Length of Time Between Anterior Cruciate Ligament Reconstruction and Return to Sport Does Not Predict Need for Revision Surgery in National Football League Players

The Impact of Knee and Ankle Injuries on National Basketball Association Player Performance Post-injury

INTRODUCTION

Athletes in the National Basketball Association (NBA) are subjected to high levels of mechanical stress increasing their risk of injury. The purpose of this study was to see how certain lower extremity injuries affect in-game performance in relation to each NBA athlete's demographics. The hypothesis was that NBA players' post-injury performance would differ depending on their demographics and the type of injury sustained.

METHODS

Descriptive epidemiology study of NBA injury list designations from the 2010/2011 season to the 2018/2019 season. About 255 lower leg injuries that met the inclusion criteria were selected from the injury lists spanning from the 2010/2011 season to the 2018/2019 season. These included ligamentous knee injuries, knee sprains, knee strains, knee hyperextensions, patellar injuries, ankle injuries, and Achilles injuries. The change in performance was determined by comparing mean game scores before and after injury with single-tailed, heteroscedastic t-testing and 95% confidence intervals for mean values.

RESULTS

An overall statistically significant decrease in mean game score from 9.82 to 8.75 was seen in all included players (p = 0.01). Only athletes taller than the mean height (199.85 cm; p = 0.01) and heavier than the mean weight (101.63 kg; p = 0.02) showed a significant decline in performance. Ankle and knee injuries both resulted in a significant loss in game score (p = 0.04), with ankle injuries resulting in a greater average decline (-1.76 post-injury) than knee injuries (-1.34 post-injury).

CONCLUSIONS

These findings suggest that treatment regimens should reflect the type of injury and demographics of the specific NBA player injured. Further research is warranted to determine if treatment may be more efficacious when streamlined based on player size and injury type.

Better Safe Than Sorry? A Systematic Review with Meta-analysis on Time to Return to Sport After ACL Reconstruction as a Risk Factor for Second ACL Injury

OBJECTIVE: To compare the time to return to sport (RTS) between patients who did and did not suffer a second anterior cruciate ligament (ACL) injury after ACL reconstruction. DESIGN: Etiology systematic review with meta-analysis. LITERATURE SEARCH: Cochrane Library, Embase, Medline, AMED, and PEDro databases were searched in August 2021 and again in November 2022. STUDY SELECTION CRITERIA: Clinical studies reporting time to RTS after ACL reconstruction and second ACL injury were eligible. DATA SYNTHESIS: We pooled continuous data (time [months] and proportions [%]), with random-effects meta-analyses. Pooled estimates were summarized in forest plots. A qualitative data synthesis was also performed. RESULTS: Twenty-one studies were included in the meta-analysis and 33 in the qualitative synthesis. Pooled incidence of second ACL injury was 16.9% (95% confidence interval [CI]: 12.8, 21.6). Patients who suffered a second ACL injury returned to sport significantly earlier (25 days; 95% CI: 9.5, 40.4) than those who did not suffer another injury. There was no difference in time to RTS for professional athletes who suffered a second ACL injury and those who did not. The certainty of evidence was very low. CONCLUSION: There was very low-certainty evidence that patients who suffered a second ACL injury had returned to sport 25 days earlier than patients who did not have another injury. For professional athletes, there was no difference in time to RTS between athletes who suffered a second ACL injury and athletes who did not. J Orthop Sports Phys Ther 2024;54(3):1-15. Epub 30 November 2023. doi:10.2519/jospt.2023.11977.

No difference in return to play rates between different elite sports after primary autograft ACL reconstruction

PURPOSE

To demonstrate return to play (RTP) rates, the level of RTP and time taken to RTP in different sports after anterior cruciate ligament reconstruction (ACL-R) and compare the differences between football and rugby. The secondary aims were to compare the differences in intra articular injuries and their treatments and reoperation rates between these sports.

METHODS

A retrospective review of a consecutive series of all primary ACL-R undertaken by the senior author between 2005 and 2019 was undertaken. Patients were included if they were elite athletes and were a minimum of 2 year post-primary autograft ACL-R. The outcomes measured were RTP (defined as participation in a professional match or in national/international-level competition in amateur sports), time to RTP after surgery and RTP level (Tegner score).

RESULTS

Three hundred and ninety-four elite athletes, with 420 ACL-Rs were included. 235 (55.9%) were in footballers and 125 (29.8%) were in rugby players. 399 (95.0%) of all elite athletes returned to competition at an average of 10.3 months after ACL-R. 386 (90.2% played at the same or higher level post-surgery. Although there was no difference in RTP rates between different sports, rugby players RTP significantly faster than footballers (9.6 vs 10.6 months, (p = 0.027). Footballers were more likely to rupture their ACL during jumping/landing manoeuvres and to receive a PT graft than rugby players. There were no other significant differences between football and rugby players regarding patient characteristics, intraoperative findings, re-rupture and re-operation rates.

CONCLUSIONS

Over 95% of all elite athletes RTP after primary ACL-R with 90% able to play at the same level. Rugby players RTP significantly faster than footballers.

LEVEL OF EVIENCE

Level IV.

Lower rates of return to sport in patients with generalised joint hypermobility two years after ACL reconstruction: a prospective cohort study

BACKGROUND

Generalised joint hypermobility (GJH) has been associated with an increased risk of suffering an anterior cruciate ligament (ACL) injury. Patients with GJH exhibit lower muscle strength and poorer scores for patient-reported outcomes after ACL reconstruction, compared with patients without GJH. The aim of this study was to examine differences in the percentages of patients who return to sport (RTS) or pre-injury level of activity (RTP), muscle function and patient-reported outcomes at the time of RTS or RTP, as well as the time of RTS or RTP in patients with GJH compared with patients without GJH in the first two years after ACL reconstruction.

METHODS

This prospective study used data from an ACL- and rehabilitation-specific register located in Gothenburg, Sweden. Patients aged between 16 and 50, who had a primary ACL injury treated with reconstruction, were included. Data up to two years after ACL reconstruction were used and consisted of achieving RTS and RTP, results from isokinetic muscle function tests for knee extension and flexion and patient-reported outcomes (Knee Self-Efficacy Scale, Knee injury and Osteoarthritis Outcome Score and ACL-Return to Sport after Injury scale) at the time of RTS, as well as the time of RTP. A Beighton Score of ≥ 5/9 was used to define GJH. A Tegner Activity Scale of ≥ 6 was used to define RTS, while a Tegner equal to or above pre-injury level was used to define RTP.

RESULTS

A total of 1,198 patients (54.7% women) with a mean age of 28.5 ± 8.6 years were included. A smaller proportion of patients with GJH achieved RTS compared with patients without GJH (49.2% vs. 57.3%, Odds ratio: 0.720, p = 0.041). Furthermore, patients with GJH were marginally less symmetrical on the knee extension strength test, expressed as a Limb Symmetry Index, at the time of RTP compared with patients without GJH (87.3 ± 13.5 vs. 91.7 ± 14.3, Cohen's d = 0.142, p = 0.022). No further differences were found between groups regarding any muscle function tests or patient-reported outcomes.

CONCLUSION

A smaller proportion of patients with GJH achieved RTS compared with patients without GJH. Patients with GJH displayed less symmetrical knee extension strength at the time of RTP compared with patients without GJH.

Return-to-Sport Outcomes After Anterior Cruciate Ligament Surgical Treatment May Be Improved by Attention to Modifiable Factors and Consideration of Nonmodifiable Factors

Today, we who treat athletes are able to effect immediate, significant improvement in anterior cruciate ligament (ACL) patient outcomes, regardless of surgical technique, by careful determination of when an athlete is ready to return to sport. "Prehabiliation," bracing, time after surgery to various rehabilitation activities, time after surgery until return to sport, functional testing, strength testing including limb symmetry indices, psychological readiness, age, gender, and type of sport are all factors influencing successful return to sport after ACL injury and treatment. Age and gender are not modifiable, and for some athletes, type of sport may be nonnegotiable. However, each of these factors could be thoughtfully considered before returning an athlete to sport after ACL treatment. All the other factors listed above, from prehab to bracing to strength to psychological readiness, may be modifiable.

Return to Sports: A Risky Business? A Systematic Review with Meta-Analysis of Risk Factors for Graft Rupture Following ACL Reconstruction

BACKGROUND

The risk of sustaining a graft rupture after anterior cruciate ligament reconstruction (ACLR) is high. Contributing risk factors are, however, still not clearly identified.

OBJECTIVE

The aim of this systematic review was to identify and quantify risk factors for graft rupture after ACLR.

METHODS

A systematic review with meta-analysis (PROSPERO CRD42020140129) based on PRISMA guidelines was performed. MEDLINE, CINAHL and EMBASE were searched from inception to September 2021. Prospective and retrospective studies addressing risk factors for graft rupture after ACLR in males/females of all ages were considered. Meta-analyses using a random effect model (effect measure: odds ratio [OR] with 95% confidence interval [CI]) were performed. The GRADE tool was used to assess evidence quality.

RESULTS

Following full-text screening of 310 relevant papers, 117 were eventually included, incorporating up to 133,000 individuals in each meta-analysis. Higher Tegner activity level (≥ 7 vs < 7) at primary injury (OR 3.91, 95% CI 1.69-9.04), increased tibial slope (degrees) (OR 2.21, 95% CI 1.26-3.86), lower psychological readiness to return to sport (RTS) (OR 2.18, 95% CI 1.32-3.61), early surgery (< 12 vs ≥ 12 months) (OR 1.87, 95% CI 1.58-2.22), RTS (pre-injury level) (OR 1.87, 95% CI 1.21-2.91) and family history of ACL injury (OR 1.76, 95% CI 1.34-2.31) were all associated with increased odds of graft rupture. Higher age (OR 0.47, 95% CI 0.39-0.59), female sex (OR 0.88, 95% CI 0.79-0.98), fewer self-reported knee symptoms pre-reconstruction (OR 0.81, 95% CI 0.69-0.95) and concomitant cartilage injuries (OR 0.70, 95% CI 0.62-0.79) instead decreased the odds. Meta-analysis revealed no association between body mass index, smoking, joint laxity, RTS time, knee kinematics, muscle strength or hop performance and graft rupture.

CONCLUSION

Conspicuous risk factors for graft rupture were mainly sports and hereditary related. Few studies investigated function-related modifiable factors or included sports exposure data.

Validity of Research Based on Public Data in Sports Medicine: A Quantitative Assessment of Anterior Cruciate Ligament Injuries in the National Football League

BACKGROUND

Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players.

PURPOSE

To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams' medical staff to the NFL Injury Surveillance System database linked to the League's electronic health record. An ACL "capture rate" for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest.

RESULTS

A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams' medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play.

CONCLUSION

The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.

Return to Play and Player Performance After Foot Fracture in UEFA Soccer Players

Background:

There is a paucity of information on rate and time to return to play (RTP) in elite-level soccer players who have sustained foot fractures.

Purpose:

To (1) determine the rate and timing of RTP after foot fracture (eg, tarsal, metatarsal, or phalangeal), (2) investigate foot fracture reinjury incidence after RTP, and (3) evaluate performance after foot fracture as compared with matched, uninjured controls.

Study Design:

Descriptive epidemiology study.

Methods:

Athletes sustaining foot fractures were identified across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Injured athletes were matched to controls (1:1) using demographic characteristics and performance metrics from 1 season before injury. The authors recorded RTP rate, reinjury incidence, player characteristics associated with RTP within 2 seasons of injury, player availability, field time, and performance metrics during the 4 seasons after injury.

Results:

A total of 192 elite soccer players sustaining a foot fracture were identified; 40 players (20.8%) underwent operative treatment. Athletes missed an average of 69.41 ± 59.43 days and 5.15 ± 23.28 games. In the 4 seasons after injury, 80% of players returned to play, with 72% returning to play within 1 season of injury. Nine players (5%) sustained a subsequent foot fracture. Athletes with a foot fracture demonstrated significantly longer league retention compared with uninjured controls (P < .001). Elite soccer players older than 30 years of age were less likely to RTP (odds ratio, 0.67; P = .002), whereas career experience, field position, and baseline performance showed no significant association with RTP rates. Injured athletes demonstrated similar performance to controls during the 4 years after injury, and there were no position-dependent differences on subgroup analysis. The players who underwent operative treatment had more assists per 90 minutes and more team points per game during the first season after injury compared with athletes treated nonoperatively.

Conclusion:

Foot fractures in elite soccer players resulted in moderate loss of play time (69.41 days). RTP rates were high at 80%, although players older than 30 years of age were less likely to RTP. On RTP, athletes who sustained a foot fracture maintained performance similar to preinjury levels and to uninjured controls.

Game Utilization and Performance Following RTP From ACL Reconstruction Does not Influence a Subsequent Second ACL Injury in National Football League Players

Purpose

The purpose of this study is to evaluate differences in game utilization or performance following primary anterior cruciate ligament (ACL) reconstruction between National Football League (NFL) players with and without a second ACL injury.

Methods

NFL players who underwent ACL reconstruction between 2013 and 2017 were identified. Players were classified as having one injury (“tear”) or having later sustained a subsequent second (reinjury or contralateral) ACL injury (“retear”). Players were excluded if they tore their ACL prior to the NFL, did not return to play (RTP), did not play the season before injury, or had concomitant injuries. Demographic characteristics, game utilization statistics, and season approximate value (SAV) performance metrics were recorded. Statistical analysis compared data after RTP from primary ACL reconstruction (seasons +1, +2, and +3) relative to the season before injury (season −1) between cohorts using mean differences and relative percentages.

Results

Analysis included a total of 45 players, 32 in the “tear” group and 13 in the “retear” group. Demographics, level of play, and time to RTP after primary ACL reconstruction did not differ between the groups (P > .05). Tear and retear groups demonstrated similar utilization and performance metrics the season prior to injury (−1) and the 3 seasons following RTP (season of injury is “0”). Both groups had a similar decrease (relative percentage) in games played and started, snap counts, and SAV during the 3 seasons following RTP compared to baseline (P > .05). The draft pick position was correlated with the relative percentage of games started the first season after RTP (r = .6, P = .02).

Conclusions

Game utilization and performance metrics following ACL reconstruction were not associated with a subsequent second ACL injury. Players with a higher draft pick position were more likely to return to the starting lineup following primary ACL reconstruction. Ultimately, player game utilization and performance following primary ACL reconstruction is not predictive of a subsequent second ACL injury.

Level of Evidence

Level III, retrospective case-control study

Acromioclavicular Joint Separation in UEFA Soccer Players: A Matched-Cohort Analysis of Return to Play and Player Performance From 1999 to 2018

Background

Acromioclavicular joint (ACJ) separation injuries are uncommon in professional soccer players, threatening future performance and team contributions. Data regarding return to play (RTP) in professional soccer players after ACJ separation are limited.

Purpose

To determine the rate, time to RTP, and player performance after ACJ separation in soccer players from the top 5 professional European leagues when compared with a retrospective, matched cohort of uninjured players.

Study Design

Cohort study; Level of evidence, 3.

Methods

Professional soccer players suffering ACJ separation injuries between 1999 and 2018 were identified and were matched to uninjured players (2 controls to 1 injured player) by position, height, age, season year, and length of time played. Information on date of injury, timing to RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) were collected from transfermarkt.co.uk, uefa.com, fifa.com, official team websites, public injury reports, and press releases. Change in performance metrics for the 4 seasons after the season of injury were based on metrics 1 season before injury. Univariate comparisons were performed using independent 2-group t tests and Wilcoxon rank-sum tests when normality of distributions was violated.

Results

A total 59 soccer players with ACJ separation injuries were identified. Mean age at injury was 24.6 ± 5.3 years. Of these, 81% of the players returned to play, with 69% returning within postinjury season 1. Mean time to RTP was 49.8 ± 24.3 days (5.9 ± 4.1 games). Two players suffered recurrent ACJ separation injuries in their professional soccer careers. There were no significant differences between athletes who sustained ACJ injuries versus control athletes in the number of games played, minutes per game per season, goals scored, assists, or points in the 4 seasons after injury. Defenders played fewer minutes and recorded fewer assists during postinjury season 1 when compared with control athletes.

Conclusion

Of the 59 elite soccer players who sustained ACJ separation injuries during the study period, 81% returned to elite competition. Performance metrics were similar to preinjury levels and matched, uninjured control players.

Adolescents Have Twice the Revision Rate of Young Adults After ACL Reconstruction With Hamstring Tendon Autograft: A Study From the Swedish National Knee Ligament Registry

Background:

Previous studies have identified young age as a risk factor for anterior cruciate ligament (ACL) revision. However, few studies have looked separately at pediatric patients and adolescents with regard to outcomes after ACL reconstruction.

Purpose:

To determine whether patient age at ACL reconstruction affects the risk of undergoing revision surgery in young patients.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study was based on data from the Swedish National Knee Ligament Registry. Patients aged 5 to 35 years who underwent a primary ACL reconstruction with a hamstring tendon autograft between January 1, 2005, and December 31, 2015, were included. The cohort was stratified into different age groups of pediatric patients, adolescents, and young adults to estimate patients with open, recently closed, and closed epiphyses, respectively. The primary endpoint was ACL revision. A multivariable Cox regression model was used to assess the ACL revision rate. The results were expressed as hazard ratios (HRs) and 95% CIs.

Results:

A total of 36,274 ACL reconstructions were registered during the study period. Of these, 2848 patients were included in the study: 47 pediatric patients (mean age, 13.6 years; range, 9-15 years), 522 adolescents (mean age, 17.4; range, 14-19 years), and 2279 young adults (mean age, 27.0; range, 20-35 years). A total of 31 patients (1.1%) underwent ACL revision within 2 years (0 pediatric patients, 9 adolescents [1.7%], and 22 young adults [1.0%]) and a total of 53 patients (2.6%) underwent ACL revision within 5 years (2 pediatric patients [6.9%], 15 adolescents [3.9%], and 36 young adults [2.2%]). The adolescent age group had a 1.91 times higher rate of ACL revision compared with the young adults (HR = 1.91 [95% CI, 1.13-3.21]; P = .015). There were no differences in revision rates between the pediatric age group and the young adults (HR = 2.93 [95% CI, 0.88-9.79]; P = .081).

Conclusion:

Adolescents had almost twice the rate of revision ACL reconstruction compared with young adults.

Return-to-Play Times and Player Performance After Medial Collateral Ligament Injury in Elite-Level European Soccer Players

Background:

Participation in elite-level soccer predisposes athletes to injuries of the medial collateral ligament (MCL), resulting in variable durations of time lost from sport.

Purpose:

To (1) determine the rate of return to play (RTP) and timing after MCL injuries, (2) investigate MCL reinjury incidence after RTP, and (3) evaluate the long-term effects of MCL injury on future performance.

Study Design:

Descriptive epidemiology study.

Methods:

Using publicly available records, we identified athletes who had sustained MCL injury between 2000 and 2016 across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A). Injured athletes were matched to controls using demographic characteristics and performance metrics from the season before injury. We recorded injury severity, RTP rate, reinjury incidence, player characteristics associated with RTP within 2 seasons of injury, player availability, field time, and performance metrics during the 4 seasons after injury.

Results:

A total of 59 athletes sustained 61 MCL injuries, with 86% (51/59) of injuries classified as moderate to severe and surgical intervention performed in 14% (8/59) of athletes. After injury, athletes missed a median of 33 days (range, 3-259 days) and 4 games (range, 1-30 games). Overall, 71% (42/59) of athletes returned successfully at the same level, with multivariable regression demonstrating no athlete characteristic predictive of RTP. MCL reinjury was reported in 3% (2/59) of athletes. Midfielders demonstrated decreased field time after RTP when compared with controls (P < .05). No significant differences in player performance for any position were identified out to 4 seasons after injury. Injured athletes had a significantly higher rate of long-term retention (P < .001).

Conclusion:

MCL injuries resulted in a median loss of 33 days in elite European soccer athletes, with the majority of injuries treated nonoperatively. RTP remained high, and few athletes experienced reinjury. While midfielders demonstrated a significant decrease in field time after RTP, player performance and long-term retention were not compromised. Future studies are warranted to better understand athlete-specific and external variables predictive of MCL injury and reinjury, while evaluating treatment and rehabilitation protocols to minimize time lost and to optimize athlete safety and health.

Traumatic Leg Fractures in UEFA Football Athletes: A Matched-Cohort Analysis of Return to Play, Reinjury, Player Retention, and Performance Outcomes

Background:

The average professional soccer team experiences 1 to 2 traumatic leg fractures per season, with unknown effects on player performance.

Purpose:

To (1) determine the rate and time to return to play (RTP) following leg fracture, (2) investigate the rate of reinjury following RTP, and (3) investigate long-term effects that lower extremity (LE) fracture may have on elite soccer player performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using publicly available records, we identified athletes sustaining a traumatic leg fracture across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Athletes with leg fracture (femur, tibia, and/or fibula) were matched 1:2 to controls by demographic characteristics and performance metrics 1 season before the index timepoint. Investigations included the RTP rate, reinjury rate, player characteristics associated with RTP within 2 seasons, long-term player retention, performance metrics during the 4 following seasons, and subgroup analysis by player position.

Results:

A total of 112 players with LE fracture and 224 controls were identified. Players with LE fractures were absent for a mean of 157 days (range, 24-601 days) and 21 games (range, 2-68 games). The rate of RTP within 1 season was 80%, with 4% experiencing subsequent refracture. Injured players remained active in the league at a higher rate than their uninjured counterparts. As compared with controls, injured athletes played 309 fewer total minutes (P < .05), scored 0.09 more assists per game (P < .01) 1 season after injury, and scored 0.12 more points per game 4 seasons after injury (P < .01). Defenders were most affected by an LE fracture, playing 5.24 fewer games (P < .05), 603 fewer total minutes (P < .01), and recording 0.19 more assists per 90 minutes of play as compared with controls 1 season after injury (P < .001). Attackers and midfielders demonstrated no significant difference in metrics after RTP when compared with controls.

Conclusion:

Most players sustaining an LE fracture returned to elite soccer at the same level after a significant loss of playing time, with a 4% rate of refracture. Player retention was higher for those sustaining an LE fracture versus uninjured controls. Overall, injured players did not experience a decline in performance after recovery from an LE fracture.

Return to Play and Player Performance After Achilles Tendon Rupture in UEFA Professional Soccer Players: A Matched-Cohort Analysis of Players From 1999 to 2018

Background:

Achilles tendon rupture (ATR) is a potentially career-ending injury in professional athletes. Limited information exists regarding return to play (RTP) in professional soccer players after this injury.

Purpose:

To determine the RTP rate and time in professional soccer players after ATR and to evaluate player performance relative to matched controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We evaluated 132 professional soccer players who suffered an ATR between 1999 and 2018. These athletes were matched 2:1 to uninjured controls by position, age, season of injury, seasons played, and height. We collected information on the date of injury, the date of RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) from official team websites, public injury reports, and press releases. Changes in performance metrics for the 4 years after the season of injury were compared with metrics 1 season before injury. Univariate comparisons were performed using independent-sample, 2-group t tests and Wilcoxon rank-sum tests when normality of distributions was violated.

Results:

The mean age at ATR was 27.49 ± 4.06 years, and the mean time to RTP was 5.07 ± 2.61 months (18.19 ± 10.96 games). The RTP rate was 71% for the season after injury and 78% for return at any timepoint. Overall, 9% of the injured players experienced a rerupture during the study period. Compared with controls, the injured players played significantly less (-6.77 vs -1.81 games [P < .001] and -560.17 vs -171.17 minutes [P < .05]) and recorded fewer goals (-1.06 vs -0.29 [P < .05]) and assists (-0.76 vs -0.02 [P < .05]) during the season of their Achilles rupture. With the exception of midfielders, there were no significant differences in play time or performance metrics between injured and uninjured players at any postinjury timepoint.

Conclusion:

Soccer players who suffered an ATR had a 78% RTP rate, with a mean RTP time of 5 months. Injured players played less and demonstrated inferior performance during the season of injury. With the exception of midfielders, players displayed no significant differences in play time or performance during any of the 4 postinjury seasons.

Return to sport following anterior cruciate ligament reconstruction: the argument for a multimodal approach to optimise decision-making: current concepts

Existing literature is varied in the methods used to make this determination in the treatment of athletes who have undergone recent anterior cruciate ligament (ACL) reconstruction. Some authors report using primarily time-based criteria, while others advocate for physical measures and kinematic testing to inform decision-making. The goal of this paper is to elucidate the most current medical evidence regarding identification of the earliest point at which a patient may safely return to sport. The present review therefore seeks to examine the evidence from a critical perspective-breaking down the biology of graft maturation, effect of graft choice, potential for image-guided monitoring of progression and results associated with time-based versus functional criteria-based return to play-to justify a multifactorial approach to effectively advance athletes to return to sport. The findings of the present study reaffirm that time is a prerequisite for the biological progression that must occur for a reconstructed ligament to withstand loads demanded by athletes during sport. Modifications of surgical techniques and graft selection may positively impact the rate of graft maturation, and evidence suggests that imaging studies may offer informative data to enhance monitoring of this process. Aspects of both functional and cognitive testing have also demonstrated utility in prior studies and consequently have been factored into modern proposed methods of determining the athlete's readiness for sport. Further work is needed to definitively determine the optimal method of clearing an athlete to return to sport after ACL reconstruction. Evidence to date strongly suggests a role of a multimodal algorithmic approach that factors in time, graft biology and functional testing in return-to-play decision-making after ACL reconstruction.Level of evidence: level V.

Epidemiology of Anterior Cruciate Ligament Tears in the National Football League

BACKGROUND

Anterior cruciate ligament (ACL) tears are common in contact athletics and have a significant effect on the athletic performance and well-being of affected players. The prevalence, timing, and characteristics of ACL tears in National Football League (NFL) athletes are lacking.

PURPOSE

To define the epidemiology of ACL tears among NFL athletes.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

This retrospective study includes all ACL injuries entered into the NFL injury database through the centralized leaguewide electronic health record system for the 2015-2019 seasons.

RESULTS

A total of 314 ACL injuries occurred during the 5-year study period, with a mean of 62 per year. The overall 1-season injury risk of an NFL player sustaining an ACL injury was 1.9% (95% CI, 1.7%-2.1%). Most ACL injuries occurred during games (n = 199), with a higher rate observed in the preseason games as compared with the regular season games (6.1 vs 2.7 per 10,000 player-plays; P < .01). NFL players with ≤3 of experience had a higher preseason injury rate (9.57 ACL tears per 1000 player-seasons) than those with ≥4 years of experience (5.12 ACL tears per 1000 player-seasons; P < .01). NFL athletes playing on special teams had the highest rate of ACL injuries (7.6 per 10,000 player-plays) in comparison with all other player positions.

CONCLUSION

ACL injury incidence was fairly consistent across all years studied and occurred more frequently in players with ≤3 years of NFL experience. Tears were more common during games, special teams play, and the preseason.

Return-to-Play Times and Player Performance After ACL Reconstruction in Elite UEFA Professional Soccer Players: A Matched-Cohort Analysis From 1999 to 2019

Background:

Anterior cruciate ligament (ACL) rupture is one of the most common injuries afflicting soccer players and requires a lengthy recovery processes after reconstructive surgery. The impact of ACL reconstruction (ACLR) on return to play (RTP) time and player performance in professional soccer players remains poorly studied.

Purpose/Hypothesis:

To determine player performance and RTP rate and time after ACLR in elite professional soccer players with a retrospective matched-cohort analysis. We expected that the RTP time and rate will be similar to those of other professional-level athletes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included were 51 players from 1 of the 5 elite Union of European Football Associations (UEFA) soccer leagues who suffered a complete ACL rupture between 1999 and 2019. These athletes were matched by position, age, season of injury, seasons played, and height and compared to uninjured control players. Change in performance metrics for the 4 years after the season of injury were compared with metrics 1 season before injury. Univariate 2-group comparisons were performed using independent 2-group t tests; Wilcoxon rank-sum tests were used when normality of distributions was violated.

Results:

Overall, 41 players (80%) returned to play after ACL rupture, with 6 (12%) experiencing a subsequent ipsilateral or contralateral ACL tear. The mean (±SD) RTP time for soccer players after ACLR was 216 ± 109 days (26 ± 18 games). Injured athletes played significantly fewer games and minutes per season and recorded inferior performances for 2 seasons after their injury (P < .001). However, the game performance of injured players equaled or exceeded that of their matched controls by season 3 after injury, with the exception of attackers, who demonstrated a continued decline in performance (P < .001).

Conclusion:

Results indicated that the mean RTP time for soccer players after ACLR is short in comparison with other major sports leagues (216 days). However, RTP rates were high, and rerupture rates were comparable with those of other sports. With the exception of attackers, player performance largely equaled or exceeded that of matched controls by the third postinjury season.

Career Longevity and Performance After Shoulder Instability in National Football League Athletes

PURPOSE

To investigate the career longevity, game utilization, and performance of National Football League (NFL) athletes after glenohumeral instability events treated operatively versus nonoperatively.

METHODS

Using public resources, we identified NFL players who sustained a shoulder instability event from September 2000 to February 2019. Players with prior shoulder instability, without NFL experience before injury, or who did not return to play (RTP) after injury were excluded. Demographic information, utilization (games and seasons), and season approximate value (SAV) statistics were recorded 1 year prior to injury and 3 years after RTP. Statistical analysis compared utilization and the SAV after RTP for athletes managed operatively versus nonoperatively.

RESULTS

We identified 97 NFL players who sustained their first instability event while playing in the NFL, 91 of whom returned to play (93.8%). Quarterbacks were significantly more likely to undergo immediate surgical management compared with players in other positions (P = .023). The final analysis included 58 players managed operatively and 33 managed nonoperatively by the end of the index season. Players treated operatively played in significantly more seasons after RTP during their remaining careers (4.1 ± 2.7 seasons vs 2.8 ± 2.5 seasons, P = .015). There were no differences in games played or started, offensive or defensive snap count percentage, or performance (SAV) before and after injury when compared between cohorts (P > .05). After surgical stabilization, time to RTP (36.62 ± 10.32 weeks vs 5.43 ± 12.33 weeks, P < .05) and time interval before recurrent instability (105.7 ± 100.1 weeks vs 24.7 ± 40.6 weeks, P < .001) were significantly longer than with nonoperative treatment. Additionally, the operative cohort experienced less recurrent instability (27% vs 50%, P = .035).

CONCLUSIONS

Athletes who RTP in the NFL after a shoulder instability injury do so with a similar workload and performance irrespective of surgical or nonsurgical management. Whereas nonoperative treatment is associated with faster RTP, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Effect of Achilles Tendon Rupture on Player Performance and Longevity in Women's National Basketball Association Players

Background

Women's National Basketball Association (WNBA) players have a greater incidence of lower extremity injury compared with male players, yet no data exist on functional outcomes after Achilles tendon rupture (ATR).

Purpose

To evaluate the effect of Achilles tendon repair on game utilization, player performance, and career longevity in WNBA athletes.

Study Design

Cohort study; Level of evidence, 3.

Methods

WNBA players from 1997 to 2019 with a history of ATR (n = 12) were matched 1:2 to a healthy control group. Player characteristics, game utilization, and in-game performance data were collected for each athlete, from which the player efficiency rating (PER) was calculated. Statistical analysis was performed comparing postinjury data to preinjury baseline as well as cumulative career data. Changes at each time point relative to the preinjury baseline were also compared between groups.

Results

Of the 12 players with ATR, 10 (83.3%) returned to play at the WNBA level at a mean (±SD) of 12.5 ± 3.3 months. Four players participated in only 1 WNBA season after injury. There were no differences in characteristics between the 10 players who returned to play after injury and the control group. After return to play, the WNBA players demonstrated a significant decrease in game utilization compared with preinjury, playing in 6.0 ± 6.9 fewer games, starting in 12.7 ± 15.4 fewer games, and playing 10.2 ± 9.1 fewer minutes per game (P < .05 for all). After the index date of injury, the players with Achilles repair played 2.1 ± 1.2 more years in the WNBA, while control players played 5.35 ± 3.2 years (P < .01) Additionally, the players with Achilles repair had a significant decrease in PER in the year after injury compared with preinjury (7.1 ± 5.3 vs 11.0 ± 4.4; P = .02). The reduction in game utilization and decrease in PER in these players was maintained when compared with the matched controls (P < .05 for both).

Conclusion

The majority of WNBA players who sustained ATR were able to return to sport after their injury; however, their career longevity was shorter than that of healthy controls. There was a significant decrease in game utilization and performance in the year after return to play compared with healthy controls.

Effect of Workload After ACL Reconstruction on Rerupture Rates in NBA Players

Background:

Rupture of the anterior cruciate ligament (ACL) is a common and potentially career-altering injury sustained by players in the National Basketball Association (NBA). Strategies have been employed by the league to prevent reinjury of players after ACL reconstruction (ACLR), including minute restrictions and rest games; however, it remains unknown whether workload metrics after ACLR influence the risk for reinjury and revision surgery.

Purpose:

To evaluate whether workload changes after return to play (RTP) from primary ACLR influences the risk of rerupture in NBA players.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We identified NBA players from 1975 to 2018 who underwent primary ACLR as well as those who required revision ACLR. Primary outcomes included workload measures such as games played, games started, and minutes per game. Secondary outcomes included in-game performance statistics. Statistical analysis was used to compare relative workload and performance 3 years before and 3 years after undergoing primary ACLR. Workload was also compared between the control group of NBA players who underwent primary ACLR and those who required revision ACLR.

Results:

A total of 68 players who underwent primary ACLR were included, 8 of whom subsequently required revision ACLR. In their first season upon RTP, control players (primary ACLR) demonstrated a significant reduction in all workload metrics relative to the season before injury (P < .001), while the revision group demonstrated an unchanged to increased workload. In a comparison between the primary and revision groups during the first season after RTP, the primary group demonstrated significantly fewer games started (mean ± SD, 22.2 ± 3.0 vs 35.8 ± 8.3; P = .039) and minutes per game (20.5 ± 1.1 vs 27.0 ± 3.1; P = .048) than revision players. The primary ACLR group demonstrated reduced cumulative workload trends for the first 3 years after RTP relative to 3 years before injury, which was not demonstrated in the revision ACLR group, albeit statistically insignificant.

Conclusion:

Our study found that after ACLR, a reduction in workload parameters relative to preinjury baseline was associated with players who did not sustain rerupture. Further study is required to determine if workload measures following RTP from primary ACLR should be individualized relative to preinjury baseline.

Adductor injuries in the National Basketball Association: an analysis of return to play and player performance from 2010 to 2019

Objectives: 1) To evaluate return to play (RTP) timing in National Basketball Association (NBA) athletes following adductor injuries, and 2) to evaluate the effect of adductor injuries on player performance, game availability, and career longevity following RTP. Methods: Adductor injuries in NBA athletes from the 2009-2010 to 2018-2019 seasons were identified utilizing publicly available records via previously validated methodology. RTP time was calculated, and player performance and game availability were compared pre- vs. post-injury. Additionally, an injury-free control group matched for age, BMI, position, and experience was assembled to allow for comparisons in performance, availability, and career length. Results: In total, 79 adductor injuries across 65 NBA athletes were identified. The average injured player was 28.3 ± 4.0 years of age, and had 6.5 ± 4.2 seasons of NBA experience. Guards were injured more frequently than forwards or centers (49% vs 25% vs 25%, respectively). All players were able to RTP following first-time adductor injury after missing an average of 7.7 ± 9.8 games (median [IQR]: 4 [1-9]) and 16.9 ± 20.4 days (median [IQR]: 9 [3.5-20]). Twelve players (18.5%) suffered an adductor re-injury at a mean latency of 509.5 ± 503.9 days. Adductor injuries did not result in significant changes in any major statistical category (points, assists, rebounds, steals, blocks, turnovers, field goal percentage), player efficiency rating (PER), minutes/game, games/season, or a number of all-star selections (all P > 0.05) following RTP. Additionally, when compared to matched controls, no difference was found in pre- to post-injury change of PER, games/season, or minutes/game (all P > 0.05). Career longevity was not significantly different between groups (P = 0.44). Conclusion: Following adductor injury, NBA players returned to gameplay after missing an average of 16 to 17 days, or 7 to 8 games. Adductor injury did not affect player performance, nor game availability or career longevity.

Return to Play and Performance After Primary ACL Reconstruction in American Football Players: A Systematic Review

Background

Anterior cruciate ligament (ACL) injuries are among the most common sports-related injuries, and they can have a negative impact on players' ability to return to play (RTP). There is a paucity of literature focused on RTP after ACL reconstruction (ACLR) in collision sports.

Purpose

To characterize the impact that an ACL injury has on the ability to RTP and the post-ACLR performance level in American football players.

Study Design

Systematic review; Level of evidence, 4.

Methods

An electronic search was performed using the following databases: the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, Embase, and the Cumulative Index to Nursing and Allied Health Literature. Included studies were written in English; were published since the year 2000; examined only American football players; and reported on RTP, performance, and/or career length after primary ACLR.

Results

The initial search yielded 442 unique studies. Of these, 427 were removed after screening, leaving 15 studies that met inclusion criteria. An additional 2 studies were identified in these studies' references, yielding a total of 17. The rate of RTP after ACLR for football players was 67.2% (1249/1859), and the mean time to return was 11.6 months (range, 35.8-55.8 weeks). Although considerable heterogeneity existed in the study design and outcomes measured, in general, a majority of football players experienced greater declines from their preinjury performance level than controls over the same time period.

Conclusion

An ACL injury negatively affected football players' ability to RTP and their post-ACLR performance. The degree of effect varied by several factors, including playing position, preinjury performance level, and National Football League Draft round. These results may be used by physicians and football players to develop reasonable expectations for returning to play and performance after an ACL injury.

Return to play and performance after shoulder instability in National Basketball Association athletes

HYPOTHESIS

We hypothesized that players in the National Basketball Association (NBA) who sustained a shoulder destabilizing injury could return to play (RTP) successfully at a high rate regardless of treatment type.

METHODS

We used publicly available data to identify and evaluate 50 players who sustained an in-season shoulder instability event (subluxation/dislocation) while playing in the NBA. Demographic variables, return to NBA gameplay, incidence of surgery, time to RTP, recurrent instability events, and player efficiency rating (PER) were collected. Overall RTP was determined, and players were compared by type of injury and mode of treatment.

RESULTS

All players (50/50) returned to game play after sustaining a shoulder instability event. In those treated nonoperatively, athletes who sustained shoulder subluxations returned after an average of 3.6 weeks, compared with 7.6 weeks in those who sustained a shoulder dislocation (P = .037). Players who underwent operative management returned after an average of 19 weeks. Athletes treated operatively were found to have a longer time interval between a recurrent instability event (70 weeks vs. 28.5 weeks, P = .001).

CONCLUSION

We found 100% rate of RTP after a shoulder instability event in an NBA athlete. Players who experience shoulder dislocations were found to miss more time before RTP and were more likely to undergo surgical intervention compared with those who experienced a subluxation. Surgical repair maintained a longer interval between recurrent instability. Future investigations should aim to evaluate outcomes based on surgical procedures and identify possible risk factors predictive of recurrent instability or failure to RTP.

Editorial Commentary: Put Me Back Into The Game Coach! It's Time, I'm Ready: Time Is of No Essence After An Anterior Cruciate Ligament Reconstruction

Retear after an anterior cruciate ligament reconstruction is unavoidable. Many variables contribute to graft failure after anterior cruciate ligament reconstruction. Time from surgery to return to play is not the sole determinant. Graft maturation and symmetrical return of function need to be more carefully evaluated to reduce the risk of reinjury.