comprised less than 1% of the entire group,2,8
whereas during the past 5 years they now comprise 15.2%. In
the very first report reflecting data from the mid-80s there
were no females.8 In another report from data reflecting all
patients evaluated in the mid-90s, there were 8.0%,2 and in a
recent profile of 5,283 recent patients with athletic pubalgia,
women represented 8.2% of the entire group. Clearly, we are
evaluating more women patients with suspected musculoskeletal
pelvic injuries. As we understand better the female
variants of these problems, we are also identifying more
precisely their anatomic problems.
Another striking feature of this patient population has
been the increasing age. Mean age of patients has increased
from 24.7 in the mid-80s, to 26.3 in the mid-90s, to 28.6 in
the past 3 years. In all instances the age range has also
widened. Age range for the entire series of all patients
evaluated was 8 to 88, and age range of patients who had
surgery for athletic pubalgia was 11 to 71 years. Neither the
8- nor the 88 year olds qualified by our definition as athletes.
The 11-year-old was a prodigious soccer player. The 71-yearold
was a ranked amateur tennis player. The oldest professional
player who had surgery was 66. He was a bowler on
the senior circuit.
Athletes
According to our definition, we classified 82.8% of the
entire evaluated patient population as athletes. Initially, 100%
of evaluated patients were athletes,8 compared with 91.1% in
the mid-1990s2 and 76.9% during the past 5 years. As
mentioned above, the increase in number of nonathletes has
increased over the past 5 years in part accounts for the smaller
number of patients who underwent this elective surgery
during those recent years. The total number of nonathletes
who underwent surgery has also increased. Likewise, the
number of women athletes who underwent surgery has increased,
as has the ages of both female and male athletes and
nonathletes who underwent surgery.
Over the past 2 decades the number of sports involved
in the injuries has increased, and the most common sports
FIGURE 1. The graph depicts total new patients seen and the number of surgeries versus the year over a 20-year period. The
units on the y-axis are the number of patients per year averaged per week based on a 48-work-week year.
Meyers et al Annals of Surgery • Volume 248, Number 4, October 2008
658 © 2008 Lippincott Williams & Wilkins
associated with the injuries has shifted slightly (Table 1). The
number of sports has increased from 68 to 152 to 32 over the
1980s, 1990s, and 2000s. Soccer players remain the number
one most afflicted athletes in the total patient population,
although football has overtaken soccer as the number one
sport seen by us in the past 3 years. Ice hockey is in a clear
third place. We have seen a marked recent increase in the
number of long distance runners and dancers. Also evolving
are clear patterns in terms types and severity of injuries
according to sport and even specific positions within a sport.
For example, baseball pitchers and hockey goalies have a
predisposition for a certain type of adductor injury and
bull-riders as a group clearly get the most severe injuries.6
Overall, 95.3% of the athletes who underwent athletic
pubalgia operations were able to return to full play within 3
months of surgery. Most patients were able to return to play
well before 3 months, but our data are not specific enough to
determine specific times of return. The precise time to return
also depended on whether the operations were done during or
after the playing seasons, and on the type or severity of
injury. Within a season, many patients were directed to either
a 3-week or 6-week return to play protocol. In a close
assessment during the past year of 20 patients who chose the
3-week protocol, 18 of the 20 patients were able to play at full
strength by their own assessments within that time frame. The
former represented a group of patients with less severe
injuries. In contrast, the entire group represents a wide variety
of athletes in various sports and who had a broad variety of
injuries. Some of the patients also had hip injuries that were
either minor or treated before or after the athletic pubalgia
surgery.
Perioperative Sequelae
The most common postoperative complaint, which occurred
in nearly all patients, was minor bruising or edema
involving the abdomen, thighs, genitals, and perineum (Table 2).
Fourteen patients (0.3%) had hematomas felt significant
enough to require reoperation. For 2007 the wound infection
rate was 0.4%. All infections were superficial. Fourteen
patients (0.3%) had dysesthesia related to ilioinguinal, genitofemoral,
anterior or lateral femoral cutaneous nerve distributions.
All but 2 of the complaints resolved within a year
period. Seven patients (0.1%) had mild penile vein thromboses.
None of these resulted in long-term sequelae or concerns.
There were 7 (0.1%) other various minor anesthetic or surgical
complications that prolonged hospitalization.
FIGURE 2. MRI appearance of osteitis pubis: Short tao inversion
recovery (STIR) sequence in a coronal plane from a traditional
musculoskeletal pelvis protocol (A) shows bright
bone marrow edema (arrows) symmetrically across the pubic
symphysis indicating an inflammatory process. Poor resolution
limits evaluation of soft tissue attachments and osseous
cortex. STIR sequence with the higher resolution of an athletic
pubalgia protocol (B) shows the bone marrow edema
(arrow), plus osseous productive change, and obvious articular
erosion (arrowhead).
TABLE 1. Top Six Sports (Total 8490 Athletes)
% of Entire Series % of Last 2 Years
Soccer 44.6 27.2
Football 22.3 32.7
Hockey 8.1 10.2
Baseball 6.3 6.1
Basketball 6.2 5.3
Distance running 1.2 4.2
TABLE 2. Non-Infectious Perioperative Sequelae (5218
Patients, 5460 Procedures)
Number of Patients (% of Surgical Patients)
Dysesthesias 14 (0.3%)
Hematomas 14 (0.3%)
Vein thromboses 7 (0.1%)
Other 7 (0.1%)
Annals of Surgery • Volume 248, Number 4, October 2008 “Sports Hernia” Spanning Two Decades
© 2008 Lippincott Williams & Wilkins 659
Reoperation
The most common reason for reoperation was development
of similar problems on the contralateral side after
unilateral surgery (182 patients). The second most common
reason for reoperation was adductor release for new or
persistent adductor problems after surgery (28 patients).
Eighteen of the latter group was in the first decade. Recurrent
problems occurred in 16 patients, one to 11 years after the
original surgeries.
Over the past 3 years, we have been operating on a
seemingly increasing number of patients who had failed
traditional hernia operations at other institutions. We did not
keep strict data on these “redo” patients in the earlier part of
the series. Perhaps reflecting this, in total 241 (4.6% of the
5218 surgical patients) had previously undergone unsuccessful
traditional hernia repair surgery for treatment of their
pain. Over a 3-month period in 2007, we identified 47 such
patients who underwent subsequent repair. Forty of the 47
were able to return to play within 3 months of subsequent
surgery.
Number of Recognized Clinical Problems
Over the past 2 decades, we have come to recognize an
increasing number of distinct clinical entities that afflict these
athletes, with at least an equal number of different treatments
(Table 3, Figs. 2–5). In 1987, we thought there was 1 basic
problem involved, the rectus abdominis being the primary
culprit. In the mid-90s, we increased that number to 3, rectus
abdominis alone or in combination with adductors, plus
adductor alone2 (Figs. 3–5). In 2008, we now recognize at
least 17 different nonhip, soft-tissue structures as causes of
primary pain.3,6 Even though we have reported 18 or 19
distinct syndromes,3,6,9 –11 in fact, the number is much
higher; recognizing that these soft tissue structures can be
involved in various combinations in the same patient. For
example, we no longer think in terms of there being just
one adductor complex involved in the injuries. In fact, 3
different adductor muscles – adductor longus, adductor
brevis, or pectineus – are involved in most of adductor
injuries (Fig. 4). Plus, there are other adductors, eg, gracilis,
adductor magnus, and obturator externus, which are
sometimes involved. In addition, there are clear female
variants of these problems that involve lateral compensatory
pelvic structures after medial pelvic injury.6
MRI Advances (Figs. 2–5). Until 2005, we knew that MRI
was occasionally helpful in the diagnosis of these injuries
and that we could with some predictability identify a
TABLE 3. Clinical Entities of Athletic Pubalgia
Structure/Syndrome Incidence (%) Defect Possibly Indicated Procedure
Unilateral RA/unilateral AD 22 Tear and compartment syndrome (CS) Repair and release
AD ongus (AL) 16
Pectineus (P) 22
AD brevis (AB) 8
Pure AD syndromes 21 Usually CS Release
Bilateral RA/bilateral AD 17 Aponeurotic plate disruption; tear and CS
Unilateral RA 16 Tear Repair
Bilateral RA 15 Tears Repair
Severe osteitis variant 8 Usually tears, CS, and bone edema Repair, release, and steroid injection
Unilateral/bilateral 7 Combination tear(s) and CS Repair(s) and release(s)
Iliopsoas variant 4 Impingement and bursitis Release
Baseball itcher/hockey goalie syndrome 4 AD tear and AD muscle belly CS Release
Spigelian 4 Tear Repair
Rectus femoris variant 3 Impingement Release
High RA variant 2 Tear Repair
Female variant 2 Medial disruption with lateral thigh compensation Repair and release(s)
Round ligament syndrome 1 Inflammation with tear Repair and excision
Dancer’s variants 1 Obturator internus/externus Release(s)
Rower’s rib syndrome 1 Subluxation Excision and mesh
Avulsions Usually acute adductor injury Repair and/or release(s)
AD/RA calcification syndromes 1 Chronic avulsion Excision, release
Midline RA variant 1 Tears and muscle separation Repair
Anterior schial tuberosity variant 1 Posterior perineal inflammation, gracilis, hamstrings Release
AD contractures 1 Often associated with hip pathology Release and hip repair
More uncommon variants 2 Eg, gracilis, quadratus, iliotibial band Variable
Any of the soft tissues attached to or crossing the pubic symphysis can be involved alone or in combination with other injuries. Note that one can count the actual number of
clinical entities or syndromes in various ways. For example, we see all the combinations of rectus abdominis injury and specific adductor injury, and both rectus abdominis and
adductor injuries can be unilateral or bilateral. Listed are the involved anatomical structures and/or pseudonyms used for reference, with relative incidences and potentially indicated
procedures. The percentages represent number of cases seen relative to total numbers of patients from 2006 and 2007. Note also that a patient can have more than one variant,
accounting for the greater than 100% total incidence.
RA indicates rectus abdominis; AD, adductor.
Meyers et al Annals of Surgery • Volume 248, Number 4, October 2008
660 © 2008 Lippincott Williams & Wilkins
number of “soft findings” in these patients.6,12 Studying
the various attachments to the pubic bone and refining the
MRI technique held the key to specific diagnoses.13–15 In
scans done by traditional techniques (Figs. 2A, 3A), what
had been generally described as “osteitis pubis” turned out
to lead to more specific diagnoses (Figs. 2B, 3B).
FIGURE 3. Unilateral rectus abdominis/
adductor injury: Low resolution
STIR MR image at 0.3 Tesla from traditional
pelvis protocol in an NBA forward
(A) and high resolution T2
weighted fat suppressed image at 3
Tesla from an athletic pubalgia protocol
in a major league baseball infielder
(B). Both show osseous and soft tissue
edema at the left anterior pelvis (arrowheads).
Note the difference in resolution.
Soft tissue edema follows the
course of the left adductor longus
origin (arrow), and a secondary cleft
on the left (curved arrow) indicates
rectus abdominis detachment from its
pubic attachment. Note the dark susceptibility
artifact just cephalad to the
superior pubic ramus in B, reflecting
mesh from the patient’s failed herniorhaphy.
Photograph of a cadaveric
dissection of the same region in a
similar plane (C) shows a relative continuity
of the caudal rectus abdominis
(RA) with the anterior pubic symphysis
(PS) and the thigh adductor longus
origin (AL). The arrow shows the
lateral edge of the rectus abdominis
as it blends into this “aponeurotic
plate.” Schematic representation of
the anterior pelvis (D) shows the close
approximation of structures on the
pubic symphysis.
FIGURE 4. MRI of adductor variants: Proton density weighted MR image in a professional soccer player with acute left-sided groin
pain (A) and long history of osteitis pubis shows an osseous avulsion of the pubic tubercle (arrow) and caudal retraction with entire
proximal adductor longus. Similar proton density weighted image in a 46-year-old marathon runner (B) shows a more indolent injury
at the adductor longus origin with enlargement, ill definition, and hypointensity (arrow) indicating hydroxyapatite deposition
disease (“calcific tendinosis”).
Annals of Surgery • Volume 248, Number 4, October 2008 “Sports Hernia” Spanning Two Decades
© 2008 Lippincott Williams & Wilkins 661
We analyzed 100 consecutive pelvic MRIs done by our
group in 2006. The distribution of anatomic structures involved
is listed in Table 4. Like Table 3 suggests, the rectus
abdominis in combination with adductor pathology predominated
as the most common soft tissue defects. Adductor
longus, pectineus, and adductor brevis pathology were the
commonly afflicted adductors in that order. Iliopsoas,
rectus femoris, and sartorius involvement were the most
frequently afflicted nonadductor groups. Again, unilateral
rectus abdominis/adductor injury was overall the most
common diagnosis (Fig. 3), followed by pure adductor
pathology (Fig. 4), and bilateral aponeurotic plate disruption
(Fig. 5). We also found clinically relevant pathology
seemingly remote to the pubic attachments. Interestingly,
over 15% of the patients with MRI findings of athletic
pubalgia also had evidence of hip pathology. Ten of the
latter group had MRI-arthrography with positive sensorcaine
tests confirming a clinical relevance and simultaneous
injury.
Rehabilitation and Performance Protocols
Rehabilitation and performance protocols have developed
that are relatively specific for the various injuries and
sports. The rehabilitation protocols called for return to play at
3 days to 3 months postoperatively depending on the specific
injury, sport, position, and choice of management. When 6
teams that strictly adhered to the protocols were analyzed, 18
of the 22 players were able to achieve return to play within
the ascribed period. Eight of the 18 achieved full-play status
ahead of the recommended time.
Over the same time period, new concepts of core
stability training16 have evolved that relate to these new
pathophysiological understandings. As a result, new performance
protocols developed for at least 16 different major
league teams within the 4 major sports (football, basketball,
hockey, and baseball). A standardized performance protocol
also developed for professional soccer and for 9 NCAA
school training programs.
DISCUSSION
This study demonstrates a rapidly enlarging knowledge
base concerning abdominal, groin, and other pelvic musculoskeletal
injuries in athletes. A 10-fold increase in the
number of patients seen has occurred over a 20-year period.
The cross-spectrum of patients shows that these injuries
include both genders, a wide range of ages, a variety of
sports, and a wide range of different levels of athletes. The
increasing knowledge base has resulted in 18 or 19 distinct
syndromes and 121 different combinations of procedures. At
least 17 distinct musculoskeletal structures can be involved.
Peri-operative and long term morbidity from the operations
are low when the operations are done in experienced hands.
Most of the current understanding has resulted from an
improved understanding of the anatomy and pathophysiology
involved in these injuries.3,6 Whereas careful history and
physical examination by experienced care-givers remain the
mainstays for diagnosis, new techniques of MRI13–15 can
show the same pathology as diagnosed by clinical examination
and/or confirmed by surgery in 91% of cases.
The success rate from these procedures in athletes
remains high. In 2000, we reported results on 276 patients.
All patients had had at least 2 years follow-up. The overall
success rate was 95.4% in returning the patients to what they
subjectively felt was their previous level of experience. As
we have continued to follow these patients closely, the
success rates remain about the same despite a wider range of
indications and more tailored types of surgery. Because our
MRI advances are just 2-year-old, we are presently awaiting
2-year results of surgery for injuries confirmed preoperatively
by MRI. These data, stratifying results according to specific
injuries and the demographics mentioned in this report,
should be forthcoming in subsequent publications.
The principal theme of the present study is that the term
“sports hernia” is a gross misnomer. Although athletes in these
age brackets can certainly develop true hernias, true hernias do
FIGURE 5. Continuous bilateral rectus abdominis aponeurotic
plate disruption.
TABLE 4. Anatomical Defects Identified in 100 Consecutive
MRIs of Athletic Pubalgia Patients in 2006
Structure Incidence (%)
Pubic symphysis 93
RA 76
Adductor longus 46
Pectineus 38
Adductor brevis 20
Iliopsoas 6
Rectus femoris 2
Sartorius 1
Pubic ramus 1
Obturator ext 1
Gracilis 1
Hamstring 1
Adductor magnus 1
Hip 16
Note that more than one defect was common so the incidence adds up to greater
than 100%.
Meyers et al Annals of Surgery • Volume 248, Number 4, October 2008
662 © 2008 Lippincott Williams & Wilkins
not cause these types of pain. Very few of these patients have
even incidental hernias. The injuries have nothing to do with
true inguinal hernias, and instead involve what we describe as
the “pubic joint.”3,6 There are a variety of different injuries
that can be involved with these muscles and other soft-tissue
structures outside of the ball-in-socket hip joint. A detailed
understanding of the anatomy and function of the pelvis is
necessary to treat these patients effectively. As adjudged by
the increasing number of athletes who seek out these operations
and the new training programs that have been incorporated
into sport, these approaches have become accepted by
the sports medicine community at large.
A brief historical perspective seems appropriate for a
more complete understanding of the development of the above
series of patients.6 The senior author developed an interest in
this subject as a result of direct observation of these injuries
in his younger days as an athlete and of participation in the
care of Duke University athletic teams in the mid-1980s with
doctors Frank Bassett and William Garrett. As a result of
studies in the fresh cadaver laboratory, a greater appreciation
of the anatomy and biomechanical forces led to the
development of a set of highly successful procedures on
competitive athletes who had been previously sidelined for
long lengths of time.2
During the 1980s and 1990s, that author’s experience
as a gastrointestinal surgeon helped to separate the musculoskeletal
disorders from a wide variety of other diagnoses. His
association with a leading physical therapist, a coauthor,
helped to understand the limitations of physical therapy and
rehabilitation as a primary treatment of many of these abdominal
and groin problems, and the roles of those modalities
after surgery and in prevention of injuries. Subsequently, his
association with several expert arthroscopic hip surgeons, one
a coauthor, helped to understand the pathophysiology of the
hip and the new advances in hip surgery.
In the 2000s, as the author learned more about the
number and complexities of these injuries, he partnered with
another coauthor in studying the radiologic anatomy of the
pelvis and these injuries. In 2005, they realized that by
correlating the clinical assessment of the patients with some
creative magnetic imaging techniques and findings at surgery,
one could identify preoperatively very precisely most of the
injuries.
The above associations helped to solidify the primary
concept upon which this series of patients is based—the pubic
bone joint. Some of the evidence that supports this concept
includes correlation of surgical and radiologic pathology,
correlation of pathology with history and physical examination
findings, the multiple sites of injury around the pubic
symphyseal bones, and the fresh cadaveric studies.6 Successful
functional correction of the variety of problems by a
variety of repairs and releases specific for the identified
pathology adds support for the fundamental concept. Other
evidence supports this concept including: the multiple sites of
pain that often occurs in the same patient, development of
opposite side problems without surgical treatment, the occurrence
of osteitis pubis in athletes, and correctability of the
osteitis by injury repair, and a large experience with successful
repair after failed hernia surgery. With regard to the last
mentioned evidence, we are now averaging over 3 “redo”
operations per week on such patients.
Under-appreciated and perhaps implied from the large
number of patients in this series is the magnitude of these
type of injuries in competitive sports. When one considers the
incidence of both hip and athletic pubalgia injuries as a
group, which these data suggest we should do, these injuries
emerge as one of the largest categories accounting for both
loss of playing time and early retirement from sport because
of injury.17–19 No doubt, recognition and understanding of
these injuries and satisfactory care shall continue to increase
the number of athletes who return to successful careers and to
impact modern sport and physical fitness.
When one looks at the large number of articles on
athletic pubalgia or sports hernia in the sports medicine,
physiatry, physical therapy and other literature, one comes
away from this literature very confused. Most of the confusion
comes from assumptions about pathophysiology, such as
occult hernias, which are rarely found, or from limited data
without compulsive patient follow-up. Two recent reviews
characterize this confusion well.20,21
This paper simply provides an overview of one large
experience with this injury. It documents the changing pattern
of patients including the increasing number of females, sports
involved, overall age of patients, and anatomic syndromes
that have been identified. In addition, it documents huge
advances that are taking place in the radiologic imaging of
these problems and in the physical therapy and performance
protocols for these problems and the acceptance of these
concepts into the athletic communities.
REFERENCES
1. Meyers WC, Szalai L, Potter N, et al. In: Extraarticular Sources of Hip
Pain. Operative Hip Arthroscopy. 2nd edn. New York, NY: Springer.
2005:86:–97.
2. Meyers WC, Foley DP, Garrett WE, et al. Management of severe lower
abdominal or inguinal pain in high-performance athletes. Am J Sports
Med. 2000;28:2– 8.
3. Meyers WC, Greenleaf R, Saad A. Anatomic basis for evaluation of
abdominal and groin pain in athletes. Oper Tech Sports Med. 2005;13:
55–61.
4. Byrd JWT. Gross anatomy. In: Byrd JWT, ed. Operative Hip Arthroscopy.
New York, NY: Springer; 2005:100 –109.
5. Ganey TM, Ogden JA. Pre- and post-natal development of the hip. In:
Callaghan JJ, Rosenberg AG, Rubash HE, eds. The Adult Hip. Philadelphia,
PA: Lippincott Williams and Wilkins; 1998:39 –56.
6. Meyers WC, Yoo E, Devon O, et al. Understanding “sports hernia”
(athletic pubalgia): the anatomic and pathophysiologic basis for abdominal
and groin pain in athletes. Oper Tech Sports Med. 2007;15:165–177.
7. Omar IM, Zoga AC, Kavanagh EC, et al. Athletic pubalgia and the “sports
hernia”: Optimal MR imaging technique and findings. Radiographics.
2008;28. In press.
8. Taylor DC, Meyers WC, Moylan JA, et al. Abdominal musculature
abnormalities as a cause of groin pain in athletes. Am J Sports Med.
1991;19:239 –242.
9. Meyers WC, Lanfranco A, Castellanos AE. Surgical management of
chronic lower abdominal and groin pain in high-performance athletes.
Curr Sports Med Rep. 2001;1:301–305.
10. Meyers WC, Ricciardi R, Busconi BD, et al. Athletic pubalgia and groin
pain. In: Garrett WE, Speer KP, Kirkendall DT, eds. Principles and
Practice of Orthopaedic Sports Medicine. Philadelphia, PA: Lippincott
Williams and Wilkins; 2000:223–232.
11. Mora SA, Mandelbaum BR, Meyers WC, et al. Extra-articular sources of
Annals of Surgery • Volume 248, Number 4, October 2008 “Sports Hernia” Spanning Two Decades
© 2008 Lippincott Williams & Wilkins 663
hip pain. In: Byrd JWT, ed. Operative Hip Arthroscopy. New York, NY:
Springer; 2005:70 –99.
12. Albers SL, Spritzer CE, Garrett WE, et al. MR findings in athletes with
pabalgia. Skeletal Radiol. 2001;30:270 –277.
13. Zoga AC, Kavanagh EC, Meyers WC, et al. MRI findings in athletic
pubalgia and the “sports hernia.” Radiology. 2008;247:797– 807.
14. Zoga AC, Kavanagh EC, Meyers WC, et al. MRI of the rectus abdominis/
adductor aponeurosis: Findings in the “sports hernia.” Scientific
paper presentation, Paper presented at: The American Roentgen Ray
Society, Annual Proceedings, Orlando, FL, 2007.
15. Petersilge C. Imaging of the acetabular labrum. Magn Reson Imaging
Clin N Am. 2005;13:641– 652.
16. McKechnie A, Celebrini R. Hard Core Strength. Vancouver, BC. Available at:
http://www.p2soccer.com/Content/Main%20Pages/Resource%20Centre.asp
.
17. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15
sports: summary and recommendations for injury prevention initiatives.
J Athl Train. 2007;42:311–319.
18. Philippon M, Schenker M, Briggs K, et al. Femoroacetabular impingement
in 45 professional athletes: associated pathologies and return to
sport following arthroscopic decompression. Knee Surg Sports Traumatol
Arthrosc. 2007;15:908 –914.
19. Witnauer WD, Rogers RG, Saint Onge JM. Major league baseball career
length in the 20th century. Popul Res Policy Rev. 2007;26:371–386.
20. Swan KG, Wolcott M. The athletic hernia: a systematic review. Clin
Orthop Rel Res. 2006;455:78–87.
21. Farber AJ, Wilckens JH. Sports hernia: diagnosis and therapeutic approach.
J Am Acad Orthop Surg. 2007;15:507–514.
Discussions
DR. KEITH D. LILLEMOE (INDIANAPOLIS, INDIANA): Some
may wonder why Dr. Meyers asked me to discuss this paper. It
is in part that he knows that I am a huge sports fan and that I
have followed his career as a sports hernia surgeon for many
years. He also knows I anticipated these results for many years.
Dr. Meyers, you describe your experience since 1987
with now over 9,000 patients and almost 6,000 operations.
This number has increased dramatically over five years. My
first question is: where were all these patients coming from
and where were they in the past? Is this a totally new
phenomenon, or are we just understanding it better?
Next, you speak of the valuable role of MRI, but you
also state that this is a relatively new test for confirming the
diagnosis and characterization of the disease. How did you
make this diagnosis prior to the use of MRI? It is hard for me
to imagine that with these million-dollar athletes you can
make this diagnosis and offer surgical treatment based simply
on a history and physical.
You describe 18 to 19 distinct syndromes. Do you have a
different operation for each of these syndromes? Can you describe
at least one of these procedures in a fashion that someone
who at least understands an inguinal hernia repair and its
associated muscle and facial layers can understand? Do you do
it open or laparoscopically? Do you use mesh? Is this done under
local or general anesthesia? Is this an operation to be performed
by general surgeons or orthopedist? Are you training your
fellows and surgical residents to do this procedure?
Finally, a tough question, I understand it was not the
purpose of this paper to give results, and you cite prior publications,
although none since 2000, but obviously there have
been thousands of patients treated since that time. Yet this is
a results-oriented organization that appreciates p-values and
statistics, and I think you owe it to this Association and the
Annals of Surgery to at least present some of your percentages
of success and how you define what you consider
a successful outcome in these high profile athletes. Data
such as the time to full recovery and any adverse outcomes
or complications associated with the procedures should be
reported.
Finally, do you have comparative data between surgical
procedures and nonoperative management? Until this data is
provided, I am afraid that the outcomes for this syndrome will
really only be known to those of us who follow the sports
pages and listen to ESPN rather than by reading the peerreviewed
literature.
DR. JOHN G. HUNTER (PORTLAND, OREGON): I think Dr.
Lillemoe asked a couple of my questions, but I want to
amplify something previously mentioned and also to ask one
additional question.
The conventional hernia repairs do not work for sports
hernias, as you pointed out, because there is no relationship
between pubalgia and inguinal hernia. Therefore, the term
“sports hernia” should be abandoned if we want patients to be
saved from unnecessary and potentially injurious surgery.
Perhaps today we can abandon this term once and for all if
you agree.
Secondly, imaging has been very helpful, as you pointed
out, in defining the various injury patterns. It seems that you
operated on a number of people with normal imaging. How do
you determine who is likely to benefit in this group?
Lastly, just to amplify Dr. Lillemoe’s question, who
will learn about these injuries? Who will perform these
procedures outside of Philadelphia? Will it be orthopedists or
will it be general surgeons?
DR. WILLIAM C. MEYERS (PHILADELPHIA, PENNSYLVANIA):
It is absolutely appropriate to be skeptical about something
that is new and for which the data are still relatively virgin in
terms of analysis and validation. This is a complex set of
injuries and proper treatment requires a detailed understanding
of the anatomy and other orthopedic and visceral problems
that afflict this area. I shall try to go through the various
questions specifically.
With respect to Dr. Lillemoe’s first question about
where these patients have been for the past many years, there
is no question in my mind that this problem has existed for
many years. It is difficult to go back and get these data for
multiple reasons. In fact, prior to recognition of the injury,
many of these players were clearly passed off as malingerers
because they articulated multiple mysterious complaints and
were not playing well. The symptoms would oscillate from
side to side and involve both the abdomen and the adduc-
Meyers et al Annals of Surgery • Volume 248, Number 4, October 2008
664 © 2008 Lippincott Williams & Wilkins
tors. I imagine that many people in this audience can
remember such patients – ones with such injuries who
dropped off teams – in their own careers in sports.
This is definitely not a new phenomenon, and we do
understand this better. There may be an increased incidence
today, but this is not clear. As I mentioned, there has certainly
been an increased recognition of this entity in both the
medical and lay literatures. There are about 20,000 more
articles on ESPN.com than in the established medical literature,
which may be related to the fact that there are more
sports stars with these injuries than in the past. There is also
perhaps an overuse aspect to the development of this injury;
more one sport athletes and repetitive training.
MRI has been a very useful adjunct to what we have
already learned. The problems can actually be diagnosed on
physical examination. In fact, history and physical examination
is the gold standard still for precise diagnosis. You can
pinpoint the area of pain and relate the pain to various
resistance maneuvers. For example, you can separate each
adductor with a combination of very precise maneuvers, but
MRI is so much better, that you can diagnose many of these
injuries with that modality alone. It is best to correlate MRI
with the history and physical findings.
With respect to the different operations, there are a
large number of operations that I perform depending on the
specific problem involved. For example, consider one wellknown
baseball player who came in with a completely disrupted
adductor longus. This occurred on television and was
a long-time highlight. In fact the adductor longus was not the
principal injury in this particular case. The rectus abdominus
muscle was completely detached and the common aponeurotic
plate on that side was nearly completely disrupted. At the
time of surgery the rectus was up around his belly button
where you could feel a ball. We had to bring that muscle all
the way back down to the pubis at surgery. It is wrong to
consider these injuries like hernias. The anatomy involves the
pubic symphysis itself and should be considered as a joint. To
repair these problems successfully, one should be thinking
more like an orthopedic surgeon working on the knee than a
hernia surgeon. One should aim to achieve stability of the
pubic joint.
We see a variety of different injuries depending on the
primary source of instability.
I perform the procedures usually under an LMA type
anesthesia, and sometimes under local or full general anesthesia.
You can perform minimal repair operations under
local anesthesia and occasionally get the patient back to work
in a few days, for example to a key playoff game. The
problem with minimal repair operations is that sometimes
they do not endure over the long term.
The way we define success depends on the patient’s
own subjective analysis of whether he is at the same level of
performance as before the injury. We assess patients at 3 and
6 months, and at 1 and 2 years. The overall success rate in
athletes is 95.4% at 2 years. We are in the process of
subdividing the injuries and providing 2-year follow-up based
on the more specific diagnoses and including MRI findings.
Because the progress in MRI has only occurred over the past
2 years, such 2-year data is still forthcoming.
It is difficult to do comparative studies on these athletes
because they have a season coming up and sometimes it is
often easier to go ahead and perform surgery immediately in
the off-season so they are ready to return to their sport. Trials
of conservative therapy for most of these injuries do not
work, although for certain types of injuries, non-operative
therapy is better.
There is a study out of Holland that goes through a
5-year physical therapy regimen, and there is actually about a
60% to 70% clear improvement rate during that period of
time. Most athletes that we deal with do not have that time
window. Interestingly, there is a success rate with conventional
open or laparoscopic hernia repairs for certain types of
injury, but it is not nearly the success rate that we would like.
Among the 15 to 17 operations per week that I perform, 3 to
4 are re-operations after failed hernia repair attempts.
Dr. Hunter, I agree that the term “sports hernia” should
be abandoned. The comparison to knee injuries is much more
pertinent than our understanding of hernias. As for training,
we require a year fellowship with me before I endorse
someone to go out and start treating these injuries on their
own. The surgeon most fit to treat these injuries is one who
understands this anatomy and has experience with the wide
variety of injuries that occur