Surgical and Radiologic Anatomy (2021) 43:595–605

https://doi.org/10.1007/s00276-020-02622-4

ANATOMIC VARIATIONS

Anatomical variations of the pyramidalis muscle: a systematic review

and meta‑analysis
Roberto Cirocchi1 · Isaac Cheruiyot2,3   · Brandon Michael Henry2,4 · Marco Artico5 · Sara Gioia1 ·
Piergaspare Palumbo6 · Vincent Kipkorir2 · Vito D’Andrea6 · Justus Randolph7

Received: 26 September 2020 / Accepted: 10 November 2020 / Published online: 24 November 2020
© Springer-Verlag France SAS, part of Springer Nature 2020

Abstract
Purpose  To provide a comprehensive evidence-based assessment of the anatomical characteristics of the pyramidalis muscle
(PM).
Materials and methods  A thorough systematic search of the literature through August 31st 2020 was conducted on major
electronic databases PubMed, Scopus and Web of Science (WOS) to identify studies eligible for inclusion. Data were
extracted and pooled into a meta-analysis using MetaFor package in R and MetaXL. A random-effects model was applied.
The primary outcome of interest was the prevalence of PM. The secondary outcomes were the dimensions (length and
width) of the PM.
Results  A total of 11 studies (n = 787 patients; 1548 sides) were included in the meta-analysis. The multinomial pooled
prevalence estimate (PPE) for a bilateral absence of the PM was 11.3% (95% CI [7.2%, 16.2%], 82.3% (95% CI [76.2%,
87.6%]) for a bilateral presence, and 6.3% (95% CI [3.3%, 10.2%]) for a unilateral presence. Of four studies (n = 37 patients)
that reported the side of a unilateral presence, the PPE of a unilateral right-side presence was 42.2% (95% CI [23.0%, 62.3%])
compared to 57.8% for a unilateral left-side presence (95% CI [37.7%, 77.0%]). The mean length of the PM displayed high
levels of heterogeneity, ranging from 3.12 to 12.50 cm.
Conclusion  The pyramidalis muscle is a rather constant anatomical structure being present in approximately 90% of
individuals.

Keywords  Pyramidalis muscle · Anatomical variations · Morphometry

Introduction

* Isaac Cheruiyot The pyramidalis muscle (PM) is a small triangular muscle

isaacbmn@outlook.com located in the lower part of the anterior abdominal wall,
between the anterior surface of the rectus abdominis muscle
1
Department of Surgical Science, University of Perugia, (RAM) and the posterior surface of the anterior layer of the
Piazza dell’Universitá, 1, 06123 Perugia, PG, Italy
rectus sheath (RS) [16, 18, 33]. It is attached by tendinous
2
Department of Human Anatomy, University of Nairobi, fibers to the front of the pubis and to the ligamentous fibers
P.O. Box 30197, 00100 Nairobi, Kenya
in front of the symphysis. The muscle diminishes in size as
3
International Evidence-Based Anatomy Working Group, 12 it runs upwards, and ends in a pointed apex that is attached
Kopernika St., 31‑034 Krakow, Poland
medially to the linea alba, midway between the umbilicus
4
Cincinnati Children’s Hospital Medical Center, 3333 Burnet and pubis [18, 46]. The PM derives its vascular supply from
Ave, Cincinnati, OH 45229, USA
the inferior epigastric artery (IEA), and motor innervation
5
Department of Human Anatomy, Sapienza University from the terminal branches of the subcoastal nerve (the ven-
of Rome, Piazzale Aldo Moro, 5, 00185 Rome, RM, Italy
tral ramus of T12), although it may often be innervated by
6
Department of General Surgery, Sapienza University L1 fibers traveling in the ilioinguinal nerve. The pyramidalis
of Rome, Piazzale Aldo Moro, 5, 00185 Rome, RM, Italy
is considered a tensor of the linea alba, but its physiological
7
Georgia Baptist College of Nursing, Mercer University, 3001 significance is still unclear [18].
Mercer University Drive, Atlanta, GA 30341, USA

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596
The prevalence and morphometric features of the PM are
rather poorly studied and documented in literature, mostly
due to its small size, inconstancy and uncertainty of its
physiological role. The reported prevalence of the PM in
literature varies widely from 30 to 100%. It is often associ-
ated with anatomical variants, such as bilateral or unilateral
absence, which are rarely described. There has, however,
been a renewed interest in the anatomy of the PM due to
its potential clinical applications. The PM can be absent in
some individuals [18], with no known functional deficits,
and can be harvested through a relatively inconspicuous
lower abdominal incision with minimal donor site morbid-
ity, making it an ideal candidate for use in reconstructive
procedures [46].
The PM flap can be utilized in the treatment of small
intractable wounds such as chemical burns and chronic
osteomyelitis in the foot and ankle region [46]. The PM mus-
cle can also be fashioned as a myofascial sling around the
bladder neck in a century-old operation (Goebell–Frangen-
heim–Stoeckel procedure) used in the treatment of refractory
urinary incontinence in children with neurogenic sphincteric
incompetence [28]. It can also be harvested and used to per-
form cultures of muscle stem cells used in the treatment of
post-prostatectomy stress urinary incontinence (SUI) [41].
The PM also serves as a useful surgical landmark to identify
the midline (linea alba) in the Pfannenstiel and median inci-
sions of the lower abdominal wall [34]. There has also been
a renewed interest in the anatomy of the PM and its potential
role in the pathogenesis and management of the athlete’s
groin pain. In fact, Schilders et al. [36] have recently intro-
duced a new anatomical concept: the pyramidalis–anterior
pubic ligament–adductor longus complex (PLAC). The
authors demonstrated that there was a close link between the
pyramidalis muscle and the adductor longus tendon through
the anterior pubic ligament [36].
The current study aimed to perform a comprehensive
meta-analysis summarizing the prevalence, and morpho-
metric characteristics of the PM, and its probable side and
differences among the populations in various geographical
regions.
Methods
Study protocol and registration
This systematic review and meta-analysis was conducted in
strict conformity with the Preferred Reporting Items for Sys-
tematic Reviews and Meta-Analyses (PRISMA) guidelines
[29]. The protocol for this study was registered on PROS-
PERO, an international prospective database for reviews
under the registration number CRD42019122975.
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Surgical and Radiologic Anatomy (2021) 43:595–605
Table 1  Search strategy for PubMed database
1 Muscle pyramidalis: “abdominal muscles”
[MeSH Terms] OR (“abdominal” [All Fields]
AND “muscles” [All Fields]) OR “abdomi-
nal muscles” [All Fields] OR (“muscle” [All
Fields] AND “pyramidalis” [All Fields]) OR
“muscle, pyramidalis” [All Fields]
2 Origin: “origin” [All Fields] OR “originate”
[All Fields] OR “originated” [All Fields] OR
“originates” [All Fields] OR “originating”
[All Fields] OR “origination” [All Fields] OR
“originations” [All Fields] OR “origins” [All
Fields]
3 1 AND 2
Search strategy
A systematic search of literature was conducted on the
electronic databases PubMed, Scopus and Web of Science
(WOS) from inception to August 31st 2020 to identify
studies eligible for inclusion. The search strategy is pro-
vided in Table 1. No date limit or language restriction was
set. Manual search using references from included articles
was also performed to identify additional eligible studies.
Studies with similar titles, authors and overlapping year of
publication were evaluated. In such cases, only the latter
report was included to avoid duplications.
Selection criteria
All studies were assessed for eligibility by two independ-
ent reviewers (ML and LC). Studies were deemed eligible
for inclusion if they had reported clearly extractable data
regarding the presence and morphology of pyramidalis
muscle. Conference abstracts, letters to editor, reviews and
studies with incomplete or irrelevant data were excluded.
Any disagreements between reviewers arising during the
eligibility assessment were settled through a consensus.
To facilitate literature retrieval, a PICOS framework was
used, and the steps taken in the course of analysis are sum-
marized in Table 2.
Data extraction
Data were independently extracted from the included stud-
ies by two independent reviewers (PP and SG). A third
author (RC) verified the extraction process and any con-
troversies. The data extracted included: author, year of
publication, country, study type (cadaveric, surgical or
radiological), number of patients (sample size), sex of
Surgical and Radiologic Anatomy (2021) 43:595–605 597
Table 2  PICOS criteria for Participants
selection of articles included in
the meta-analysis Intervention
Comparators
Outcomes
Studies
included patients, number of pyramidalis muscles identi-
fied (unilaterally and bilaterally), as well as the dimensions
(length and width of the pyramidalis muscle).
Outcomes
The primary outcome of interest was the prevalence of
pyramidalis muscle. The secondary outcome was the mor-
phometry of the pyramidalis muscle: length (mean ± stand-
ard deviation) and width (mean ± standard deviation).
Meta‑analytical synthesis methods
Binomial pooled prevalence estimates (PPEs) and estimates
of moderator effects were created with the MetaFor pack-
age in R. Binomial PPEs were calculated using a DerSi-
monian and Laird (DL) random-effects model. Multinomial
PPEs, which constrain multiple-category proportions to sum
to 100%, were calculated with MetaXL, also using a DL
random-effects model. A leave-one-out sensitivity analysis
of multinomial PPEs. For both types of PPEs, the data were
transformed using a double arc sine transformation prior to
analysis and backtransformed prior to reporting. In R, the
harmonic mean was used in back transformations of PPEs.
The slight differences in binomial and multinomial PPE
estimates are due to variations in the prevalence normaliza-
tion and backtransformation algorithms between software
programs.
To examine heterogeneity, we followed the procedures
specified in the Cochrane Handbook of Systematic Reviews
[19]. The I2 statistic and Cochrane’s Q were reported as
statistical measures of heterogeneity. Because of the small
number of studies and the high degree of heterogeneity
between studies, funnel plots and other statistical measures
of publication bias are not reported here [26, 43]. Moderator
analyses were conducted for five geographical regions (i.e.,
Asia, Africa, Europe, North America, and South America)
and for two evaluation types (i.e., evaluation of fresh-frozen
cadavers or Formalin-preserved cadavers).
Fresh-frozen or formalin-fixed cadavers of either sex
1. Midline abdominal incision with careful dissection of the fat and subcu-
taneous tissue to expose the rectus sheath
2. Paramedian incision in the anterior layer of the rectus sheath on each
side to reveal the rectus abdominis and pyramidalis muscles
3. Determination of presence and dimensions (length and width) of the
muscle
None
1. The prevalence of the pyramidalis muscle (unilateral, bilateral and total)
2. Morphometric features of the pyramidalis muscle (length and width)
Original cadaveric studies reporting the above outcomes. Letters to the edi-
tor, case reports, conference abstracts were excluded
Results
Study identification
The literature search yielded 790 articles. Following the
removal of duplicates and primary screening, 20 articles
were assessed by full text for eligibility in the meta-analysis.
Of these, 11 were deemed eligible for inclusion (Fig. 1).
Characteristics of the included studies
The characteristics of the included studies are as summa-
rized in Tables 3, 4 and 5. A total of 11 studies (n = 787
patients; 1548 sides) were included in the meta-analysis [6,
8, 10, 20–22, 24, 33, 35, 36, 39]. The years of publication
of the studies ranged from 1985 to 2020. All the included
studies were performed on cadavers. In all the studies, the
prevalence of the pyramidalis muscle was reported. The
studies of the major included patients were performed in
Asia (5 studies: 268 patients, 34.05%) and South America
(3 studies: 392 patients, 49.81%); the rest were from North
America (1 study: 7 patients, 0.89%), Europe (1 study: 96
patients, 12.2%) and Africa (1 study: 24 patients, 3.05%).
Quality assessment of the included studies
The AQUA tool probes for potential risk of bias in five study
domains (objective and subject characteristics, study design,
methodology characterization, descriptive anatomy and
reporting of results). The risk of bias within each domain
is normally categorized as “Low”, “High”, or “Unclear”.
Majority of the studies included in this systematic review
and meta-analysis revealed domain three (methodology
characterization) and domain four (descriptive anatomy) to
be at high risk of bias. Similarly, most studies revealed an
“Unclear” risk of bias in domain 1 (objectives and study
characteristics) and domain 5 (reporting of results). Almost
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598 Surgical and Radiologic Anatomy (2021) 43:595–605

Fig. 1  PRISMA flow chart of

study identification and inclu-

Identification
Records identified through database searching
sion into the meta-analysis
(n = 790)

Records after duplicates removed

(n = 554)

Screening
Records screened Records excluded
(n = 554) (n = 534)

Full-text articles assessed for Full-text articles excluded

eligibility (the primary or secondary
Eligibility

(n = 20) outcome of the study did not

match that of this review
(n = 9)

Studies included qualitative

synthesis
(n = 11)
Included

Studies included in quantitative

synthesis
(n = 11)

Table 3  Characteristics of the Author Country Type of evaluation No. of par- Male Female No. of side
included studies ticipants evaluated

Kogima [24] Brasil Cadavers 21 7 14 42

Schilders [36] USA Fresh-frozen cadavers 7 7 0 14
Das [8] India Formalin-fixed cadavers 25 17 8 50
Costa [6] Brasil Fresh-frozen cadavers 341 293 48 682
Natsis [32] Greek Fresh-frozen cadavers 96 50 46 166
Kaur [22] India Formalin-fixed cadavers 15 13 2 30
Rajawasam [34] Sri Lanka Fresh-frozen cadavers 42 NR NR 84
Didia [10] Nigeria Formalin-fixed cadavers 24 NR NR 48
Jit [21] India Fresh-frozen cadavers 155 117 38 310
Sinha [38] India Cadavers 31 NR NR 62
Hojaij [20] Brasil Fresh-frozen cadavers 30 11 19 60

all studies revealed the remaining domain 2 (study design) to be at low risk of bias. The summary chart of the quality
and risk of bias assessment as evaluated by the AQUA tool
is displayed below (Fig. 2).

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Surgical and Radiologic Anatomy (2021) 43:595–605 599

Table 4  Bilateral and unilateral Author Bilateral absence (no. of Bilateral presence (no. of Unilateral presence
presence of pyramidalis muscle cadavers; %) cadavers; %) (no. of cadavers; %)

Kogima [24] 3 (14.3%) 16 (76.2%) 2 (9.5%)

Schilders [36] 0 7 (100%) 0
Das [8] 2 (8%) 18 (72%) 5 (20%)
Costa [6] 74 (21.4%) 250 (73.3%) 17 (5.3%)
Natsis [33] 6 (6.2%) 76 (79.2%) 14 (14.6%)
Kaur [22] 0 14 (93.3%) 1 (6.7%)
Rajawasam [35] 6 (14.3%) 36 (85.7%) 0
Didia [10] 2 (8.3%) 22 (91.7%) 0
Jit [21] 19 (12.3%) 126 (81.3%) 10 (6.4%)
Sinha [39] 2 (5.9%) 28 (91.3%) 1 (2.9%)
Hojaij [20] 4 (13.3%) 25 (83.3%) 1 (3.4%)

Table 5  Side evaluation of the prevalence of pyramidalis muscle Multinomial pooled prevalence estimates
Author PM presence PM presence PM pres-
(right side) ence (left The multinomial pooled prevalence estimates (PPE) were
side) calculated across the 11 studies evaluating 787 cadavers.
The multinomial PPE was 11.3% (95% CI [7.2%, 16.2%]
Kogima [24] 34 (81%) NR NR
for a bilateral absence, 82.3% [(95% CI [76.2%, 87.6%])
Schilders [36] 14 (100%) 7 7
for a bilateral presence, and 6.3% [95% CI 3.3%, 10.2%]
Das [8] 41 (82%) 21 20
for a unilateral presence (Figs. 3, 4, 5). The heterogeneity
Costa [6] 517 (76%) 257 260
between multinomial PPEs was high, I2 = 63.6, Q(9) = 27.48,
Natsis [33] 166 (94%) 81 85
p = 0.002. The Costa [6] study appeared to be an outlier with
Kaur [22] 29 (96.7%) 15 14
a PPE of 21.7% for a bilateral absence; however, the leave-
Rajawasam [35] 72 (85.7%) NR NR
one-out sensitivity analysis showed that no single study
Didia [10] 44 (91.7%) NR NR
influenced a multinomial PPE by more than 3.0%.
Jit [21] 272 (87%) NR NR
Sinha [39] 57 (93.4%) NR NR
Hojaij [20] 51 (85%) NR NR

Fig. 2  Summary for AQUA

assessment of the included
studies

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Fig. 3  Forest plot for multino-

mial PPE of bilateral absence

Fig. 4  Forest plot for multino-

mial PPE of bilateral presence

Fig. 5  Forest plot for multino-

mial PPE of unilateral presence

Binomial pooled prevalence rates between studies, I2 = 63.5%, Q(10) = 27.48, p = 0.002.

i. Bilateral absence
  The binomial PPE for a bilateral absence of the
pyramidalis muscle across the 11 included stud-
ies (N = 787 cadavers) was 10.0% (95% CI [5.2%,
15.0%]). There was a high degree of heterogeneity
1
  QM refers to a statistic measuring the omnibus statistical signifi-
cance of the moderators.
The type of cadaveric preservation technique (forma-
lin-fixed vs fresh-frozen cadavers) was not a statisti-
cally significant moderator of this outcome, omnibus
QM1(1) = 1.39, p = 0.239. The three South American
studies had an average PPE of 20.04%, while the one
North American study had a PPE of 0.00%, indicating
that geographical origin of the studies could be sig-
nificant moderator of the absence of the pyramidalis
muscle, QM(4) = 21.89, p < 0.000 (Table 6).
ii. Bilateral and unilateral presence

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Surgical and Radiologic Anatomy (2021) 43:595–605 601

Table 6  Pooled prevalence Subgroup Studies N PPE PPE 95% PPE 95% I2 Q

estimate of bilateral absence of upper CI lower CI
the pyramidalis
All studies 11 787 9.99 5.78 15.01 63.62 27.48**
Evaluation QM(1) = 1.39, p = 0.239
 Fresh 6 671 11.9 6.25 18.82 74.24 19.41**
 Formalin 3 64 5.28 0.53 13 0 1.72
Region: QM(4) = 21.89, p ≤ 0.0002
 Asia 5 268 9.73 6.02 14.1 4.8 4.2
 Africa 1 24 8.33 0.16 23.5 0 0
 Europe 1 96 6.25 2.13 12.12 0 0
 North America 1 7 0 0 23.19 0 0
 South America 3 392 20.04 16.07 24.3 0 1.4

Two studies did not report the evaluation type

PPE pooled prevalence estimate (PPEs are expressed as percentages), Q Cochrane’s Q statistic (statistically
significant values indicate heterogeneity), QM Q for moderators (statistically significant values indicates
omnibus differences in PPEs between subgroups)
*p < 0.05, **p < 0.01, ***p < 0.001

Table 7  The pooled prevalence Subgroup Studies N PPE PPE 95% PPE 95% I2 Q
estimates of bilateral presence upper CI lower CI
of the pyramidalis
All studies 11 787 82.3 77.48 86.7 44.52 18.02
Evaluation: QM(1) = 0.51, p = 0.476
 Fresh 6 671 80.61 75.14 85.59 47.86 9.59
 Formalin 3 64 86.02 71.1 96.57 49.38 3.95
Region: QM(4) = 12.32, p = 0.015
 Asia 5 268 83.76 78.38 88.56 8.22 4.36
 Africa 1 24 91.67 76.5 99.84 0 0
 Europe 1 96 79.17 70.41 86.76 0 0
 North America 1 7 100 76.81 100 0 0
 South America 3 392 74.75 70.19 79.07 0 1.35

Two studies did not report the evaluation type

PPE pooled prevalence estimate (PPEs are expressed as percentages), Q Cochrane’s Q statistic (statistically
significant values indicate heterogeneity), QM Q for moderators (statistically significant values indicates
omnibus differences in PPEs between subgroups)
*p < 0.05, **p < 0.01, ***p < 0.001

  The PPE for the bilateral presence of the PM was

82.3% (95% CI [77.5%, 86.7%]) and was 4.9% (95%
CI [2.1%, 8.54%]) for a unilateral presence. There was Morphometry of the pyramidalis muscle
low study heterogeneity for both bilateral presence
(I2 = 63.5%, Q(10) = 27.48, p = 0.002) and unilateral The mean length of pyramidalis muscle was reported in seven
presence, (I2 = 63.5%, Q(10) = 27.48, p = 0.002). As studies and displayed high levels of heterogeneity: between
Tables 7 and 8 show, neither region nor evaluation 3.12 [20] and 10.67 cm [20] (Table 9). The mean width of
type was statistically significant moderators for either the pyramidalis muscle was reported in five studies and was
of these outcomes. similarly heterogeneous: between 1.2 [22] and 1.99 ± 0.23 [39]
iii. Right vs left unilateral presence (Table 10).
  Of four studies (n = 37 patients) that reported the
side of a unilateral presence, the PPE of a unilat-
eral right-side presence was 42.2% (95% CI [23.0%,
62.3%]) compared to 57.8% for a unilateral left-side
presence (95% CI [37.7%, 77.0%]).

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Table 8  The pooled prevalence Subgroup Studies N PPE PPE 95% PPE 95% I2 Q
estimates of unilateral presence upper CI lower CI
of the pyramidalis
All studies 11 787 4.91 2.1 8.54 56.41 22.94
Evaluation: QM(1) = 0.33, p = 0.568
 Fresh 6 671 4.42 1.33 8.73 65.42 14.46
 Formalin 3 64 6.57 0 24.05 71.86 7.11
Region: QM(4) = 4.08, p = 0.396
 Asia 5 268 5.06 0.7 11.99 63.11 10.84
 Africa 1 24 0 0 7.04 0 0
 Europe 1 96 14.58 8.15 22.42 0 0
 North America 1 7 0 0 23.19 0 0
 South America 3 392 4.2 2.19 6.68 0 1.08

Two studies did not report the evaluation type

PPE pooled prevalence estimate (PPEs are expressed as percentages), Q Cochrane’s Q statistic (statistically
significant values indicate heterogeneity), QM Q for moderators (statistically significant values indicates
omnibus differences in PPEs between subgroups)
*p < 0.05, **p < 0.01, ***p < 0.001

Table 9  Measurement of length of pyramidalis muscle [mean ± standard deviation (cm)]

Author Overall Male Female
Right Left Right Left Right Left

Kogima [24] NR NR NR NR NR NR
Schilders [36] NR NR NR NR NR NR
Costa [6] NR NR NR NR NR NR
Das [8] NR NR 5.22 ± 1.43 5.39 ± 1.51 5.01 ± 1.36 5.12 ± 1.37
Natsis [33] 7.0 (2.0–14.0) 8.37 ± 2.80 7.50 ± 2.66 6.18 ± 1.64 6.56 ± 1.68
Kaur [22] NR 4.97 (2.53–7.25)^ 4.87 (4.78–4.96)^
Rajawasam [34] 6.24 ± 0.12 7.09 ± 0.20 NR NR NR NR
Didia [10] 8.09 ± 0.7 7.94 ± 1.71 NR NR NR NR
Sinha [39] 6.11 6.26 NR NR NR NR
Hojaij [20] 6.80 ± 2.14 6.64 ± 2.04 7.06 ± 2.38 6.80 ± 2.16 6.40 ± 1.81 6.42 ± 1.78

^Mean (min–max)

Table 10  Measurement of width of pyramidalis muscle [mean ± standard deviation (cm)]

Author Overall Male Female
Right Left Right Left Right Left

Schilders [36] NR NR NR NR NR NR
Costa [6] NR NR NR NR NR NR
Das [8] NR NR 1.83 1.7 1.78 1.62
Natsis [33] 1.50 (0.5–2.6)* 1.61 ± 0.55 1.56 ± 0.53 1.50 ± 0.44 1.55 ± 0.38
Kaur [22] NR 1.7 (1.03–2.16)^ 1.72 (1.15–2.18)^ 1.2 (0.9–1.45)^ 1.45°
Rajawasam [35] 1.32 ± 0.14 1.52 ± 0.18 NR NR NR NR
Didia [10] 1.55 ± 0.28 1.6 ± 0.30 NR NR NR NR
Sinha [39] 1.5 (1–1.5)* 1.75 (1–2.5)* NR NR NR NR
Hojaij [20] 0.91–2.93 0.91–2.93 1.10–2.64 0.91–2.93 1.41–2.50 1.47–2.48

*Median (min–max)
^Mean (min–max)
°Single value

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Surgical and Radiologic Anatomy (2021) 43:595–605 603
Discussion
The current knowledge of the morphology of the pyrami-
dalis muscle is based on various anatomical studies car-
ried out on cadaveric dissections published before 1940
[1, 2, 5, 7, 11, 23, 25, 31, 37, 44]. This systematic review
of the literature and meta-analysis is the most recent and
comprehensive account of the anatomy of the pyramidalis
muscle (PM).
The prevalence of the pyramidalis muscle reported
in literature is highly variable, ranging from 30% [9] to
100% [36]. The current study reports a 11.3% pooled
prevalence estimate (PPE) for a bilateral absence of the
PM. Some studies reported similar PPE [20, 22], while
others reported PPE ranging from 0.0% [8, 15] to 21.7%
[6]. Moderator analysis was performed to identify the
source of heterogeneity. Cadaveric preservation technique
(formalin-fixed vs fresh-frozen cadavers) was not a sta-
tistically significant moderator of this outcome, but the
geographical origin of the studies could be a statistically
significant moderator. The three South American studies
[6, 20, 24] had an average PPE of 20.04%, while the one
North American study [8] had a PPE of 0.00%. The study
by Costa et al., [6] was an outlier with a PPE of 21.7%.
This suggests that the PM could be relatively inconstant
anatomical structure among the South Americans, and
is available for harvesting in approximately 80% of that
population. More studies are, however, needed to confirm
this trend. The current study also documents that the PM
is more likely to be present bilaterally than unilaterally
(82.3% vs 6.3%). There was a high degree of heterogene-
ity between studies (I2 = 44.52), and geographical region
was statistically significant moderators of this PPE. We
suspect that the observed high heterogeneity is due to the
intrinsic variability in the anatomy of the PM between
individuals. Although some studies have reported side dif-
ferences in the presence of the PM [5, 32, 33], the current
meta-analysis did not find any significant side differences
(PPE for the right and left-sided prevalence = 42.2% and
57.8%, respectively). Gender dimorphism in the presence
of the PM muscle has also been reported, with a female
predominance [33]. This has been postulated to be due to
the need for adaptation of the anterior abdominal wall to
stresses and strains as seen during pregnancy [33, 45].
The exact physiological function of the PM is still
unknown, and the fact that it can be bilaterally absent in
some individuals without any known functional deficiency
suggests that it may be harvested with a minimal donor site
morbidity and utilized as muscle flaps for reconstructive
procedures such as treatment of intractable wounds [46]
and surgical management of urinary incontinence [14, 17,
28, 40]. Although alternative sources of flaps exist, their
harvesting is often associated with various morbidities.
For instance, harvesting of the gracilis muscle flap is asso-
ciated with functional deficits in hip adduction and knee
flexion, as well as donor site scar on the medial aspect
of the knee. Similarly, harvesting of the latissimus dorsi
or serratus anterior-based muscle flaps is associated with
complications such as formation of seromas at donor sites,
large donor site scars and functional deficits at the shoul-
der joint [46]. The small size of the muscle has been cited
as one of the limitations to its use in reconstructive proce-
dures. For instance, the mean length of the PM reported
in the included studies ranged from 4.97 to 8.09 cm, while
the mean width ranged from 1.2 to 1.99 cm. This means
that the PM can be used to cover a defect with a maximum
length and width of 8 cm and 2 cm, respectively. Similarly,
we could not find published reports on the variations of its
innervation and vascular supply, which may compromise
the success of harvesting of PM-based muscle flaps.
There has been a renewed interest in the anatomy of the
pyramidalis muscle since its anatomical variations may be
a causal factor of the chronic groin pain in the athletes. This
pain was considered a consequence of a “groin disruption”.
Morelli and Weaver [30] included “various distinct anatomi-
cal variations of the anterior abdominal wall”: tears of the
transversalis fascia, tears of the external oblique, aponeu-
rosis/avulsion of fibers of the internal oblique at the pubic
tubercle [36], abnormalities of the insertion of the rectus
abdominus [13, 27], tears of the conjoined tendon, or dehis-
cence of the conjoined and inguinal ligaments [30]
The correct classification and treatment of chronic groin
pain represent a real challenge for the physicians. In 2009,
Falvey et al. [13] suggested the 3G patho-anatomic approach
(groin, gluteal, and greater trochanter triangle) to improve
the identification of the causes of the chronic groin pain
in athletes. Taken together, these three physical landmarks
outline a 3D triangle in which some structures that may be
the underlying cause of chronic groin pain are contained.
These structures have been called by Cavalli et al. [4] as
“pubic inguinal pain syndrome”, the so-called “sports her-
nia” [4, 13, 15, 42]. In similar cases, the pain is localized
in the pubic region, which usually radiates inferiorly to the
insertion of the adductor longus muscle, and superiorly to
the insertion of the rectus abdominis, close to the insertion
of the pyramidalis muscle, which is not usually taken into
adequate consideration.
In 2014, an expert consensus of the British Hernia Soci-
ety’s was carried out in Manchester. It was established that
a diagnosis of chronic groin pain could be arrived when the
presence of at least five clinical signs reported to detect the
“inguinal disruption” has been well ascertained: pinpoint
tenderness over the pubic tubercle at the point of insertion
of the conjoined tendon, palpable tenderness over the deep
inguinal ring, pain and/or dilation of the external ring with
13

604
no obvious hernia’s evidence, pain at the origin of the adduc-
tor longus tendon and a dull, diffuse pain in the groin, often
radiating to the perineum and inner thigh or across the mid-
line [38]. In the Doha agreement meeting, held in Dubai in
2014, the causes of the athletes’ groin pain were standard-
ized: iliopsoas-related pain, adductor-related pain, inguinal-
related groin pain and pubic-related groin pain [47]. The
adductor-related groin pain was a consequence of a direct
connection from the distal end of the rectus abdominis mus-
cle and the proximal end of the adductor longus [3, 12, 27,
48]
Recently, Schilders et al. [36] have introduced a new
anatomical concept: the pyramidalis–anterior pubic liga-
ment–adductor longus complex (PLAC). In their study,
carried out on cadavers, the authors demonstrated a strong
direct connection between the PM and the adductor longus
tendon via the anterior pubic ligament. The rectus abdominis
(RA) was, however, not attached to the adductor longus. Its
lateral tendon was attached to the cranial border of the pubis
and its slender internal tendon appeared to be attached infe-
riorly to the symphysis together with fascia lata and gracilis.
These novel findings, if supported by subsequent studies,
could have important radiological and surgical implica-
tions in the management of the adductor and pubic-related
groin pain. Recognition of the anatomical connections of the
PLAC may play a key role in achieving anatomical repairs
following acute proximal adductor’s avulsions. These find-
ings are, however, based on a single study with a small sam-
ple size of seven cadavers. More studies with larger sample
sizes are recommended to confirm these results.
Our meta-analysis was limited by a number of fac-
tors, such as the small number of cases and sample size
of included studies, as well as the unclear or difficult-to-
interpret data which led to the exclusion of several stud-
ies. Additionally, high heterogeneity often persisted with
regards to the presence and dimensions of the PM, despite
subgroups analysis by geographical region and type of inves-
tigation. While differences in studies’ methodologies cannot
be excluded, we suspect that the observed high heterogeneity
may be due to the intrinsic variability in the anatomy of the
PM between individuals. The findings of the current study
should, therefore, be interpreted with caution. The high het-
erogeneity points out to the need for a careful pre-operative
evaluation of surgical anatomy of the PM. This objective
may be achieved through ultrasonography (USG) and mag-
netic resonance imaging (MRI).
Conclusions
The pyramidalis muscle is a rather constant anatomical
structure being present in up to 90% of individuals.
13
Surgical and Radiologic Anatomy (2021) 43:595–605
Author contributions  Protocol/project development: RC. Data collec-
tion or management: RC, IC. Data analysis: RC, IC, JR. Manuscript
writing/editing: all authors.
Funding  None was sought for this study.
Compliance with ethical standards 
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical approval  This article does not contain any studies with human
participants performed by any of the authors.
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