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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 t tests. 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.
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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
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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 Identiication
Google Search: Each NFL team +
“sports hernia”
“athletic pubalgia”
“osteitis pubis”
“core muscle injury”
“groin injury”
329 Players Identiied
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
... Previous literature has highlighted remarkably successful rates of RTP following AP ranging from 80% to 100% across multiple sports. 6,13,15,16,[25][26][27][28][29][30] From 1996 to 2015, 56 National Football League (NFL) players who underwent AP surgery had a RTP rate of 94.7%. 25 A cohort of predominately amateur and professional soccer players likewise experienced a 94.4% RTP rate after laparoscopic inguinal disruption repair. 27 In the National Hockey League, 80% of hockey players are reported to successfully RTP after AP repair. ...
... 6,13,15,16,[25][26][27][28][29][30] From 1996 to 2015, 56 National Football League (NFL) players who underwent AP surgery had a RTP rate of 94.7%. 25 A cohort of predominately amateur and professional soccer players likewise experienced a 94.4% RTP rate after laparoscopic inguinal disruption repair. 27 In the National Hockey League, 80% of hockey players are reported to successfully RTP after AP repair. ...
... There is conflicting evidence in the literature regarding game use and performance following surgical treatment of AP in professional sports. 15,17,25 Jack et al. 25 compared 56 NFL players who underwent surgical treatment of AP to a control group, finding that those in the surgery group played in significantly fewer seasons (3.8 AE 2.4 vs 3.2 AE 2.1 years) and GPS (14.0 AE 2.3 vs 12.0 AE 3.4) after RTP; however, they found no difference in performance between groups. 25 A retrospective review of NFL combine participants (mean age 22.1 years old) with a history of surgical treatment for AP was conducted by Knapik et al., 17 who found no significant impact on GPS, GS, draft status, roster activity, or number of seasons played. ...
Article
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Purpose To assess the effects of surgical treatment of athletic pubalgia (AP) on game use and performance metrics in National Basketball Association (NBA) players. Methods A retrospective review of all NBA players who underwent surgical management for AP from 1996 to 2018 was performed. A matched control group was created for comparison. The index period was defined as the entire NBA season in which surgery occurred, including the corresponding offseason. Player demographics, use (games played, games started, and minutes per game) and performance (player efficiency rating) metrics were collected for all players. Statistical analysis was performed to compare data before and after return to play. Results Thirty players with a history of surgical management for AP were included in the final analysis. Following surgery for AP, NBA players were found to have a return to play (RTP) rate of 90.91% (30/33). The average RTP following surgery was 4.73 ± 2.62 months. Compared with control athletes, athletes in the AP group played significantly fewer seasons postinjury (4.17 ± 2.70 vs 5.49 ± 3.04 seasons, respectively; P = .02). During the first year following RTP, NBA players experienced significant reductions in game use and performance, both when compared with the year prior and matched control athletes (P < .05). At 3-year follow-up, players continued to demonstrate significant reductions in game use (minutes per game, P < .05) but not performance. Conclusions Following surgical treatment of AP, NBA players demonstrated a high RTP rate, but shortened career. A short-term reduction in game use and performance metrics was found the year of return following surgery. However, 3-year follow-up performance metrics normalized when compared with healthy controls. Study Design Level III; retrospective case-control study.
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Article
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Article
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Article
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Article
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Article
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Background: Distal biceps ruptures are rare injuries that tend to occur younger in high level athletic populations. There is a lack of data analyzing athletes ability to return to play, and performance, after surgery for a distal biceps rupture. Methods: All National Football League players from seasons 2000-2016 that were found to have a surgically treated distal biceps rupture were included. Performance analysis and career length was conducted with a position, age, experience, and performance statistics matched control group. Data for cohort versus control, and pre-injury vs post-injury were analyzed with paired-samples Student t-test with a value of p less than 0.05. Results: Thirty-five NFL players were identified for the study and 33 were able to return to sport (94%) at an average of 351.4 (+/- 123.9) days. Offensive lineman undergoing surgery played less games per season compared to the control group p = 0.04). However, average seasons post surgery and post index was not found to not be significant (p > 0.05). Mean career length, or games per season, did not differ for post-surgical versus control group (p >0.05) for all other positions. Performance scores within skill players did not prove to be significant between postoperative and control groups (p> 0.05). Conclusions: Distal biceps ruptures treated surgically in NFL players allow for return to play at a high rate. Level of performance post-surgery is similar to performance of the player pre-injury. On average NFL career length does not appear to be affected after distal biceps surgery.
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Background Core muscle injury (CMI), often referred to as a sports hernia, is a common cause of groin pain in athletes characterized by concomitant injury to the insertion of the adductor longus and the rectus abdominis muscles. Currently, the literature on CMI is sparse with no standardized physical examination tests used in the diagnosis of this type of injury. Purpose To determine the diagnostic accuracy of various physical examination tests in the diagnosis of CMI. Study Design Cohort study (Diagnosis); Level of evidence, 3. Methods A consecutive series of patients evaluated by the senior author with symptoms consistent with CMI were included. Four physical examination tests were routinely performed in these patients by the senior author and were noted in each patient’s chart as positive or negative: (1) pain with resisted cross-body sit-up in figure-of-4 position, (2) pain with straight-leg sit-up, (3) pain with resisted hip flexion in external rotation (external rotation Stinchfield test), and (4) the presence of an adductor contracture. CMI was independently diagnosed by a reference standard (magnetic resonance imaging [MRI]). All MRI scans were read by a musculoskeletal fellowship-trained radiologist. The sensitivity and specificity of each physical examination test alone and in combination were calculated based on this reference standard. Results A total of 81 patients were included in this study. MRI was positive for a CMI in 39 patients (48%) overall. Both the cross-body sit-up test and the presence of an adductor contracture were found to have a sensitivity of 100% (specificity, 3% for both). The external rotation Stinchfield test was found to have the highest specificity of 60% (sensitivity, 15%). The sensitivity of all 4 physical examination tests in combination was found to be 100% (specificity, 0%). Conclusion Certain physical examination maneuvers can be used to assist in the diagnosis of a CMI. The cross-body sit-up test and the presence of an adductor contracture are highly sensitive but nonspecific tests for CMI and therefore should be used in conjunction with diagnostic imaging before deciding on an appropriate treatment course.
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Groin pain is common in athletes. Yet, there is disagreement on aetiology, pathomechanics and terminology. A plethora of terms have been employed to explain inguinal-related groin pain in athletes. Recently, at the British Hernia Society in Manchester 2012, a consensus was reached to use the term inguinal disruption based on the pathophysiology while lately the Doha agreement in 2014 defined it as inguinal-related groin pain, a clinically based taxonomy. This review article emphasizes the anatomy, pathogenesis, standard clinical assessment and imaging, and highlights the treatment options for inguinal disruption.
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Heterogeneous taxonomy of groin injuries in athletes adds confusion to this complicated area. The 'Doha agreement meeting on terminology and definitions in groin pain in athletes' was convened to attempt to resolve this problem. Our aim was to agree on a standard terminology, along with accompanying definitions. A one-day agreement meeting was held on 4 November 2014. Twenty-four international experts from 14 different countries participated. Systematic reviews were performed to give an up-to-date synthesis of the current evidence on major topics concerning groin pain in athletes. All members participated in a Delphi questionnaire prior to the meeting. Unanimous agreement was reached on the following terminology. The classification system has three major subheadings of groin pain in athletes: 1. Defined clinical entities for groin pain: Adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain. 2. Hip-related groin pain. 3. Other causes of groin pain in athletes. The definitions are included in this paper. The Doha agreement meeting on terminology and definitions in groin pain in athletes reached a consensus on a clinically based taxonomy using three major categories. These definitions and terminology are based on history and physical examination to categorise athletes, making it simple and suitable for both clinical practice and research. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Groin pain in athletes occurs frequently and can be difficult to treat, which may partly be due to the lack of agreement on diagnostic terminology. To perform a short Delphi survey on terminology agreement for groin pain in athletes by a group of experts. A selected number of experts were invited to participate in a Delphi questionnaire. The study coordinator sent a questionnaire, which consisted of demographic questions and two 'real-life' case reports of athletes with groin pain. The experts were asked to complete the questionnaire and to provide the most likely diagnosis for each case. Questionnaire responses were analysed by an independent researcher. The Cohen's κ statistic was used to evaluate the level of agreement between the diagnostic terms provided by the experts. Twenty-three experts participated (96% of those invited). For case 1, experts provided 9 different terms to describe the most likely diagnosis; for case 2, 11 different terms were provided to describe the most likely diagnosis. With respect to the terms provided for the most likely diagnosis, the Cohen's κ was 0.06 and 0.002 for case 1 and 2, respectively. This heterogeneous taxonomy reflects only a slight agreement between the various diagnostic terms provided by the selected experts. This short Delphi survey of two 'typical, straightforward' cases demonstrated major inconsistencies in the diagnostic terminology used by experts for groin pain in athletes. These results underscore the need for consensus on definitions and terminology on groin pain in athletes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Anterior cruciate ligament (ACL) rupture is a significant injury in National Football League (NFL) quarterbacks. The purpose of this study was to determine (1) return-to-sport (RTS) rate in NFL quarterbacks following ACL reconstruction, (2) performance upon RTS, and (3) the difference in RTS and performance between players who underwent ACL reconstruction and controls. Thirteen quarterbacks (14 knees) who met inclusion criteria underwent ACL reconstruction while in the NFL. Matched controls were selected from the NFL during the same time span to compare and analyze age, body mass index (BMI), position, performance, and NFL experience. Student t tests were performed for analysis of within- and between-group variables. Bonferroni correction was used in the setting of multiple comparisons. Twelve quarterbacks (13 knees; 92%) were able to RTS in the NFL. Mean player age was 27.2±2.39 years. Mean career length in the NFL following ACL reconstruction was 4.85±2.7 years. Only 1 player needed revision ACL reconstruction. In both cases and controls, player performance was not significantly different from preinjury performance after ACL reconstruction (or index year in controls). There was also no significant performance difference between case and control quarterbacks following ACL reconstruction (or index year in controls). There is a high rate of RTS in the NFL following ACL reconstruction. In-game performance following ACL reconstruction was not significantly different from preinjury or from controls.
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Anterior cruciate ligament (ACL) rupture is a significant injury in National Basketball Association (NBA) players. NBA players undergoing ACL reconstruction (ACLR) have high rates of return to sport (RTS), with RTS the season following surgery, no difference in performance between pre- and postsurgery, and no difference in RTS rate or performance between cases (ACLR) and controls (no ACL tear). Case-control. NBA players undergoing ACLR were evaluated. Matched controls for age, body mass index (BMI), position, and NBA experience were selected during the same years as those undergoing ACLR. RTS and performance were compared between cases and controls. Paired-sample Student t tests, chi-square, and linear regression analyses were performed for comparison of within- and between-group variables. Fifty-eight NBA players underwent ACLR while in the NBA. Mean player age was 25.7 ± 3.5 years. Forty percent of ACL tears occurred in the fourth quarter. Fifty players (86%) RTS in the NBA, and 7 players (12%) RTS in the International Basketball Federation (FIBA) or D-league. Ninety-eight percent of players RTS in the NBA the season following ACLR (11.6 ± 4.1 months from injury). Two players (3.1%) required revision ACLR. Career length following ACLR was 4.3 ± 3.4 years. Performance upon RTS following surgery declined significantly (P < 0.05) regarding games per season; minutes, points, and rebounds per game; and field goal percentage. However, following the index year, controls' performances declined significantly in games per season; points, rebounds, assists, blocks, and steals per game; and field goal and free throw percentage. Other than games per season, there was no significant difference between cases and controls. There is a high RTS rate in the NBA following ACLR. Nearly all players RTS the season following surgery. Performance significantly declined from preinjury level; however, this was not significantly different from controls. ACL re-tear rate was low. There is a high RTS rate in the NBA after ACLR, with no difference in performance upon RTS compared with controls.
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The aim was to produce a multidisciplinary consensus to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of Sportsman's groin (SG). Experts in the diagnosis and management of SG were invited to participate in a consensus conference held by the British Hernia Society in Manchester, UK on 11-12 October 2012. Experts included a physiotherapist, a musculoskeletal radiologist and surgeons with a proven track record of expertise in this field. Presentations detailing scientific as well as outcome data from their own experiences were given. Records were made of the presentations with specific areas debated openly. The term 'inguinal disruption' (ID) was agreed as the preferred nomenclature with the term 'Sportsman's hernia' or 'groin' rejected, as no true hernia exists. There was an overwhelming agreement of opinion that there was abnormal tension in the groin, particularly around the inguinal ligament attachment. Other common findings included the possibility of external oblique disruption with consequent small tears noted as well as some oedema of the tissues. A multidisciplinary approach with tailored physiotherapy as the initial treatment was recommended with any surgery involving releasing the tension in the inguinal canal by various techniques and reinforcing it with a mesh or suture repair. A national registry should be developed for all athletes undergoing surgery. ID is a common condition where no true hernia exists. It should be managed through a multidisciplinary approach to ensure consistent standards and outcomes are achieved.
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Background: Anterior cruciate ligament (ACL) rupture is a significant injury in male Major League Soccer (MLS) players in the United States. Purpose: To determine (1) return-to-sport (RTS) rate in MLS following ACL reconstruction (ACLR), (2) timing of RTS, (3) performance upon RTS, and (4) the difference in RTS and performance between players who underwent ACL reconstruction (ACLR) and controls. Study Design: Case-control study; Level of evidence, 3. Methods: MLS players undergoing ACLR between 1996 and 2012 were evaluated. Player data were extracted from publically available sources. All demographic data were analyzed. A control group of players matched by age, body mass index (BMI), sex, position, performance, and MLS experience (occurred at 2.6 years into career, designated ‘‘index year’’) was selected from the MLS during the same years as those undergoing ACLR. The RTS and performance in the MLS were analyzed and compared between cases and controls. Student t tests were performed for analysis of within- and between-group variables. Results: A total of 52 players (57 knees) that met inclusion criteria underwent ACLR while in the MLS. Mean player age was 25.6+/- 3.98 years. Forty players were able to resume play (77%). Of the 40 players (45 knees), 38 (43 knees; 95%) resumed play the season following ACLR (mean, 10+/-2.8 months after surgery). Mean career length in the MLS after ACLR was 4.0+/-2.8 years. The revision rate was 10%. There was a significant increase in the incidence of ACL tears in the MLS by year (P < .001), and there was a significantly (P = .002) greater number of ACL tears on the left knee as opposed to the right. Performance in the MLS upon RTS after ACLR was not significantly different versus preinjury. There was no significant difference in survival in the MLS between cases and controls after ACLR or index year. The only significant performance differences between cases and controls were that cases had significantly greater shots taken per season (P = .005) and assists (P = .005) than did controls after the index year. Conclusion: There is a high RTS rate in the MLS following ACLR. Nearly all players resumed play the season after surgery. Performance was not significantly different from preinjury. Only 2 performance measures (shots taken and assists) were significantly different between cases and controls. A significantly greater number of ACL tears occur in the left versus the right knee. Keywords: anterior cruciate ligament; Major League Soccer; return to sport; knee
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Background: A complete rupture of the Achilles tendon is a devastating injury. Variables affecting return to competition and performance changes for National Basketball Association (NBA) players are not readily evident. Hypothesis: Players in the NBA who ruptured their Achilles tendons and who underwent surgical repair would have more experience in the league, and the performance of those who were able to return to competition would be decreased when compared with their performance before injury and with their control-matched peers. Study design: Cohort study; Level of evidence, 3. Methods: Data for 18 basketball players with Achilles tendon repair over a 23-year period (1988-2011) were obtained from injury reports, press releases, and player profiles. Variables included age, body mass index (BMI), player position, and number of years playing in the league. Individual season statistics were obtained, and the NBA player efficiency rating (PER) was calculated for 2 seasons before and after injury. Controls were matched by playing position, number of seasons played, and performance statistics. Univariate and multivariate analyses were performed to assess the effect of each factor. Results: At the time of injury, the average age was 29.7 years, average BMI was 25.6, and average playing experience was 7.6 years. Seven players never returned to play an NBA game, whereas 11 players returned to play 1 season, with 8 of those players returning for ≥2 seasons. Players who returned missed an average of 55.9 games. The PER was reduced by 4.57 (P = .003) in the first season and by 4.38 (P = .010) in the second season. When compared with controls, players demonstrated a significant decline in the PER the first season (P = .038) and second season (P = .081) after their return. Conclusion: The NBA players who returned to play after repair of complete Achilles tendon ruptures showed a significant decrease in playing time and performance. Thirty-nine percent of players never returned to play.
Article
Background: Injuries are inherent to the sport of American football and often require operative management. Outcomes have been reported for certain surgical procedures in professional athletes in the National Football League (NFL), but there is little information comparing the career effect of these procedures. Purpose: To catalog the postoperative outcomes of orthopaedic procedures in NFL athletes and to compare respective prognoses and effects on careers. Study design: Case series; Level of evidence, 4. Methods: Athletes in the NFL undergoing procedures for anterior cruciate ligament (ACL) tears, Achilles tendon tears, patellar tendon tears, cervical disc herniation, lumbar disc herniation, sports hernia, knee articular cartilage repair (microfracture technique), forearm fractures, tibial shaft fractures, and ankle fractures were identified through team injury reports or other public records. Game and performance statistics during the regular season were collected before and after surgery. Statistical analysis was performed with significance accepted as P < .05. Results: A total of 559 NFL athletes were included. Overall, 79.4% of NFL athletes returned to play after an orthopaedic procedure. Forearm open reduction and internal fixation (ORIF), sports hernia repair, and tibia intramedullary nailing (IMN) led to significantly higher return-to-play (RTP) rates (90.2%-96.3%), while patellar tendon repair led to a significantly lower rate (50%) (P < .001). Athletes undergoing ACL reconstruction (ACLR), Achilles tendon repair, patellar tendon repair, and ankle fracture ORIF had significant declines in games played at 1 year and recovered to baseline at 2 to 3 years after surgery. Athletes undergoing ACLR, Achilles tendon repair, patellar tendon repair, and tibia IMN had decreased performance in postoperative season 1. Athletes in the Achilles tendon repair and tibia IMN cohorts recovered to baseline performance, while those in the ACLR and patellar tendon repair cohorts demonstrated sustained decreases in performance. Conclusion: ACLR, Achilles tendon repair, and patellar tendon repair have the greatest effect on NFL careers, with patellar tendon repair faring worst with respect to the RTP rate, career length after surgery, games played, and performance at 1 year and 2 to 3 years after surgery.
Article
Background Chronic groin pain in athletes forms a major diagnostic and therapeutic challenge. Hypothesis Evaluate and treat undiagnosed groin pain in the athlete by endoscopy. Study Design Prospective cohort study. Methods Athletes who were referred to the Ikazia Hospital with undiagnosed chronic groin pain between January 1998 and August 2001 were included. Radiography, bone scintigraphy, and ultrasonography were performed. In 14 athletes, groin pain remained undiagnosed. Ten patients complained of unilateral, 4 of bilateral groin pain. Patients underwent a transabdominal or extraperitoneal diagnostic endoscopy. Results All patients were operated ambulatory without significant difficulties. Pathology found by endoscopy was hernia inguinalis (n = 9), hernia femoralis (n = 4), preperitoneal lipoma (n = 3), and hernia obturatoria (n = 1). Only once was there no pathology. In 17 groins, a Prolene mesh was placed preperitoneally. Thirteen patients (93%) returned to full activity within 3 months of surgery. One year after surgery, one patient had minor symptoms and one patient had persistent symptoms. All other patients had no complaints. Conclusions An occult hernia should be high on the list of differential diagnoses in undiagnosed chronic groin pain in athletes. Operative treatment can return the patient to his sport within 3 months.