Dr. Jeffrey E. Budoff is a board-certified orthopedic surgeon who wades through misleading coach-speak and vague team injury information to offer advice for your fantasy team.
Full disclosure: I won one of my leagues last year after talking to a colleague that flat-out does not like fantasy football. When Adrian Peterson went on the injury report week 11 for a groin injury after having a sports hernia repair earlier that year (February, 2013), I got that queasy feeling in my stomach. After talking to a sports medicine colleague with extensive lower extremity experience, he told me that I was right to be concerned. So when AP ran for only 6.5 points (standard scoring) in week 11, I traded him for Demarco Murray. Obviously, my trade partner thought he’d found a sucker who panicked while rostering one of the greatest running backs of our generation. The rest is history, and I’ll take my titles however I can get them.
Sports Hernias are a clinical diagnosis of exclusion: This means that, although MRIs can be helpful, the diagnosis is often difficult to establish, and made mainly through history, physical examination and ruling out all other diagnoses that could be causing the problem. Unlike ACL tears, there’s no test to definitely confirm the diagnosis. The basic issue is a weakness of the inguinal floor, ie. fascia/supporting tissue where the abdomen meets the groin. Sports hernia surgery reinforces this weakened area.
Peterson was able to play through his sports hernia from weeks 15-18 (wildcard playoff game) of the 2012 season. And he played well. However, after suffering an adductor tendon injury in week 10 of the 2014 season, he didn’t do quite as well. He was relatively ineffective in week 11, played well in weeks 12 and 13, was ineffective again in week 14, missed week 15, was ineffective in week 16, and missed week 17.
The hip adductors bring the leg towards the body. Athletically, once the lead leg is planted, the adductors bring the body to the hip during walking or running. Groin pain can sap an athlete’s speed and explosion. Both sports hernias and groin pain are part of the syndrome known as ‘athletic pubalgia’, which means chronic lower abdominal and groin pain, which is common in elite-level athletes.
Adductor tendinosis, meaning overuse degeneration of the adductor (groin) tendons, occur in roughly 24% of patients with sports hernias. For this reason, surgery for sports hernias and the adductor tendon are often performed at the same time. In this case, they were performed 11 months apart. In January, 2014 Peterson underwent release of the adductor longus tendon (one of the groin muscles) and a compartment release (which decreases pressure in the leg caused by athletics). After releasing the adductor tendon and removing the degenerative tendon tissue, some surgeons then reattach it to the bone. I’m not sure if this was done in Peterson’s case, and it may not matter as far as his future performance is concerned.
The problem is that many times the exact injury is not able to be definitively diagnosed. Both a sports hernia and an adductor tendon problem could be causing Peterson’s problems. But there are also other diagnosis that could be causing his athletic pubalgia, such as hip impingement and other tendon injuries about the lower abdomen and groin. In fact, multiple injuries often co-exist, greatly complicating diagnosis and treatment of the exact pain-generator. Because of this, diagnosing and treating athletic pubalgia can be extremely challenging. It’s often very difficult to determine the exact structure or structures causing the problem, making treatment less predictable.
Peterson’s two surgeries may or may not be related; without his medical records it’s impossible to say for sure. So what does the medical literature say?
The literature reports that the results following sports hernia repair seem to be better than results following adductor tendon release. A study of 71 professional soccer players who underwent sports hernia repair +/- adductor tendon release reported 95% success; the other 5% saw their athletic careers end. A study of 23 NHL players found that 80% returned to play 2 or more full seasons following sports hernia repair. Those that returned to sport often performed similar to their pre-injury level. However, younger players did better than older players, possibly because their injured tendon had accumulated less wear and tear. Players with over 7 full seasons returned, but with a significant decrease in their overall performance level. Less veteran players were able to return to play without a significant decrease in performance. Peterson is currently entering his 8th year in the NFL.
That’s concerning, but not nearly as much as the literature on adductor/groin tendon surgery. A series of adductor tendon releases +/- sports hernia repairs in 155 soccer players showed 80% good results. Of course, the flip-side of this is that there was up to a 20% failure rate. Another study quoted a 69% success rate, with only 84% returning to sport. Another series reported that while 54% of 45 athletes returned to play at their previous level of competition, none (0) of these 45 athletes was able to return to their previous full level of ability.
Sobering. And one of my colleagues who is an acknowledged expert on the hip has informed me that, in reality, the results not as good as reported. He was kind enough to review this article and agrees with everything, except that he thinks I’m under-stating the risk to Peterson going forward. So what do we do with this information?
I have no doubt that, if he remains healthy, the new Norv Turner offense could lead to a career year for Peterson. And I won’t talk you out of selecting him #1 overall if you want to. I’m just here to make sure that you’re not blind-sided by something you could have known about. I want you to have good information from which to make your own informed decisions. However, for my fantasy football teams, there’s too much risk taking Peterson early in the first round (or spending a lot on him in an auction draft) when I can draft another elite running back without such concerns. My own personal risk tolerance in the first half of the first round is low.
But what about the common consensus that Peterson is a machine, and can beat any and all injuries with his super-human healing abilities? I’m sorry, but why do we think that? Because he came back and had a career year following ACL reconstruction? Might as well compare apples to artillery shells.
ACL tears can be definitively diagnosed. ACL reconstruction surgery is well-established, with extremely predictable results. The diagnosis and treatment of athletic pubalgia? Not so much. The medical profession is decades behind in our level of understanding of athletic pubalgia compared to our insight into knee ligament injuries. Consequently, our surgeries for these lower abdominal / groin soft tissue injuries are not nearly as effective or as predictable. Peterson already may have failed his sports hernia surgery. His ability to continue his elite, hall of fame worthy, level of play for a full season following adductor tendon surgery remains to be seen.
It has been said that those who forget history are doomed to repeat it. Remember: even the greatest Greek warrior of his time, Achilles, had a vulnerable lower extremity.