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Content uploaded by Joshua David Harris
Author content
All content in this area was uploaded by Joshua David Harris on Apr 20, 2017
Content may be subject to copyright.
Original Research
Performance and Return to Sport After
Sports Hernia Surgery in NFL Players
Robert A. Jack,* MD, David C. Evans,* BS, Anthony Echo,
†
MD, Patrick C. McCulloch,* MD,
David M. Lintner,* MD, Kevin E. Varner,* MD, and Joshua D. Harris,*
‡
MD
Investigation performed at Houston Methodist Orthopedics and Sports Medicine,
Houston, Texas, USA
Background: Recognition, diagnosis, and treatment of athletic pubalgia (AP), also known as sports hernia, once underrecognized
and undertreated in professional football, are becoming more common. Surgery as the final treatment for sports hernia when
nonsurgical treatment fails remains controversial. Given the money involved and popularity of the National Football League (NFL), it
is important to understand surgical outcomes in this patient population.
Hypothesis: After AP surgery, players would: (1) return to sport (RTS) at a greater than 90% rate, (2) play fewer games for fewer
years than matched controls, (3) have no difference in performance compared with before AP surgery, and (4) have no difference in
performance versus matched controls.
Study Design: Cohort study; Level of evidence, 3.
Methods: Internet-based injury reports identified players who underwent AP surgery from January 1996 to August 2015.
Demographic and performance data were collected for each player. A 1:1 matched control group and an index year analog were
identified. Control and case performance scores were calculated using a standardized scoring system. Groups were compared
using paired Student ttests.
Results: Fifty-six NFL players (57 AP surgeries) were analyzed (mean age, 28.2 ±3.1 years; mean years in NFL at surgery, 5.4 ±3.2).
Fifty-three players were able to RTS. Controls were in the NFL longer (P< .05) than players who underwent AP surgery (3.8 ±2.4 vs
3.2 ±2.1 years). Controls played more games per season (P< .05) than post-AP players (14.0 ±2.3 vs 12.0 ±3.4 games
per season). There was no significant (P> .05) difference in pre- versus post-AP surgery performance scores and no significant
(P> .05) difference in postoperative performance scores versus controls post-index.
Conclusion: There was a high RTS rate after AP surgery without a significant difference in postoperative performance, though
career length and games per season after AP surgery were significantly less than that of matched controls.
Keywords: hip; groin; sports hernia; athletic pubalgia; core muscle injury
Groin injuries in professional football players are a common
source of lost playing time and decreased performance.
39
The differential diagnosis of groin pain may involve osse-
ous, static soft tissue, dynamic soft tissue, or neuromecha-
nical structures.
10
These injuries may include structures in
and around the hip joint, the pelvis, and the lumbosacral
spine and may include one or more pathomorphologies
accounting for the athlete’s symptoms. Athletic pubalgia
(AP) (also known as sports hernia, core muscle injury,
Gilmore groin, or sportsman groin) is a common cause of
groin pain in the National Football League (NFL).
20
The
injury mechanism may involve hyperabduction of the thigh
with associated trunk hyperextension, which produces
shear forces to the pubic symphysis and surrounding
musculature.
13,25
The injury may beacute trauma or chronic
overuse microtrauma.
In 2015, a survey presenting 2 “typical, straightforward”
cases of groin pain was sent to 23 experts for diagnosis,
resulting in 9 different terms used as the likely diagnosis
‡
Address correspondence to Joshua D. Harris, MD, Houston Meth-
odist Orthopedics & Sports Medicine, 6445 Main Street, Outpatient
Center, Suite 2500, Houston, TX 77030, USA (email: joshuaharrismd@
gmail.com).
*Houston Methodist Orthopedics & Sports Medicine, Houston, Texas,
USA.
†
Houston Methodist Plastic & Reconstructive Surgery, Houston,
Texas, USA.
One or more of the authors has declared the following potential con-
flict of interest or source of funding: P.C.M. is a paid presenter for Gen-
zyme and receives research support from DePuy and Arthrex. K.E.V.
receives royalties from Solana, is a paid consultant for Solana, and has
stock/stock options in Wright Medical. J.D.H. receives publishing royalties
from SLACK Inc, receives research support from DePuy Synthes and
Smith & Nephew, and is a paid consultant for NIA Magellan and Smith &
Nephew.
Ethical approval was not sought for the present study.
The Orthopaedic Journal of Sports Medicine, 5(4), 2325967117699590
DOI: 10.1177/2325967117699590
ªThe Author(s) 2017
1
This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (http://creativecommons.org/
licenses/by-nc-nd/3.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are
credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For reprints and permission queries, please visit SAGE’s website at
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for the first case and 11 different terms for the second
case.
39
This high variation in terms prompted the “Doha
agreement meeting on terminology and definitions in groin
pain in athletes” to establish guidelines regarding the diag-
nosis of groin pain in athletes.
37,38
The diagnosis is primar-
ily based on physical examination and leads to 3 categories
of groin pain: (1) adductor-related, iliopsoas-related, and
pubic-related groin pain (or AP); (2) hip-related groin pain;
and (3) other causes of groin pain in athletes (ie, intra-
abdominal, nerve entrapment, genitourinary). The cause
of AP emanates from the anterior and medial hip and abdo-
minopelvic musculotendinous units. These structures are
variable and highly intricate, leading to an often misunder-
stood, underrecognized, and undertreated entity.
21
The
Manchester consensus statement described 5 physical
examination findings, of which 3 must be present for diag-
nosis: (1) pinpoint tenderness over the pubic tubercle at the
point of insertion of the conjoint tendon, (2) palpable ten-
derness over the deep inguinal ring, (3) pain or dilation of
the external ring with no hernia, (4) pain at origin of adduc-
tor longus tendon, and (5) dull, diffuse groin pain.
9,30
Addi-
tionally, others report magnetic resonance imaging as a
useful modality for diagnosis of AP.
17
Treatment of AP begins with a nonoperative approach
(rest, activity modification, anti-inflammatory medication,
heat, ice, deep massage, and an AP physical therapyprogram
with modalities).
25
Failure of nonsurgical treatment may be
an indication for surgery. Electing surgery as the final treat-
ment for sports hernia remains controversial. Primary
repair, as described by Meyers et al,
24
tightens the attach-
ments around the pubis through imbrication in the inferolat-
eral border of the rectus abdominis to the pubis and inguinal
ligament. It has also been described that the adductor com-
partmenthas a relative compartment syndrome at the time of
the procedure due to the weakness of the abdominal muscu-
lature, thus requiring a release of the epimysium and
debridement of fibrosis in the adductor musculature. This
report, in combination with additional studies using an open
or minimal repair technique, has indicated a rate of return to
competitive sports from 80%to 97%.
1,14,19,26,29,31,34,36
Lapa-
roscopic treatment has recently offered less invasive surgery
with rapid return to sport (RTS). Using this technique, RTS
occurred within 4 to 8 weeks in 87%to 97%of surgeries
involving athletes.
3,18,32,35
Radiofrequency denervation of
the inguinal nerve and inguinal ligament as both a primary
treatment and for refractory pain after prior AP surgery has
recently been described in athletes, with encouraging results
up to 6 months postprocedure.
8
With a total revenue expected to surpass 13 billion dol-
lars in 2016, the NFL is recognized as one of the most pop-
ular professional sports leagues in America.
4
The average
NFL player makes 1.9 million dollars annually, as reported
in 2013.
23
Given the amount of money involved and the
popularity of the sport, it is important to understand sur-
gical outcomes in this patient population. The primary pur-
pose of this study was to determine (1) the RTS rate in NFL
players after AP surgery, (2) pre- and postoperative perfor-
mance, (3) postoperative performance compared with
matched controls, and (4) postsurgery career length and
games per season. We hypothesized that NFL players who
underwent AP surgery would (1) RTS at a greater than 90%
rate, (2) have no difference in performance compared with
before AP surgery, (3) have no difference in performance ver-
sus matched controls, and (4) play fewer games for fewer
years than matched controls because of the athlete dealing
with reinjury or chronic injury.
METHODS
A series of Google searches was performed by 2 authors in
August 2016 to identify NFL players who underwent AP
surgery, also known as sports hernia surgery (Figure 1).
The 5 search phrases paired with each NFL team included
the following: “athletic pubalgia,” “osteitis pubis,” “sports
hernia,” “groin injury,” and “core muscle injury.” Internet-
based injury reports, press releases, and player profiles were
used to identify players who underwent surgery. All infor-
mation was publicly available and not extracted from the
NFL Orthopedic Surgery Outcomes Database. Players were
included if they were found to have AP surgery as reported
by at least 2 separate online sources (including but not lim-
ited to profootballreference.com, ESPN.com, prosportstran-
sactions.com, and local news reports). Players were excluded
from the study if they did not play in the NFL for at least
1 full season prior to surgery. Players were also excluded if
they did not have 1 full season of follow-up since the date of
surgery. Surgeries that were isolated central or peripheral
compartment hip procedures, unspecified hernia surgeries,
or abdominal/inguinal hernia surgeries were excluded. In
addition, online reports that were conflicting, incomplete,
or did not have a date of surgery were also excluded from
the study. Players who underwent AP surgery combined
with hip arthroscopy were not excluded.
After application of exclusion criteria, the remaining AP
surgeries included in the study ranged from February 2003
to August 2015. The search intended to determine the loca-
tion of each surgery, but in the majority of reports, informa-
tion on treating surgeon and location was poor. Statistics
were collected from profootballreference.com for each of the
players identified, including position, age, years of experi-
ence, and performance data specific to the player’s position
before and after the surgery (Appendix 1). Statistics were
collected for regular-season NFL games only. Players were
categorized by their positions, including quarterback (QB),
running back(RB), tight end (TE), wide receiver (WR), offen-
sive lineman (OL), defensive lineman (DL), linebacker (LB),
defensive back (DB), kicker (K), or punter (P).
Control Group
A control group was selected to compare data with the
study group. Controls were matched to study cases based
on position, age, years of experience, and performance data
prior to the surgery date. Ages and years of experience for
control players were always within 3 years (most frequently
within 1 year) of the case players. Total career statistics
were used for performance data for each case and control.
Each control was given an index date, which matched the
case player’s surgery date. For example, if a player had AP
2Jack et al The Orthopaedic Journal of Sports Medicine
surgery on August 1, 2008, the control’s index date was
assigned as August 1, 2008. Demographic and performance
data specific to each control’s playing position were col-
lected and categorized as pre- or postindex data.
Player statistics for cases pre- and postsurgery and con-
trols pre- and postindex were collected and aggregated.Each
statistical category was divided by games played to account
for discrepancies in number of games played per season. A
player’s performance score (Appendix 2) was then calculated
by using a previously published and standardized scoring
system based on metrics important to the player’s specific
position.
6,16,22
The scoring system is much like current fan-
tasy football scoring systems. For example, a running back
would receive6 points per touchdown and one-tenth of a point
for each rushing or receiving yard. Statistics per game were
used to calculate each performance score per game, which
was defined as “performance score.” RTS was defined as a
player playing in a regular-season NFL game after surgery.
Statistical Analysis
There were 3 groups excluded from statistical analysis.
First, positions without previously defined performance
scores (punters, kickers, and offensive lineman) were
excluded from statistical analysis (n ¼11). Second, players
who returned to sports but retired without a full year of
statistics were excluded from statistical analysis (n ¼4).
Third and finally, players who did not RTS were excluded
from statistical analysis (n ¼3). The first 2 groups were not
excluded from survivor analysis, games per season, and
career length analysis. Paired 2-tailed Student ttests were
used to compare cases and controls for the remaining players
(n ¼40). Career length was defined by number of seasons
with a recorded game after the injury or index date, regard-
less of whether the player was retired or still active. Com-
parisons were made between performance statistics pre-
and post-AP surgery in cases, pre- and postindex date in
controls, and postsurgery and postindex for cases and con-
trols. Statistical significance was defined as P< .05.
RESULTS
Fifty-six players (57 AP/sports hernia surgeries) were
analyzed (Table 1). One player had 2 sports hernia sur-
geries (of unknown laterality) greater than 2 years
apart. The performance statistics for this player were
included as if each surgery was a separate event. Fifty-
three (94.7%) players (54 AP/sports hernia surgeries)
achieved RTS in the NFL. Four players (4 AP/sports her-
nia surgeries) achieved RTS in the NFL and ended up
playing their last game within 1 year of surgery. The
Screening
Included Eligibility Identiication
Google Search: Each NFL team +
“sports hernia”
“athletic pubalgia”
“osteitis pubis”
“core muscle injury”
“groin injury”
329 Players Identiied
Sports hernia surgery:
Between 9/25/1996-2/1/2016
87 surgeries, 86 players
No surgery
243 players
No NFL experience:
12 surgeries, 12 players
< 1 year follow-up:
11 surgeries, 11 players
<1 year NFL experience:
7 surgeries, 7 players
Sports hernia surgery in NFL:
57 surgeries, 56 players
Return to
sport:
50 surgeries,
49 players
Return to sport,
retired within 1
year:
4 surgeries, 4
players
Did not return
to sport:
3 surgeries, 3
players
Figure 1. Flowchart illustrating application of exclusion criteria.
The Orthopaedic Journal of Sports Medicine Sports Hernia Surgery in NFL Players 3
overall 1-year career survival rate of players undergoing
AP surgery was 87.7%.
There were no significant differences (P> .05) in demo-
graphic, performance, and games per season data between
cases and matched controls presurgery and preindex,
with the exception of games per season for quarterbacks
(Tables 2-4).
Players in the control group (3.8 ±2.4 years) were in
the NFL longer (P< .05) than players who underwent
AP surgery (3.2 ±2.1 years) after index and surgery
date, respectively (Table 5). Players in the control group
(14.0 ±2.3 games per season) played in more games per
season (P< .05) than players who underwent AP surgery
(12.0 ±3.4).
Twenty-two (69%) of the 32 NFL teams had at least 1
player who underwent AP surgery. The team with the
greatest number of players undergoing AP surgery was 8
(14%) players. The most common position to undergo AP
surgery was defensive back, with 11 (19%) players (Table 1).
Time to RTS was difficult to quantify due to a large number
of players (65%) undergoing surgery in the offseason. Compar-
ing case performance scores pre- and postsurgery also yielded
no statistically significant differences (Table 6).
There was a statistically significant (P< .05) decrease in
games per season for tight ends after surgery (Table 7).
Finally, there were no statistically significant differences
in performance scores between the cases postsurgery and
controls postindex (Table 8).
The time to RTS in players who underwent AP surgery
during the season was 119.1 days (range, 26-353 days). For
players who underwent AP surgery during the season and
did not have surgery within the last month of the season,
the time to RTS was 58.3 days (range, 26-286 days). Over-
all, the total number of AP surgeries has increased over the
years (Figure 2).
TABLE 2
Age and Experience for Each Position at Time of Surgery
(for Cases) and Index Time (for Controls)
a
Age, y Experience, y
Position n Cases Controls PCases Controls P
QB 2 28.1 ±1.3 28.6 ±2.3 .592 5.3 ±1.8 5.3 ±3.2 >.999
RB 4 25.9 ±1.9 25.3 ±2.1 .481 3.0 ±2.1 3.0 ±2.1 >.999
TE 7 27.0 ±2.7 27.0 ±2.4 .924 4.3 ±2.5 4.3 ±2.2 .999
WR 8 28.6 ±3.8 28.4 ±3.6 .387 5.7 ±3.5 5.6 ±3.4 .598
DB 10 27.6 ±2.2 27.6 ±2.4 .925 5.0 ±2.3 4.9 ±2.2 .678
LB 6 28.5 ±3.6 28.1 ±3.4 .458 5.4 ±3.5 5.1 ±3.0 .363
DL 7 29.2 ±2.2 29.7 ±2.2 .217 6.8 ±1.9 7.3 ±2.1 .210
OL 7 27.4 ±2.7 27.6 ±2.5 .760 4.5 ±2.7 4.9 ±2.4 .513
K 2 32.2 ±7.1 32.8 ±6.1 .561 9.3 ±7.8 9.3 ±5.0 >.999
P 1 30.1 28.7 3.2 6.2
Overall 54 28.1 ±3.0 28.0 ±2.9 .870 5.2 ±3.0 5.3 ±2.7 .469
a
Values are expressed as mean ±SD. DB, defensive back; DL,
defensive lineman; K, kicker; LB, linebacker; OL, offensive line-
man; P, punter; QB, quarterback; RB, running back; TE, tight end;
WR, wide receiver.
TABLE 3
Preoperative and Preindex Performance Scores for Cases
and Matched Controls
a
Performance Score ±SD
Position n Cases Controls PValue
QB 2 11.1 ±9.7 12.3 ±1.5 .872
RB 4 9.5 ±5.9 9.7 ±2.7 .934
TE 6 4.5 ±1.9 4.3 ±2.2 .735
WR 6 6.0 ±2.8 6.8 ±3.9 .363
DB 10 4.2 ±1.3 3.9 ±1.4 .358
LB 6 3.8 ±2.4 4.2 ±1.4 .391
DL 6 3.8 ±1.5 3.5 ±0.8 .546
a
DB, defensive back; DL, defensive lineman; LB, linebacker; QB,
quarterback; RB, running back; TE, tight end; WR, wide receiver.
TABLE 1
Number of Surgeries With Return to Sport (RTS) Numbers
by Position
a
Position n RTS, n RTS, %
RTS, Retired Within
1 Full Season, n
QB 2 2 100 0
RB 4 4 100 0
TE 7 7 100 1
WR 8 8 100 2
DB 11 10 90.9 0
LB 7 6 85.7 0
DL 7 7 100 1
OL 8 7 87.5 0
K 2 2 100 0
P 1 1 100 0
Total 57 54 94.7 4
a
DB,defensiveback;DL,defensivelineman;K,kicker;LB,
linebacker; OL, offensive lineman; P, punter; QB, quarterback;
RB, running back; TE, tight end; WR, wide receiver.
TABLE 4
Mean Games per Season for Cases and Controls
Presurgery and Preindex
a
Games/Season
Position Case Presurgery Control Preindex PValue
QB 9.1 ±6.1 7.8 ±6.0 .042
b
RB 13.8 ±1.3 13.9 ±1.3 .760
TE 15.0 ±1.7 13.5 ±2.8 .126
WR 13.6 ±2.1 14.0 ±1.2 .605
DB 13.8 ±1.2 13.9 ±1.4 .918
LB 13.2 ±1.7 13.1 ±3.3 .964
DL 13.6 ±2.5 13.6 ±2.3 .996
OL 12.3 ±4.0 13.5 ±2.3 .267
K 15.1 ±0.6 15.7 ±0.5 .090
P 11.0 10.8
a
Values are expressed as mean ±SD. DB, defensive back; DL,
defensive lineman; K, kicker; LB, linebacker; OL, offensive line-
man; P, punter; QB, quarterback; RB, running back; TE, tight end;
WR, wide receiver.
b
Statistically significant (P< .05).
4Jack et al The Orthopaedic Journal of Sports Medicine
TABLE 5
Games per Season and Career Length Postsurgery and Postindex for Cases and Controls
a
Games/Season Career Length, y
Position n Cases Controls PValue Cases Controls PValue
QB 2 8.7 ±4.9 7.7 ±3.5 .500 5.0 ±1.4 7.0 ±4.2 .500
RB 4 10.8 ±0.7 13.2 ±2.0 .157 4.5 ±3.4 4.5 ±3.4 >.999
TE 7 12.7 ±3.2 13.3 ±1.7 .446 3.1 ±1.8 3.7 ±2.7 .387
WR 8 11.6 ±4.0 14.3 ±1.4 .165 2.5 ±1.9 3.4 ±1.5 .056
DB 10 13.6 ±2.2 14.2 ±1.9 .400 3.7 ±2.6 4.3 ±2.9 .329
LB 6 11.5 ±3.9 15.0 ±1.8 .141 2.3 ±0.8 2.5 ±1.0 .611
DL 7 12.0 ±4.7 14.9 ±2.1 .188 2.2 ±1.5 2.7 ±1.2 .218
OL 7 11.8 ±3.7 13.6 ±2.4 .191 3.3 ±2.4 3.7 ±2.4 .200
K 2 12.7 ±4.7 16.0 ±0.0 .500 3.5 ±2.1 6.5 ±3.5 .205
P 1 9.4 16.0 5.0 5.0
Overall 54 12.0 ±3.4 14.0 ±2.3 <.001 3.2 ±2.1 3.8 ±2.4 .001
a
Values are expressed as mean ±SD. DB, defensive back; DL, defensive lineman; K, kicker; LB, linebacker; OL, offensive lineman; P,
punter; QB, quarterback; RB, running back; TE, tight end; WR, wide receiver.
TABLE 6
Pre- and Postsurgery Performance Scores by Position
for Cases
a
Performance Score ±SD
Position Presurgery Postsurgery PValue
QB 11.1 ±9.7 14.5 ±3.9 .566
RB 9.5 ±5.9 8.6 ±4.4 .526
TE 4.5 ±1.9 3.9 ±2.0 .304
WR 6.0 ±2.8 4.9 ±2.1 .434
DB 4.2 ±1.3 5.1 ±0.9 .096
LB 3.8 ±2.4 2.6 ±1.1 .129
DL 3.8 ±1.5 3.1 ±2.0 .343
a
DB, defensive back; DL, defensive lineman; LB, linebacker;
QB,quarterback;RB,runningback;TE,tightend;WR,wide
receiver.
TABLE 7
Mean Games per Season Pre- and Postsurgery for Cases
a
Games/Season
Position Presurgery Postsurgery P
QB 9.1 ±6.1 8.7 ±4.9 .740
RB 13.8 ±1.3 10.8 ±0.7 .068
TE 15.0 ±1.7 12.7 ±3.2 .022
WR 13.6 ±2.1 11.6 ±4.0 .262
DB 13.8 ±1.2 13.6 ±2.2 .690
LB 13.2 ±1.7 11.5 ±3.9 .429
DL 13.6 ±2.5 12.0 ±4.7 .496
OL 12.3 ±4.0 11.8 ±3.7 .785
K 15.1 ±0.6 12.7 ±4.7 .640
P 11.0 9.4
a
Values are expressed as mean ±SD. DB, defensive back; DL,
defensive lineman; K, kicker; LB, linebacker; OL, offensive line-
man; P, punter; QB, quarterback; RB, running back; TE, tight end;
WR, wide receiver.
TABLE 8
Postoperative and Postindex Performance Scores for Cases
and Matched Controls
a
Performance Score ±SD
Position Cases Controls PValue
QB 14.5 ±3.9 12.1 ±1.8 .366
RB 8.6 ±4.4 9.8 ±3.9 .075
TE 3.9 ±2.0 6.1 ±3.7 .052
WR 4.9 ±2.1 6.6 ±4.1 .350
DB 5.1 ±0.9 5.4 ±1.1 .542
LB 2.6 ±1.1 3.8 ±2.3 .090
DL 3.1 ±2.0 3.0 ±1.2 .912
a
DB, defensive back; DL, defensive lineman; LB, linebacker;
QB, quarterback; RB, running back; TE, tight end; WR, wide
receiver.
Figure 2. Number of sports hernia surgeries by year in the
National Football League (NFL). * ¼projected.
The Orthopaedic Journal of Sports Medicine Sports Hernia Surgery in NFL Players 5
DISCUSSION
The purpose of this study was to determine (1) the RTS rate
in NFL players after AP surgery, (2) performance for
players undergoing AP surgery pre- and postsurgery, (3)
performance on RTS between players who underwent AP
surgery and controls, and (4) postsurgery career length and
games per season. The hypotheses were confirmed. There
was a 94.7%RTS rate, no statistically significant differ-
ences between pre- and postsurgery performance scores,
no statistically significant differences between case and
control performance numbers, and shortened career length
and less games per season when compared with controls.
One previous study investigated RTS and performance
for players who underwent AP surgery in the NFL.
22
It
showed an RTS rate of 90.2%(n ¼51) and no statistically
significant differences in performance statistics. It also did
not have a true control group, as players were used as con-
trols for themselves. The current study found a similar RTS
of 94.7%(n ¼57) and no significant differences in perfor-
mance statistics. By using controls that were matched for
age, NFL experience, and performance, the current study
was able to improve performance data comparisons for case
players against controls at thesamejunctureoftheir
career. By simply comparing a player with himself, rapid
improvements (or regressions) in performance that are
prevalent among similar players in the league may other-
wise not be accounted for. Furthermore, there may be the
same pathology present on the contralateral side similar to
that of the surgical side. There may also be a biomechanical
relationship between the hip and groin from underlying
femoroacetabular impingement (FAI). Birmingham et al,
5
in a cadaver model, observed stress transfer in cam FAI
with increasing hip internal rotation imparting increased
rotational motion at the pubic symphysis. There may also
be a biomechanical relationship to the contralateral side
after correction of the ipsilateral pathology.
Prior studies have also failed to comment on specific dif-
ferences between positions that exist. For example, the
defensive back and defensive lineman positions, compared
with their respective controls, tend to improve and regress
statistically at roughly the same rates (Figure 3).
The RTS rate was high (94.7%); however, there were a
large number of players who retired within the next few
seasons after surgery and index year (Figure 4).
By year 3 postsurgery, the percentage of players who
underwent AP surgery and were still playing was 52.6%.
The average career length in the NFL is reported as 6 years
for players making the opening-day roster in their rookie
season and 3.3 years for all NFL players overall.
33
The
average experience for players in this investigation was 5.2
years, already surpassing the overall career length average.
The average career length after AP surgery has previously
been described as 2.5 years.
22
The current investigation
found an average career length of 3.2 years after AP surgery
(Table 5). The increase in career length in this investigation
compared with that previously reported is likely due to more
seasons being included in the current study (an additional 3
NFL seasons). The current investigation found a statistically
significant (P< .05) difference in career length after surgery
and index when comparing cases (3.2 years) with controls
(3.8 years). Additionally, players in the control group (14.0 ±
2.3 games per season) played in more games per season post-
index (P< .05) than players who underwent AP surgery
(12.0 ±3.4 games per season) postsurgery (Table 5).
The majority (65%) of NFL players in this study under-
went AP surgery in the offseason, typically just after the
previousseason.Therefore,theaveragetimetoRTS
could not be calculated as it would have been inaccu-
rately inflated. Every player who returned to play after
surgery in the offseason did so during the first game of
the subsequent season. For players who had surgery dur-
ing the season, the time to RTS was 119 days. For players
who underwent surgery during the season and not in the
finalmonthoftheseason,thetimetoRTSwas58days.
The amount of AP surgeries has increased significantly
over the years (Figure 2). This is possibly due to the increas-
ing awareness of AP in athletes. Because of the nature of
the data collection method in this study, it is possible the
increase in AP surgeries seen is attributable to the
increased availability of injury reports on the Internet.
Limitations and Strengths
Limitations of the study include the use of publicly avail-
able data, which may be subject to observer bias and may
Figure 3. Performance scores by position before and after
surgery compared with controls pre- and postindex. DB,
defensive back; DL, defensive lineman; LB, linebacker;
QB, quarterback; RB, running back; TE, tight end; WR, wide
receiver.
Figure 4. Kaplan-Meier survival analysis for cases and con-
trols. Zero (0) signifies year of surgery for cases and index
year for controls.
6Jack et al The Orthopaedic Journal of Sports Medicine
not completely contain all patients undergoing AP surgery.
As such, we were unable to include player demographics
such as height, weight, and body mass index at time of
surgery. Nonetheless, this method of data acquisition has
been used in multiple previous studies.
2,7,11,12,15,22,27,28
Additional limitations were the absence of patient-reported
outcomes, small number of subjects, single sport, incom-
plete follow-up and career length for players still in the
NFL, and inability to compare offensive lineman or special
teams players with performance scoring. Additionally,
inherent to this type of study, there are multiple unknown
confounding variables, such as: underlying hip pathology
(FAI or labral pathology) that may or may not have been
corrected, unknown presurgical course including
unknown conservative treatments, no direct physical con-
tact to corroborate diagnosis or range of motion, and no
access to operative reports to determine which operative
technique was used. Strengths of this study include its
case-control comparative design as well as the perfor-
mance scoring system, which was used to easily compare
across positions. However, the performance scoring sys-
tem is not a validated outcome measure and is not appli-
cable in all positions.
CONCLUSION
There is a high RTS rate in the NFL after AP/sports hernia
surgery. There were no significant differences in perfor-
mance measures for any position comparing pre– versus
post–AP surgery. There were no significant differences in
performance measures post–AP surgery compared with
controls. Career length and games per season after AP sur-
gery were significantly less than those of matched controls.
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APPENDIX 1
APPENDIX 2
Position Variables Collected
Quarterback Demographic: Age, experience
Presurgery and postsurgery (and index) variables: Number of seasons, games
Total, per game, and per season variables collected pre- and postsurgery (and index): Completions,
attempts, completion percentage, passing yards, passing touchdowns, interceptions, sacks, fumbles,
rushing yards, rushing touchdowns
Running back Demographic: Age, experience
Presurgery and postsurgery (and index) variables: Number of seasons, games
Total, per game, and per season variables collected pre- and postsurgery (and index): Rushing attempts,
rushing yards, rushing yards per attempt, rushing touchdowns, receptions, receiving yards, receiving
touchdowns, fumbles
Tight end/wide receiver Demographic: Age, experience
Presurgery and postsurgery (and index) variables: Number of seasons, games
Total, per game, and per season variables collected pre- and postsurgery (and index): Receptions, receiving
yards, receiving yards per reception, receiving touchdowns, fumbles
Offensive lineman/punter/kicker Demographic: Age, experience
Presurgery and postsurgery (and index) variables: Number of seasons, games
Defensive back/linebacker/
defensive lineman
Demographic: Age, experience
Presurgery and postsurgery (and index) variables: Number of seasons, games
Total, per game, and per season variables collected pre- and postsurgery (and index): Tackles, assisted
tackles, total tackles, sacks, safeties, interceptions, forced fumbles, touchdowns, passes deflected
Position Performance Score Formula
Quarterback (Passing yards O25) þ(Passing touchdowns 4) þ(Rushing yards O10) þ(Rushing touchdowns 6)
Running back/wide receiver/
tight end
(Receiving yards O10) þ(Receiving touchdowns 6) þ(Rushing yards O10) þ(Rushing touchdowns 6)
Defensive players (Tackles) þ(Assists O2) þ(Sacks 4) þ(Passes defended) þ(Interceptions 5) þ(Interceptions/Fumbles
returned for touchdowns 6) þ(Forced fumbles 3) þ(Fumbles recovered 2) þ(Safeties 2)
8Jack et al The Orthopaedic Journal of Sports Medicine
