Understanding “Sports Hernia” athletic pubelgia

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Understanding “Sports Hernia” (AthleticPubalgia): The Anatomic and PathophysiologicBasis for Abdominal and Groin Pain in AthletesWilliam C. Meyers, MD,* Edward Yoo, MD,* Octavia N. Devon, MD,* Nikhil Jain,*Marcia Horner,* Cato Lauencin, MD,† and Adam Zoga, MD‡

Recent publicity and some scientific reports suggest increasing success in treating anentity called “sports hernia,” more accurately named athletic pubalgia. The primary pur-pose of this article is to portray what we believe to be the key concepts for understandingthis wide variety of abdominal and groin injuries that afflict high-performance athletes.These injuries have been plaguing athletes for a long time, and past treatments, based onconcepts of occult hernia or simple strains, have generally failed. The former concepts donot take into account the likely mechanisms of injury or various patterns of pain that theseathletes exhibit. The authors believe that the concept of a “pubic joint” or “pubic dynamiccomplex” is fundamental to understanding the anatomy and pertinent pathophysiology inthese patients. Many injuries can now be treated successfully. Some of the injuries requiresurgery, and others do not. In most cases, decisions regarding treatment and timing forreturn to full play require proper identification of the problems and consideration of a widevariety of medical, social, and business factors.Oper Tech Sports Med 20:33-45 © 2012 Elsevier Inc. All rights reserved.

KEYWORDS sports hernia, athletic pubalgia, core stability, abdomen, groin, injuries

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During the past several years, there has been increasingpublic wonderment about the entity called “sports her-

ia.” What is it? How long has the problem been around?hy haven’t we heard much about this before? The purpose

f this article is to try to shed some light on the subject.ecause the past literature and terminology are so confusing,

t seems important to first make a number of general com-ents and then provide our perspectives on historical, ana-

omical, and clinical aspects of these problems. Finally, wehall make some additional comments about optimal treat-

Reprinted with permission from Meyers WC, Yoo E, Devon ON, et al: Un-derstanding “Sports Hernia” (Athletic Pubalgia): The Anatomic andPathophysiologic Basis for Abdominal and Groin Pain in Athletes. OperTech Sports Med 15:165-177, 2007 (© 2007 Elsevier Inc.).

*Department of Surgery, Drexel University College of Medicine, Philadel-phia, PA.

†Department of Orthopedic Surgery, University of Virginia Medical Center,Charlottesville, VA.

‡Department of Radiology, Thomas Jefferson University Hospital, Philadel-phia, PA.

Address reprint requests to William C. Meyers, MD, Department of Surgery,Drexel University College of Medicine, 245 N 15th St, Mail Stop 413,
Philadelphia, PA 19102-1192. E-mail: [email protected]
1060-1872/12/$-see front matter © 2012 Elsevier Inc. All rights reserved.doi:10.1053/j.otsm.2012.03.005

ents that take into account traditionally nonmedical con-iderations, such as contracts, owners, and agents. These per-pectives and comments are based on an experience of morehan 8000 examinations and more than 5000 surgeries onatients with these problems. Success rates and other clinicalollow-up have been reported in other articles.1-4

General CommentsLet us first make some general comments on what we aretalking about. We are talking about a wide variety of injuriesto the anterior pelvis outside of the hip joint. The locations ofthe symptoms and signs involve the lower abdomen, thepubic symphysis, thigh adductors and hip flexors, as well asmany other structures, such as the gracilis, sartorius, andobturator externus muscles. Therefore, from an anatomic ba-sis alone, the term sports hernia seems much too simplisticand just doesn’t fit with the fact that numerous anatomicstructures are involved.

Plus, the primary mechanism for most of these injuriesinvolves hyperextension of the abdomen and/or hyperabduc-tion of the thigh, and the pain occurs primarily with exertion,
often in multiple locations, rarely involving the internal ring.
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34 W.C. Meyers et al

Therefore, thinking along the lines of occult, garden-varietyinguinal hernias seems intuitively wrong. Instead, we shouldbe thinking in terms of some sort of imbalance that affectsmultiple soft tissue structures, often symmetrically, aroundthe pubic bone. So, to understand the many abdominal andgroin injuries that afflict athletes, it is likely appropriate tofirst throw out of one’s head all assumptions associated withthe pathophysiology of inguinal hernias. Instead, it is betterto think more “orthopedically,” that is, in terms of attach-ment disruption and instability of a “joint.”

The term athletic pubalgia seems a much better fit thansports hernia because the former term captures the idea ofmultiple possible afflictions around the pubis and does notconnote a likely misleading cause of pain. Unfortunately, aspoor a term as “sports hernia” may be, we may be stuck withit because the sports news media has recently so popularizedit. The press has popularized the term for 3 presumptivereasons: a demand for stories (as the result of several prom-inent athletes having gotten injuries), an apparent need toconnote understanding, and easier pronunciation.

The Past LiteratureWhen one looks at the large number of articles on suchinjuries in the sports medicine, physiatry, physical therapy,and other literature, one comes away very confused. Tworecent reviews well characterize this confusion.5,6 A huge

umber of other terms and diagnoses are introduced: osteitisubis, hockey groin, “Gilmore’s” groin, gracilis syndrome,ectineus syndrome, to name a few.7-12 There seems a tre-endous amount of overlap among both the diagnoses and

erms used, and it is often difficult to distinguish the objec-ivity of the various observations. To confuse things more,erms such as “athletic hernia,” “sports hernia,” or “sports-an’s hernia” were actually around since at least the 1970s

nd then at some time came into disrepute. Apparently, theoor results from surgical hernia repairs for such problems

ed to the well-incorporated dogma in surgery residencyeaching that one should not operate on the groin unless onealpates a distinct hernia-type bulge.a

In parallel with the confusing terminology, the past litera-ture also seems devoid of any consistency with respect to howto think about the pertinent pelvic anatomy or pathophysi-ology of the injuries. There may be 2 main reasons for thisinconsistency. First, the musculoskeletal anatomy of the an-terior pelvis is very complicated. Second, no real surgicalspecialty has had to deal very much in this region of the body,except for severe blunt trauma when treatment often involvesnonoperative measures such as mass trousers or prolongedbed rest.

One might even describe the pelvic anatomy involved inthese athletic injuries as a “no-man’s land” for the variousspecialties. Orthopedists classically take care of problems upto the hip except for the rare resections of large pelvic can-

aSabiston DC: Textbook of Surgery. See “Hernia” chapters in editions 1964-
1997.
cers. General surgeons take care of problems of the colo-rectum, internal inguinal ring/Hasselback triangle areas, andlarge blood vessels. Urologists think of the pelvis according tothe genitourinary anatomy, and gynecologists define the pel-vis according to the reproductive organs that reside in thisspace. For these specialists, the musculoskeletal attachmentsof the pelvis may once have been studied in medical schoolbut later had little pertinence to their current practices.

On the other hand, the anatomy and the pathophysiolog-ical considerations of the pelvis are indeed complicated and,in a way, it is appropriate for there to be some confusion. Forexample, each of the aforementioned specialties does treat avariety of conditions that cause pelvic pain, and it is particu-larly important to consider this wide differential diagnosis inathletes and nonathletes with pelvic pain. We have seenmany cases of inflammatory bowel disease, endometriosis,cancer, as well as many other nonmusculoskeletal problemsin this generally young group of patients referred for abdom-inal and groin pain.

Let us mention one additional point about the past litera-ture. In that literature, there are many claims with respect tothe best way to treat the many injuries. We must be extremelycareful in interpreting these results. There is a misleadingtendency to lump all the injuries into one category when thepatients clearly have multiple different problems.2,3,13,14 Fol-low-up parameters in such series must be carefully defined,measured, and sufficiently detailed to permit critical inter-pretation. In addition, it is easy to become biased on someinitial success. For example, the zeal15 of the “laparoscopicevolution”16-19 during the past 15 years may have carried

over to the treatment of these injuries.To be more specific, we have been reoperating on a large

number of patients who have had open or laparoscopic meshrepairs unsuccessful in solving the pains. During a 16-monthperiod, we reoperated on 153 such athlete-patients treatedunsuccessfully by laparoscopic or open mesh hernia repairs.Fortunately, the 2-year success rate with the re-repairs inthese patients approaches the same rate as for first-time re-pairs.1 We have also treated several disastrous complicationsrom the laparoscopic attempts at treatment of otherwise veryealthy patients. For the aforementioned reasons and theide range of reported results,20-27 we are skeptical of lapa-

roscopic hernia repair as a primary treatment for most, butnot all, of these patients. Plus, we worry about the increas-ingly large number of athletes for whom we are taking out themesh from their prior open or laparoscopic repairs.

The “Pubic Joint”In this article, we shall make numerous references to what wecall the pubic joint because we believe this to be the mostimportant concept for understanding and treating these in-juries. Multiple injuries occur around this joint, and surgeryvaries depending on the specific musculoskeletal anatomythat is involved. With current techniques of magnetic reso-nance imaging (MRI), we can image each of these injuries andcorrelate the images precisely with the clinical diagnoses
(Figs. 1 and 2).28-33

Understanding “sports hernia” (athletic pubalgia) 35

The pubic joint is not the same as the pubic symphysealjoint, that is, the space between the 2 sides of the pubicsymphysis. Instead, we are talking about a large, complexrotational joint that involves both pubic symphyseal bonesand the entire anterior pelvic musculo-skeleton around thesebones. The joint involves all the nonhollow organ, soft-tissueattachments on either side of the pubis, specifically excludingthe ball-in-socket hip joint. According to the U.S. NationalLibrary of Medicine and the National Institutes of Health, a

Figure 1 Axial (A) and sagittal (B): T2-weighted fast spin echo fatsuppressed (images from a noncontrast MRI dedicated to the pelvisusing an athletic pubalgia protocol acquired at 1.5 Tesla in a pro-fessional football player with refractory right sided groin pain: Onthe axial image, the left rectus abdominis (RA), pectineus (P), andadductor longus (AL) are intact, and the pubic symphysis (PS) isnormal. On the right, the rectus abdominis is amputated (arrow-heads) and the adductor longus is retracted (arrow). On the sagittalimage, the rectus abdominis is disrupted at its anteroinferior pubicattachment (arrow). On this lateral representation of anatomy onecm lateral to the pubic symphysis, “P” denotes the pubic bone, and
“RA” the rectus abdominis muscle.
joint is defined by “the point of contact between elements ofan animal skeleton whether movable or rigidly fixed togetherwith the surrounding and supporting parts.”34 Consideringthe rotational activity around the pubic bone, we see noreason that the “pubic joint” does not satisfy this definition.Most of the abdominal and groin injuries that afflict athletesare caused disruptions of this joint and can be managed ef-fectively after identifying the precise anatomy that has beendisrupted. We shall go into this anatomic concept in moredetail later.

Another way to think of this anatomy is to liken the anat-omy and function to the inferior glenohumeral ligamentcomplex in its role of providing stability, function, and theprevention of overextension and overrotation. So, alterna-tively, we might call the “pubic joint” the “dynamic pubiccomplex.” “Pubic joint” is easier to say, so we shall use thisterm mostly in this article.

A Historical PerspectiveEarly HistoryThese injuries are not just a recent phenomenon. Let us beginthis history with Richie Szaro.b Richie was a college classmateof one of the authors in the late 1960s/early 1970s. In hissenior year in high school, Richie was considered the toprecruited high school football player in the country. A run-ning back, Richie’s first love was actually soccer. An immi-

Figure 2 Coronal short tau inversion recovery image of the pelvisacquired at 1.5 Tesla using an athletic pubalgia protocol in a pro-fessional baseball player with an acute right sided groin injury whilefielding a bunt: The brightest signal represents fluid on this fluidsensitive sequence. Note the abnormal fluid signal tracking infero-laterally from the pubic symphysis (arrowhead), sometimes referredto as a secondary cleft sign and often indicating a tear at the rectusabdominis attachment on the pubic bone. The adductor longustendon has been avulsed and is retracted caudal and lateral (arrow).

bSee http://gocrimson.collegesports.com/ or Harvard University website.

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grant from Hungary, Richie actually played both sports at thesame time.

Throughout Richie’s years at Harvard, Richie had a nag-ging lower-abdominal or groin injury that kept him fromplaying full-time American football. This author rememberswell first-hand the disappointment that this caused, both toRichie and the Harvard alumni. It was obvious at the timethat Richie had a real injury that was not understood and thatinjury functionally ended his career as a running back.

While playing soccer at amateur and professional levels inthe United States and South America,c the author saw multi-

le other soccer players who probably had similar injurieshat ended their careers. It is clear, therefore, that such inju-ies are not just a recent problem. It is not just a conditionaused by recent training methods or changes in turf condi-ions. A large number of such injuries have occurred forany years.In the mid-1980s, the author had the good fortune of

ssisting Drs. Frank Basset and William Garrettd with the careof the Duke University athletic teams. It seemed that on eachteam there were 1 or 2 players who prematurely ended theircareers because of abdominal or groin injuries. At the time,we did not know how to take care of such injuries. As welooked around, no one else seemed to have the answer, ei-ther. Partially as a result of listening to a Yugoslavian physi-cian named Nesovic,e we developed the concept of the pubicjoint.

At the time, we were following 3 players with similar inju-ries: a college soccer player, one of our basketball players,and a minor league centerfielder. We decided to apply tothese athletes a surgical procedure that made sense in thelight of our new concept. To our delight, the patients did welland returned to their previous performance levels.

Then, by word of mouth and the result of an early publi-cation,14 other patients came to us for treatment. This expe-rience allowed us early on to amass a very large series and tocollect detailed long term follow-up initially on about threehundred patients.1

The 1990sDuring this time, we recognized several things. There weremultiple types of injuries that required tailoring of the oper-ations to those specific injuries.1,2 Also, we initially had ex-cluded patients who had similar problems but also carriedthe bone scan or MRI diagnosis “osteitis pubis.” On the basisof some verbal communications with European surgeonswho had reproduced some of our results, we called backsome of the latter patients and did surgery on them. Theresults from surgery on the osteitis patients were similar tothe group as a whole.4,f

During the early 1990s, we also spent considerable time in

cObservations from U.S., Brazil, and Argentina in the late 1960s and early1970s.

dChiefs of Sports Medicine at Duke University 1971-1996.eNesovic B: Abstract and presentation at Olympic Medical Meeting, 1986.fEmpiric observations and decision-making. Data on these “osteitis” patients

were not separated out as group in our publications.

the fresh cadaver laboratory. With these fresh specimens thathad not undergone the distortions of rigor mortis, we soughtto understand better the anatomy and the mechanics of theconceptual joint. None of these studies had enough numbersto meet statistical standards, nor were they done with rigor-ous scientific calibrations, so they remain unpublished.Nonetheless, they formed the basis of our devising severalnew operations. Therefore, we feel it important to mentionone study on eight fresh cadavers.

In these specimens, varying degrees of cutting the inser-tion of the rectus abdominis attachment to the pubis with thecadaver in a supine position resulted in 30 to 100 cm (water)increases in pressure within the adductor longus musclecompartments. In fact, when observers inserted their fingersbehind the adductors while the rectus was being cut, bonyprojections from the anterior edge of the inferior pubic ramuscaused dramatic pain in the observers.

Such observations led us to understand better the anat-omy. The abdominal attachments to the pubis and hips in-terrelated profoundly in a mechanical way with the adduc-tors, flexors, and rotators of the hip; thus, providingadditional evidence that the pubic joint concept was applica-ble to severe injuries.

During the same time period, we also recognized empiri-cally that there were a variety of musculoskeletal syndromesto consider as well as many diagnoses involving the gastro-intestinal, genitourinary, and other body systems.1 At thattime, MRIs in fact revealed the specific musculoskeletal prob-lem in only 10% to 15% of patients,35 it often provided evi-

ence of the nonpubalgia diagnoses. Therefore, even thoughRI usually did not identify precisely the problems, it was

onetheless still important to perform.This imaging test was helpful in interesting other ways. In

pproximately 90% of cases, the imaging tests revealed mul-iple “soft” musculoskeletal findings, such as tiny avulsionractures or peculiar edema patterns, on the side(s) of thenjury. Considering the National Library definition of a jointited previously, “multiple points of contact” would provideultiple potential sites for injury if the joint were unstable.herefore, the latter constellation of observed MRI findingst well with the concept of joint instability.35,36

Intrinsic hip pathology often surfaced as an important con-sideration particularly when the clinical findings were equiv-ocal. And in fact, several problems in nearby locations weresometimes seen in the same patient, such as the coexistenceof rectus abdominis tears with a psoas bursitis or a labral tear(Fig. 1). MRI also revealed multiple other hip and other mus-culoskeletal problems, as well as other problems that hadnothing to do with the musculoskeleton.1,35

Surprisingly, Crohn’s disease was one of the more com-mon nonmusculoskeletal problems the MRIs initially re-vealed. We also picked up several cancers of various typesplus some benign tumors. The test also revealed a number ofurologic and other problems. In women, endometriosis, ovar-ian, and other gynecologic and obstetric pathology emerged asrelatively frequent considerations.

To test the veracity of the concept of joint instability, we
did what we believed was an important study using the MRI

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images. Our hypothesis was this: Although the “soft” findingsdid not always correlate specifically with the clinical findingson the patients, the radiologists would be able to predict theside(s) of the injury without their knowing any of the clinicalfindings.

So we gave 40 sets of images, 30 on injured patients and 10on normal, uninjured patients, to 3 MRI experts and askedthem to tell us, in a blinded fashion, whether they suspectedan injury and, if so, on which side(s) they believed the injuryto be. Interestingly, the radiologists were correct in identify-ing the injuries in 29 of the 30 patients with injuries, and alsoin naming the correct side or sides of injury (or absence ofinjury) in 36 of the 40 patients. Therefore, the “soft” findingson MRI may not have identified the primary site of injury;nevertheless, the findings were useful in identifying generaldisturbances on the side of injury, perhaps via compensatorymusculoskeletal effects and fitting with the concept of jointinstability.

Some of the aforementioned results were subsequentlypublished,35 but at the time we already knew that often theinjury would begin on one side of the abdomen and groinand then involve the other. We subsequently learned thatwhen the patient initially presented with unilateral pain, weshould suspect that the other side might also be at risk even ifthe MRI showed no findings on the contralateral side. Theincidence of a new problem on the side opposite a successfulrepair turned out to be about 4%. Therefore, we now use“soft” findings on the side opposite a unilaterally symptom-atic abdomen/groin as a potential indication to do bilateralrepairs.

It is interesting that a recent paper37 from Europe reportedbjective findings very similar to ours. In this recent paper,2 MRI examinations were given to 2 radiologists “masked tohe clinical details.” Through similar “soft” findings, bothadiologists identified the side(s) of injury with a high degreef accuracy. Assessment of imaging side severity using post-adolinium sequences correlated significantly with the clin-cal findings (P � 0.048 and P � 0.023 for the 2 radiologists).

Several other events are noteworthy from the 1990s. Abouthe same time as we were studying the problems, Gilmore inngland was making observations similar to our own initialbservations. He was caring mostly for European soccer play-rs.38,39 He also seemed to be performing similar operationso our own and was reporting similar success rates. Althoughome of Gilmore’s observations were different than ours, weelieved that Gilmore was more or less independently con-rming many of our concepts and surgical results.Also at about the same time, Nesovic from Yugoslavia also

ppeared to be independently coming up with observationsimilar to ours and Gilmore’s. We have in our possession anpparently unpublished paper written by Nesovic fromround the year 2000. The paper, entitled “Painful Symphy-is Syndrome in Athletes and Possibilities of its Treatment,”escribes many observations and successful management ofn unspecified number of athletes. Nesovic’s observations gonto some detail concerning the anatomy of the muscular
ttachments to the pubic symphysis, a “kynesiological anal- s
sis” of 63 patients, and a long list of operations that areimilar to our own.2

During the decade of the 1990s, team trainers, physicaltherapists, and physicians became much more skilled at rec-ognizing these injuries.1 In the first half of the decade, most

atients had had their symptoms well over a year. In the latteralf, the diagnosis was made, for the most part, withinonths after the injury.In general, the trainers and physical therapists became

onvinced that these injuries were real before many teamhysicians did. Most of the proliferation of papers on theubject was printed in the orthopedic literature. Goodeviews also appear in multiple trainers’ manuals and inhe physiatry literature.40-51 These reviews point out both

the multiplicity of problems and the difficulty sortingout the underlying pathology and treatment.

Also during the 1990s, we came to recognize that a varietyof tightening and loosening operations2 have major applica-bility in the care of these patients. As mentioned, the set ofinjuries involve multiple different areas in the abdomen andpelvis. Therefore, performing applicable operations requiresa detailed understanding of the applicable anatomy. Painsoften result from not only the primary injury but also fromcompensatory attempts to restore joint stability. We will re-view some of these syndromes and procedures later in thisreview.

The 2000sDuring the latter half of the 1990s, we came to recognize thatthe pathology associated with these injuries can be obvious orsubtle. The group with the most dramatic pathology has beenbull-riders, many of whom have been under the care of DrTandy Freeman in Dallas. Riding their animals, these athletesroutinely exhibit postures that highlight the classic mecha-nism of injury: a combination of hyperextension of the ab-dominal muscles and hyperabduction of the adductors of thethigh. Complete avulsions of the rectus abdominis musclesand/or multiple adductor muscles from the pubic symphysisoccur frequently in these rodeo performers.

The 2000s have brought additional advances in the under-standing and management of these injuries as well as a fewsteps backwards. Recent MRI studies exemplify this in-creased understanding.28-33 With the advent of high-defini-ion MRI and other MRI techniques, we are now imagingore pathology. As noted, in a recent presentation at theadiologic Society of North America,28 we found in a largeeries that 98% of patients had findings on MRI deemedikely to be related to the abdomen and/or groin pain. Whenompared with surgical findings, MRI had sensitivity andpecificity of 68% and 100% for rectus abdominis pathologynd 86% and 89% for adductor tendon pathology. Only 2atients had inguinal hernias. Interpretation of the MRI find-

ngs still is very tricky from the standpoint of identifyingrimary versus compensatory pathology, but MRI was over-ll 91% effective in identifying the precise pathology corre-ating with clinical findings. Compared with MRI, ultra-
onography52,53 or herniography5,6 remain more subjective

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and less helpful. Like the knee, the most important problemwith respect to stability of the pubic joint may be obscured byother identifiable pathology. Overall, the existence and fix-able nature of many of the severe injuries has become morerecognized. More syndromes have become established.2

Some injuries are more reparable than others and some inju-ries do not require surgery.

The 2000s have brought with it not only an increasedrecognition of the problem, but also some likely advances inboth rehabilitation and prevention. During the season, wenow return most athletes to full performance within severalweeks after the repairs. The observations of a German sur-geon54 who tried to return players within 2 to 3 days of her

rocedure, rather than the 2 to 3 week protocol now com-only employed for simple tears, challenges us to returnlayers to full activity even sooner than we have doing as wells to consider the roles of nerves in the causation of pain. Theotion of such early return challenges us that sensory dener-ation may play a role in treatment.55 The problem here, ofourse, is that many patients who had denervation ap-roaches alone actually persisted with symptoms, had earlyecurrences, and in some instances developed more seriousnjuries, presumptively because the primary injury was neverxed.Various factors affect optimal timing for return to full ac-

ivity such as: specific type of injury or injuries, severity of thenjury, type of sport, the playing season, preoperative fitness,trength re-building, and contract negotiations. Often, injuryepair can be postponed until the end of the season. For mostut not all injuries, continued physical activity before repair

s unlikely to change the success rates of surgery. After sur-ery, the incidence of persistence or recurrence for most in-uries is very low.

We have learned that this multifactorial nature of the de-ision-making can profoundly affect timing for return tolay. For example, consider the multiple variables involved

n a baseball pitcher having a great season in his contract yearnd suddenly avulses his adductor longus and part of hisectus abdominis. Say, for the purposes of discussion, that hiseam is on the bubble for the playoffs. Does one do surgeryight away or wait? After surgery, how quickly should heome back, taking into account the danger to his arm of pooritching mechanics? The answers also have to take into ac-ount the player, agent, manager, and owner, and in addi-ion, how long will it take for him to re-build his arm strengthfter being free of pain? Other factors include the signabilityf the player after the season as well as the contract riskelated to performance if he comes back too soon. Clearly,hese answers are not simple.

Prevention of injury has also become now become a specialocus in the 2000s. Alex McKechnie, now working for the.S. basketball team Los Angeles Lakers, has now applied aertain combination of core stabilization and flexibilityraining to the prevention of such injuries.56 He bases hisxercises on the anatomically neutral position. In the past,ttempts at preventing injuries had been conducted pro-pectively within individual teams from various profes-
ional sports. The previous attempts at prevention focused
ore purely on strengthening of certain abdominal mus-les, and may even have led to some injuries. Trials arenderway with McKechnie-type protocols in Majoreague Soccer and several other venues to see whetheruch training can prevent such injuries.57

Interestingly, a similar protocol may have, in one study,decreased the incidence of anterior cruciate knee injuries inwomen college soccer players.57 The latter observation sug-gests the same core training may have applicability for avariety of sports and injuries.

In a recent study of NFL players, it appeared that injuryoccurrence was influenced by specific player positions andthe timing of pre- and off-season workout sessions.g Effortsare underway to optimize in-season and off-season protocolswith respect to prevention of these injuries.

Anatomic PerspectiveThe anatomy pertinent to the understanding of athletic pub-algia syndromes appears in the latest edition of Byrd’s Oper-ative Techniques in Sports Medicine.2 Basically, one thinks ofhe anterior pelvis not only as a large number of complexoints, but also as one joint that we call the “pubic joint.” Lets consider a brief summary of this anatomy.It is probably easiest to consider this joint in 3 ways: (1) by

ts bony anatomy and the forces the joint creates (Fig. 3); (2)y the 3 compartments of muscles or other attachments thatrovide ligamentous type support (Fig. 4); and (3) by the netffect of the forces—a slight anterior tilt (Fig. 5) that helpsefine the normal anatomical position and forms the basis forhe newer preventive protocols.

Bony AnatomyThe bony pelvis has 2 principal functions: to transfer weightand to withstand compression forces resulting from its sup-port of the weight. There are 4 major pelvic bones joinedanteriorly at the pubic symphysis. The 4 pelvic bones are, ofcourse, the two hip bones, the sacrum, and the coccyx.

The ForcesA key part of the anterior pelvic anatomy that forms thefulcrum for many of the forces is the pubic symphysis. Co-ordinated contraction of the muscles that directly attach tothis fulcrum produces a slight anterior tilt consistent with thecombined nature of the anterior tension that results.

The muscles that attach to the fulcrum probably play moreof a role in stability than the fibrocartilaginous disc that con-nects the two sides of the symphysis. Note that the latterstatement represents a difference in the thinking comparedwith older concepts about “osteitis pubis.” Most athletic pa-tients with osteitis pubis actually have some degree of inflam-mation that relates to the disruption and compensation of themuscles that attach to the pubis rather than an intrinsic in-

gMeyers WC: Information presented at the NFL Physicians Meeting in Indi-
anapolis, February 2006.

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flammatory condition that relates to the fibrocartilaginousdisc that connects to two parts of that bone.

Therefore, for most athletes, use of the term osteitis pubisin athletes simply describes an empiric sign or a radiologicfinding rather than an actual diagnosis. Another way to thinkabout this is to use the term primary osteitis pubis to describethe patient with unexplained severe pain and inflammationof the pubic symphysis mostly at rest. One then calls theexertional pain or tenderness in athletes that relates to sec-ondary inflammation of the pubic symphysis–secondary os-teitis pubis.

One can then think in terms of there being 4 sets of forcesand counterforces that point to and from the symphysis ful-crum. For convenience, we think of these forces as residing in3 different compartments. The anterior compartment con-sists mainly of the abdominal muscles plus some complexinterdigitations with fibers from the thighs and medial andposterior pelvis. The posterior compartment then consistsprimarily of the hamstrings, a portion of the adductor mag-nus, and several key nerves, and an artery. The medial com-partment consists of the most important thigh components,which include the gracilis, the 3 adductors, and the obturatorexternus.

The LigamentsThe anterior compartment is particularly important with re-spect to many of the relatively uncommon, but nonethelessextremely important, variants of the athletic pubalgia syn-drome. Together, these variants comprise approximately50% of the patients that we see.

The anterior aspect of the thigh accounts for a number ofthese variants. For these particular variants, we are talkingabout the: sartorius, iliacus, psoas, pectineus, vastus lateralis,vastus medialis, vastus, intermedius, and the rectus femoris

Figure 3 Bony skeleton and forces ofthe pubic joint. Note the pubic sym-physis is at the center of the forcescreated by these muscles. Signs andsymptoms distribute around this axis.For illustrative purposes, we list thelocation of signs in a recent series of100 patients: left rectus abdominis,72; right rectus abdominis, 68; leftadductor longus, 43; right adductorlongus, 37; left pectineus, 28; rightpectineus, 24; pubic symphysis, 23;left adductor brevis, 16; right adduc-tor brevis, 14; left psoas, 11; rightpsoas, 7; either sartorius, 9; either rec-tus femoris, 4; obturator externus, 3;adductor magnus, 1; gracilis, 1.

muscles and tendons. One can think of the attachments as e

providing different types of either central or strap support –depending on their medial or lateral locations, insertions, ororigins. For example, a combination of the rectus femoris andthe obturator externus are particularly important in place-kicking, the adductor longus and magnus are particularlyimportant as push-off muscles in pitching.

We also can think in terms of 4 groups of muscles: adduc-tors, abdominal flexors, thigh flexors, and internal or externalrotators. The adductors that are most important are the ad-ductor longus, brevis, and magnus, the gracilis, and thepectineus. The rectus abdominis and to a much lesser degreethe obliques and transverses comprise the more superiorflexors, and the psoas major and minor combines with theother thigh flexors as the key inferior flexors of the pubicjoint. The rotators consist primarily of the obturator externusand internus and the quadrator femoris.

Other ImportantAnatomic Considerationsthat Relate to the PathophysiologyIt is important to recognize that there used to be 2 ratherdifferent traditional definitions of the pelvis or pelvis floor,and now there are 3. Traditionally, there is the gynecologicdefinition that includes primarily the gynecologic organs thebladder and urethra.58 Second, there is a laparoscopic defini-tion that describes both the anterior and posterior aspects ofthe entire pelvis (or “abdominal floor” as seen through thelaparoscope).59 The second definition describes only the

eep aspects of the pelvis that faces the peritoneal cavity.From that viewpoint of the laparoscopic surgeon, the floor

s made up of several muscles that include the pubococcy-eus, puborectalis, and iliococcygeus muscles that are com-only called the levator ani. The floor also represents the

ntire inferior, saccular muscle-organ complex that holds the


intraabdominal viscera inside the peritoneal cavity. The flooralso includes the organs in the gynecologic definition and therectum.

Now we have a third definition. In the present definition,the “pelvis” or “pelvic floor” portrays just the anterior half ofthe pelvis. This floor includes the rectus abdominis musclesand tendons, the thigh muscles, and the other stabilizers inthe three compartments mentioned above and also the semi-membranosus, the sartorius, and the biceps femoris muscle

Figure 4 (A) Muscles, etc. that comprise the anterior,Anterior view. (C) Lateral view. Note relatively anteritrochanter.

insertions. We think of the latter three muscles as having

various functions including strap, flexion, abduction, andlateral rotation functions.

In athletes, tremendous torque occurs at the level of thepelvis. The anterior compartment often, but not always, takesthe brunt of the forces resulting from this torque. Contractionof many of the aforementioned muscles, especially the rectusabdominis, adductor longus, and psoas major, creates tre-mendous force and counts as a major factor in this torque.The net normal anatomic effect of this torque is a net anterior

or, and medial compartments of the pubic joint. (B)tion of insertion of the psoas tendon onto the lesser

posterior loca

or anteromedial tilt60-63 of the pubic joint (Fig. 5). When one

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muscle weakens, the result is an unequal distribution of pel-vic forces compared with normal. This is basically what hap-pens in the athletic pubalgia syndromes.

Another key consideration here is to consider the hip jointitself. The hip joint sits rather passively within these hugebody forces. Therefore, the hip joint is particularly vulnerableto the large forces that commonly apply themselves here. Thesoftest part of the hip joint may be the anterior labrum. So,that feature is particularly vulnerable to these forces.

In athletes that we treat, we commonly try to separate outthe diagnoses of athletic pubalgia from labral tears or otherintrinsic hip pathology. One needs to recognize clearly thatthese injuries often do occur together. Plus, even when multi-ple injuries are recognized, one or more of the injuries may beasymptomatic. Therefore, the precise diagnosis that relates tothe pain problem may not be immediately apparent. Impor-tant judgments then need to be made with respect to whichinjury to attack first in the treatment of the athlete’s pain. Tocomplicate things further, the afferent sensory nerve distri-bution overlaps greatly among the above anatomic struc-tures.

We should also consider that if one thinks of these attach-ments as ligaments, the injuries then often occur in the mostphysically fit of athletes. The latter observation suggests thatinadequate fitness per se is not a pathophysiologic factor inthe development of most injuries. Like anterior cruciate in-juries, anterior pelvic injuries often occur in the most fit ofathletes. Acute pelvic injuries, like anterior cruciate injuries,probably result from an exertional imbalance and temporaryloss of core body control.

The latter concepts also possibly explain why the pelvic

Figure 5 The anterior tilt: the anteromedial tilt of the “ready” posi-tion of the athlete. Note the importance of the anterior and medialcompartments of the pubic joint.

injuries are more common in males than females1 and why

hen women do get these injuries, they are often slightlyifferent.2 We once attributed the relatively fewer abdominalnd groin injuries in females to less participation in majorports. The latter explanation is obviously not the case today.

The differences are undoubtedly a result of differences inemale versus male anatomy (Fig. 6). These anatomical dif-erences include: (1) a more slender and lighter female pelvisith fewer shifts in forces, (2) a relatively wider subpubic

ngle leading to a different distribution of forces, and (3) aelatively wider, more stable pelvis of the female resulting inransference of dangerous, destabilizing forces to the morearrowly based lower extremities, particularly the knees. The

atter, of course, also probably explains the increased inci-ence of anterior cruciate injuries in females.

Clinical PerspectiveUnderstanding the anatomic principles outlined sketchily inthis article leads to the recognition of a number of differentsyndromes. In the recent chapter in Byrd mentioned previ-ously,2 we described 17 different syndromes or variants ofthe same athletic pubalgia syndrome.

The way to think about each of these syndromes is toidentify which muscles or group of muscles have been weak-ened and which are overcompensating. Like the knee, thebasic injury may be of one particular ligament, but the resul-tant instability causes pain in other locations represented byfailed attempts by attachments to restore stability.

General ConsiderationsAbout the More Common SyndromesThe syndromes include some of the more classic athleticpubalgia abdominal problems with or without adductor oriliopsoas components, as well as a number of relatively un-common syndromes. The most common mechanism of in-jury is a tear or a series of microtears of the rectus abdominismuscle or tendon as it inserts onto the pubis.

The tears are most obvious in its anterior and lateral as-pects but also may be seen posteriorly or intramuscularly.Because the torque that causes most injuries results fromhyperextension of the abdomen and hyperabduction of thethighs, the anterior and lateral pathology are the most impor-tant.

One way to think about the pathology associated with themore common injuries is to imagine pulling on 2 ends of arope. The pathology that becomes most evident immediatelyis the fraying that occurs on the superficial aspects of therope. The sides that get most torn depend on the direction offorces associated with the torque. And although we see thepathology on the outside of the rope (or muscular sheath),this is because this is the only aspect of the rope that we cansee. We must assume that the inside of the rope is also in-jured.

This is precisely what we see in patients. There are multipleareas of fraying on the lateral and anterior aspects of the fasciaof the muscles. Sometimes the tears are deep and sometimes
they are only superficial. It is a mistake to think that what we


are seeing is the only site of injury. These tears occur both inthe abdominal muscles as well as the adductors and otherattachments.

It is also logical to think, based on the directions offorces and torque, that the more anterior and lateral as-pects of the abdominal attachments will be most affected,and this is usually the case. On the other hand, the poste-rior and medial aspects may also be affected, but to a moreminor degree.

There is actually no posterior sheath on the lower third ofthe rectus abdominis muscle so descriptions of tears of theposterior sheath in this region are simply not accurate. In-stead, minor injuries to the posterior muscle fibers are some-times seen, but again these are not, generally, as important asthe anterior and lateral pathology. During the course of thepast 17 years, we have performed multiple laparoscopic ex-aminations of the pelvis in these and other patients. We cannot usually tell a difference in pathology in the male athleteswith groin pain compared with nonathletes undergoing lap-aroscopy for other reasons. However, we do occasionally seesmall tears of the transversalis and internal oblique, consis-tent with observations of others64 and consistent with themulti-focal nature of the injury depicted by the above “rope”analogy.

In the extreme, such as what has been seen often in thebull-riders, partial or complete avulsions from the pubic
symphysis of the rectus abdominis or adductor muscles oc-
cur. In the worst cases, there are multiple avulsions at thesame time.

Therefore, we classify the pathology seen at surgery for thecommon syndromes as: Grade 1, single or multiple smalltears; Grade 2, partial avulsion or avulsions; or Grade 3,complete avulsion or avulsions or a complete avulsion asso-ciated with another partial avulsion.

Another source of pathology that we are appreciating withincreasing frequency in these athletes is labral and/or otherhip pathology. An upcoming publication will illustrate thisoverlap of athletic pubalgia and hip pathology, which wehave seen in as high as 27% of hockey players referred to us.This co-occurrence of pathology probably should not be toosurprising considering the proximity of the hip and pubicjoints as well as the interplay of the musculoskeletal struc-tures that probably serve both joints.60-63

Less-Common VariantsA number of different variants of the aforementioned syn-dromes populate our database. The more common of the“less-common variants” consist of injuries to the same orsimilar attachments. We’ll mention several interesting exam-ples. The principal pathology of soccer players with particu-larly strong kicks from the ground may be in the more supe-rior aspects of the rectus abdominis muscles. The Spigelian areas

Figure 6 Basic differences in male ver-sus the female anatomy that relate tothe pubic joint and injury. Note thedifferences in width between the pel-ves and knees of the 2 genders. Thesedifferences suggest a different distri-bution of forces during extremes ofexertion, for example, more lateralforces emanate from the female pelvisand more acutely angled forces aretransmitted to female knees duringlanding.

seem particularly vulnerable to shearing forces. Women are

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much more likely to have the sartorius variants. Basically, thehinking here is that the sartorius is a strap muscle that re-eives relatively more force. In a relatively wider pelvis, thisould be logical and might explain why women relatively

ommonly have pain in this location when they have athleticubalgia symptoms.Similarly, the gracilis, the pectineus, or the rectus femorisay exhibit similar problems, and we have named the syn-romes according to the musculotendinous insertions thatre most intimately associated with the pains. We have alsoeen prominent pain in more unusual areas such as theuadratus or the iliotibial tract. Pains in these locations haveesolved with surgery aimed at these locations.

Other SyndromesDuring the duration of our experience, we have also had theopportunity to see a large number of other problems forwhich we have identified specific pathology and sometimesdevised ways to treat them effectively, either operatively onnonoperatively. Others have described some of these prob-lems previously.

One of the more common of these syndromes that hasbeen described by many authors is coxa saltans or internalsnapping hip syndrome. This syndrome can occur in con-junction with the athletic pubalgia syndrome or as an isolatedentity and is described as an audible, palpable, or visible snapresulting from the repeated shifting of the iliopsoas tendonlaterally over the head of the femur.65 This syndrome, ofcourse, involves the snapping of the psoas tendon over anumber of possible protruding structures between the hipand the tendon. The possible protrusions include 2 bonyeminences, the hip capsule itself, or granulation tissue thathas accumulated as a result of injury.

Sometimes, but not always, this syndrome is cured or ame-liorated by one or a series of well-placed steroid injections.The snapping hip syndrome that occurs in conjunction withathletic pubalgia responds to a combination of psoas releaseand pelvic floor repair.

Some other interesting problems include the baseballpitcher/hockey goalie syndrome, athlete’s rib syndrome, theround ligament syndrome, and various calcification syn-dromes. The first occurs mostly in players in those positionsand consists of a true muscular hernia through the nearbyepimesia sometimes in conjunction with a partial or avulsionof the adductor longus or magnus. The problem often re-solves on its own but is fixable through a variety of methods.When surgery is necessary it involves rather extensive focalepimesiotomies and a neurolysis.

We have seen the second of these syndromes primarily inrowers and tennis players. Basically, the problem involves asubluxation of the lowermost ribs or costo-chondral carti-lages. Treatment may mean resection of ribs and replacementby mesh to prevent hernias or re-growth of bone. The roundligament syndrome may be a manifestation of endometriosis.The clinical diagnosis involves a trigger point for the painassociated with manipulation of the round ligament. The
pathology consists of considerable acute and chronic inflam- a
mation of the round ligament and occasionally true endo-metriomas.

The calcification syndromes involve pain relating to thecalcifications associated with chronic partial or completeavulsions of key attachments such as the rectus adominismuscle or adductor longus. We have also seen the lattersyndrome following unusual operations for athletic pubalgia.

For example, an unusual operation actually worked for 10years. The patient was a collegiate tight end, and the opera-tion consisted of a pubic periosteal flap lifted onto the rectusmuscle to stabilize it and three months of bed rest. We sawthe patient initially 11 years after his original operation, whenhe developed severe pain resulting from a massive rectuscalcification. Management was surgical and consisted of ex-cision of part of the rectus muscle and mesh replacement.

Additional CommentsLet us summarize briefly what has been stated thus far so thatwe may add a few more comments about how best to manageor possibly prevent these problems and also when to bestreturn the athletes to game activities. It should be clear thatthese injuries are real and that these are not new problemsrelated to recent training activities or new facilities. The con-cept of the pubic joint is key to understanding the variousinjuries. And the diagnosis and management of these injuriescan be tricky considering that most of us were not providedvery sophisticated courses in the anatomy or biomechanics ofthe pelvis.

Consistent with the reality that athletes get a variety ofinjuries to the abdomen and groin, proper clinical care re-quires careful consideration of the specific structures in-volved and the short and long term consequences of theprescribed treatment. Therefore, no one treatment techniquefits most patients. Similarly, proper rehabilitation and timingof return to game activity depends on both the precise diag-nosis and the consequent treatment.

Prevention of such injuries, on the other hand, may indeedinvolve a common protocol. The protocol should be directedat maintaining balance with respect to the pubic joint. Theconcept of “losing core control” involves losing balance inthis joint. Proper use of this joint involves a slightly pronatedposture, as might be suggested by in the basic tenet of thenormal anatomic position.

Therefore, proper balance involves improving strengthand fitness to maintain this slightly anterior bend. Manyevolving protocols are now focusing on these points. Therelatively easy acceptance of some of the protocols by soccercoaches may be a testimony to the aforementioned logic.

It should not be surprising that these new methods oftraining may not only decrease the incidence of pelvic inju-ries but also may also decrease the incidence of other injuries,such as to the back, hip, or knee. The results of this newfitness training may be better training in general for athletes.

To this effect, we quote the statement of Alex McKechnie ata recent soccer conference66: “As trainers and physicians, we
re not, and should not be in the business of training soccer


players. We are and should be in the business of training theplayers to be better athletes.”

Let us say a few more words about identification of theinjuries, timing of treatment, rehabilitation, and return tosport. We and others have published various algorithms andprograms with respect to these important decisions.3,4,67,68 Itis important to understand whether these protocols are de-signed for the in- or off-season. Those algorithms or pro-grams have value in a general sense but not so much valuewith respect to a specific patient.

The aforementioned decision points depend on a variety ofmedical and social/business factors. The medical factors in-clude identification of the specific suspected injury, the de-gree of debility the injury causes, the possible negative con-sequences of playing with the specific type of injury, and thesuccess rates of operative versus nonoperative treatments.The social/business factors include the relative risks of play-ing on the injury, the timing of the injury, that is, whether ornot the injury occurs within or at the end of a season, theimportance of the upcoming games such as playoffs, the in-dividual player’s contract, the team’s interest in the player,and the player’s confidence that his/her performance will notaffect subsequent interest or contracts.

Although most of the injuries to the abdomen or groin maybe treated according to the degree of produced debility, sev-eral injuries can be made worse by continued playing. Cor-rect decisions, therefore, can be complex and require gooddoctor/patient/management relationships.

Certain general considerations seem worth mentioning asguidelines to the aforementioned decision-making. Most, butnot all, operative repairs can get the athletes back to full gameactivity before 6 weeks. It makes sense that if the operationinvolves re-attachment or re-enforcement of a structure, thenone must allow a certain amount of time for scarring to takeover the function of the stabilizing sutures. Whether or notsuch stabilizing scarring takes 1 week or 4 or 5 weeks isarguable. The arguments must involve a discussion of relativerisks of return with respect to disruption, etc. The variousloosening operations,69,70 that is, adductor releases, etc., donot require stabilizing time, and time for return to gameactivity in general may be shorter. However, the surgical painresolution may vary and take at least several weeks.

ConclusionsIn this article, we have tried to provide some perspectives ona large set of real injuries that afflict high performance ath-letes. From a historical basis, the injuries have been aroundfor a long time. Some initial mistakes attributing the cause ofthe injuries to occult hernias led to many unsuccessful oper-ative repairs and a general surgical dogma against surgery foruncertain abdominal or groin pain. Increased understandingof the basic underlying anatomy and pathophysiology has ledto considerable advances in the care of these patients.

The concept of the pubic joint is key to the understandingof the anatomy and pertinent pathophysiology in these pa-tients. These patients develop a large set of injuries. Many of
these injuries can now be treated successfully. Some of the
injuries require surgery and others do not. In most cases,decisions regarding treatment and timing for return to activ-ity require proper identification of the problem and a consid-eration of a wide variety of medical and social/business fac-tors. Fortunately, protocols for prevention of these and otherinjuries look promising. These protocols utilize the conceptof playing under core body control.

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Documents

Understanding “Sports Hernia” athletic pubelgia