Athletic Performance at the NFL Scouting Combine After Anterior Cruciate Ligament Reconstruction

Global knee function rating more strongly influences adolescent athletes that sustain a sports-related surgical ACL re-injury or contralateral ACL injury

PURPOSE

This study evaluated differences between adolescent athletes who sustained a surgical anterior cruciate ligament (ACL) re-injury, or contralateral ACL injury following return to sports bridge programme participation (Group 1) compared to those that did not (Group 2).

METHODS

At 19.9 ± 7 years of age, 198 athletes participated in this study. Groups were compared for time postsurgery, preprogramme and postprogramme Knee Outcome Survey Sports Activity Scale (KOS-SAS) and global rating of knee function (GRKF) during sports activities, postprogramme lower extremity physical function test performance and perceived sports performance compared to preinjury level.

RESULTS

By 6.0 ± 3.2 years postsurgery, 11 (5.6%) sustained another ACL injury. Group 1 was younger (17.3 ± 1.7 years vs. 20.1 ± 6.8 years, p < 0.001). Postprogramme re-evaluation revealed that Group 1 had a greater GRKF compared to their programme initiation GRKF than Group 2 (32.6 ± 38 vs. 20.0 ± 23, p = 0.04). Group 1 also had a greater mean preprogramme to postprogramme GRKF change than Group 2 (51.3 ± 31 vs. 35.5 ± 21, p = 0.02) (effect size = 0.73). More Group 1 subjects also had a GRKF difference that exceeded the overall mean than Group 2 (p = 0.04). Group 1 had moderately strong relationships between preprogramme and postprogramme GRKF score change and the postprogramme GRKF score (r = 0.65, p = 0.04) and between preprogramme and postprogramme KOS-SAS score change and postprogramme GRKF score (r = 0.60, p = 0.04).

CONCLUSION

Global rating scores had a stronger influence among adolescent athletes that sustained either surgical ACL re-injury or contralateral ACL injury. Since group physical function and neuromuscular control factors were similar, clinicians need to increase their awareness and understanding of other factors that may influence surgical ACL re-injury or contralateral ACL injury risk.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Anterior Cruciate Ligament Reconstruction Return-to-Sport Decision-Making: A Scoping Review

CONTEXT

Clinical guidelines support the use of testing batteries to assess athlete readiness for return to sport (RTS) and risk of reinjury after anterior cruciate ligament (ACL) reconstruction (ACL-R). There is no consensus on the composition of the testing batteries. Test selection is based mainly on commonality in research, personal preference, and equipment availability. Including athletic performance assessments (APA) used in the athlete's sport may assist RTS decision-making for stakeholders.

OBJECTIVE

To determine whether APA for speed, agility, strength, or cardiovascular endurance are (1) used in ACL-R RTS literature and (2) indicative of RTS or reinjury rates.

DATA SOURCES

A systematic search was performed in MEDLINE, EMBASE, CINAHL, SPORTDiscus, Scopus, Web of Science, and ProQuest Dissertations and Theses Global.

STUDY SELECTION

Eligibility criteria were as follows: (1) athletes between 6 months and 2 years post-ACL-R, (2) commonly used APA, (3) peer-reviewed primary study with original published data.

STUDY DESIGN

Scoping Review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

A total of 17 studies included 24 instances of APA with a high degree of heterogeneity for both tests and protocols.

RESULTS

Agility makes up 75% of the APA. Only 17.6% of studies reported RTS or reinjury rates, none of which reported a significant relationship between these rates and APA outcomes.

CONCLUSION

Speed, strength, and cardiovascular endurance tests are underrepresented in ACL-R RTS literature. Compared with healthy controls, deficits in APA results for ACL-R athletes were common; however, many studies reported significant improvements in results for ACL-R athletes over time. There is some evidence that well-trained ACL-R athletes can match the performance of uninjured athletes in high-level sports.

Return to play in elite rugby players after severe knee injuries

Background

Medical professionals working in an elite sport environment have the challenging task to balance the athlete's readiness to return to the playing field after severe injury with other stakeholders' (coaches, sponsors, teammates) opinions and objectives.

Objectives

Our study aimed to evaluate differences in the physical profiles of elite rugby players at return to play (RTP) after a severe knee injury, compared with their pre-injury profiles and matched controls.

Method

Before the injury, participants performed four performance tests during their preseason screening. These tests were repeated and compared to baseline once a player was declared fit to play.

Results

Significant differences (p ≤ 0.05) were found in the injured players' group who were slower over 10 m speed, in their decision-making time and the total time of the reactive agility tests at RTP, whilst controls were significantly faster over 10 m and 30 m speed tests. The countermovement jump outcomes showed significant improvement in the uninjured participants (p ≤ 0.05).

Conclusion

Our study highlights that injured players' running speeds and decision-making times are slower after injury. The uninjured players have a positive outcome to training and match stimulus by improving their running speed and lower body explosive power during the season.

Clinical implications

Our study provides insight into the RTP profile of elite rugby players, and a novel finding was the decision-making time deficit. This highlights the importance of cognitive training during injury rehabilitation as athletes make numerous decisions in a pressured and uncontrolled environment during a match. Speed training development is recommended as the athletes were slower after severe knee injury.

National Football League Wide Receivers and Running Backs Have Decreased Production Following ACL Reconstruction: An Evaluation of Fantasy Football Performance as an Outcome Measure

Purpose

To use fantasy football points as a simple measure alongside on-field statistics to compare performance in National Football League (NFL) offensive skill position players before and after anterior cruciate ligament (ACL) reconstruction.

Methods

A retrospective review of all NFL quarterbacks (QB), running backs (RB), wide receivers (WR), and tight ends (TE) who sustained an isolated, unilateral ACL injury from 1988 to 2017 was conducted. Data were collected from public data sources, team releases, NFL injury reports, press releases, and other Internet resources. For each player, a matched control with similar demographics was identified. Their in-game performance post-ACL reconstruction was analyzed using fantasy football points as an outcome measure.

Results

A total of 13 QBs, 30 RBs, and 29 WRs who underwent ACL reconstruction from 1988 to 2017 and who met inclusion criteria were retrospectively identified and reviewed. Of the 13 quarterbacks included in the study, there was no statistically significant difference in fantasy football points between the pre- and post-ACL reconstruction groups, as well as post-ACL and matched control groups. There was a statistically significant decrease in career fantasy football performance of running backs post-ACL reconstruction compared with matched control groups (129.6 vs 553.6; P < .0001). There was also a statistically significant decrease in per game fantasy football points post-ACL reconstruction (4.4 vs 11.2; P < .0001). Lastly, WRs also demonstrated a decrease in career fantasy football performance post-ACL reconstruction compared with matched controls (145.3 vs 460.9; P = .002). In addition, they also had a decrease in per game fantasy football performance (5.0 vs 7.7; P = .042).

Conclusions

Quarterbacks did not have a statistically significant decrease in performance following ACL reconstruction based on fantasy football performance. Conversely, both running backs and wide receivers had decreased per game and career performance post-ACL reconstruction based on their fantasy football statistics. Furthermore, RBs had the largest decline in production each season over a 3-year period following ACLR compared to QBs and WRs, respectively.

Level of Evidence

Level III, case-control study.

Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in National Football League Players

Background:

Considerable variability exists in return-to-play rates after anterior cruciate ligament (ACL) injury and reconstruction (ACLR) among National Football League (NFL) players of different positions.

Purpose/Hypothesis:

The purpose of this study was to compare return-to-play and performance levels by position in NFL players after ACLR. It was hypothesized that (1) ACL injuries have significant effects on the careers of NFL players, including return to play and performance, and (2) players of certain positions that involve relatively less pivoting and cutting perform better after ACLR.

Study Design:

Descriptive epidemiology study.

Methods:

All NFL players who underwent ACLR between 2013 and 2018 were identified using the FantasyData injury database. Player characteristics, snap count, games played, games started, and performance metrics were collected for 3 years before and after injury using the Pro Football Reference database. Performance was measured using an approximate value (AV) algorithm to compare performance across positions and over time. Nonparametric tests were used to compare the pre- and postinjury data and the percentage change in performance between different positions.

Results:

Overall, 312 NFL players were included in this study, and 174 (55.8%) returned to play. Of the eligible players, only 28.5% (n = 59/207) remained in the league 3 years postinjury. Within the first 3 years postinjury, players played in fewer games (8.7 vs 13.7; P < .0001), started in fewer games (3.0 vs 8.3; P < .0001), had lower AVs (1.5 vs 4.3; P < .0001), and had decreased snap counts (259.0 vs 619.0; P < .0001) compared with preinjury. Quarterbacks were most likely to return to play (92.9% vs 53.7%; P = .0040) and to return to performance (2% vs 50% decrease in AV; P = .0165) compared with the other positions. Running backs had the largest decrease in AV (90.5%), followed by defensive linemen (76.2%) and linebackers (62.5%).

Conclusion:

The study findings indicated that NFL players are severely affected by ACL injury, with only 28.5% still active in the league 3 years after the injury. Running backs, defensive linemen, and linebackers performed the worst after injury. Quarterbacks were most likely to return to play and had superior postinjury performance compared with the other positions.

Multiple ACL Revision: Failure Analysis and Clinical Outcomes

Anterior cruciate ligament (ACL) reconstruction represents one of the most successful orthopedic surgical procedures. Nevertheless, ACL revisions are still very frequent, with a small but relevant number of failures. The purpose of this study is to analyze the failure causes and the clinical outcomes of patients who underwent a re-revision ACL reconstruction. Between January 2009 and December 2017, 263 ACL revisions were performed by a single senior surgeon. Seventeen patients (12 males and 5 females) underwent re-revision ACL reconstruction meeting the inclusion criteria. The mean age was 28.4 years (range, 19-41 years). Before the re-revision, the patients were evaluated preoperatively and after a mean follow-up of 29 months (range, 13-58 months). Assessment included subjective and objective evaluations (Lysholm and International Knee Documentation Committee [IKDC]), KT-2000 arthrometer, radiographic study, and preoperative computed tomography scan. Five patients showed a too anterior previous femoral tunnel and seven a too vertical and posterior tibial tunnel; eight meniscal tears were found. Five patients had grade III-IV according to Outerbridge cartilage lesions. IKDC showed a statistically significant improvement (A + B 35%, C + D 65% preop, A + B 82%, C + D 18% postop, odds ratio: 0.1169; p = 0.0083). The mean Lysholm score ranged from 43 ± 9 to 87 ± 7 (p < 0.001). The KT-2000 arthrometer showed a statistically significant improvement from a mean of 5.8 ± 1.4 to 1.5 ± 1.1 (p < 0.001) at last follow-up. Out of 17 patients, only 4 returned to sports activity at the same preinjury levels. Postoperatively at the last follow-up after last revision surgery, no osteoarthritis evolution was observed. This study showed good clinical and radiological results after the last revision ACL surgery in patients with multiple failures of ACL reconstruction but only one-fourth of the patients returned to the same preoperative sport level. Traumatic events, technical errors, and untreated peripheral lesions are the main causes of multiple previous failures; the worst clinical outcomes were found in the patients with high grade of chondral lesions.

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 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.

Return to sports bridge program improves outcomes, decreases ipsilateral knee re-injury and contralateral knee injury rates post-ACL reconstruction

PURPOSE

To present the results of a return to sports bridge program designed to reduce knee injuries following ACL reconstruction and physical therapy.

METHODS

One hundred and fifty (male = 83, female = 67) patients participated in a whole body neuromuscular control, progressive resistance strength and agility training program. Post-program testing included functional movement form, dynamic knee stability, lower extremity power, agility, and sports skill assessments. Participants completed the Knee Outcome Survey-Sports Activity Scale (KOS-SAS) before and after program initiation. Pre-participation scores were re-estimated following program completion.

RESULTS

Global rating KOS-SAS score at program entry was 75 ± 13. Post-program global rating and calculated KOS-SAS were 91.0 ± 9.8 and 90.9 ± 9.7, respectively (p < 0.0001). Pre-participation KOS-SAS score re-estimates at program completion were 54.5 ± 23.3 and 57.3 ± 18.5, respectively. The approximately 20% lower pre-program KOS-SAS score re-estimates (p < 0.0001) observed at program completion suggests that subjects had inaccurately high sports readiness perceptions at program entry. Perceived overall sports activity knee function ratings improved from 2.9 ± 0.6 (abnormal) at program entry to 1.3 ± 0.5 (normal) at completion (p < 0.0001). Most subjects returned back to sports at or above their pre-injury performance skill/performance level (84%, 126/150). By 6.8 ± 3.2 years (range = 2-13 years) post-surgery, ten subjects had sustained an ipsilateral knee re-injury or contralateral knee injury (6.7%). The 2.7% non-contact contralateral and 1.3% non-contact ipsilateral knee injury rates observed were significantly lower than those cited in previous reports.

CONCLUSION

Supplementing primary ACL reconstruction and standard physical therapy with a return to sports bridge program prior to release to unrestricted sports performance was effective at improving patient outcomes and decreasing ipsilateral knee re-injury and contralateral knee injury rates.

LEVEL OF EVIDENCE

II.

National Basketball Association combine performance after a partial meniscectomy

BACKGROUND

An arthroscopic meniscectomy is one of the most common orthopedic procedures in athletes. Return to play rates and deficits in muscle function have been reviewed after meniscectomy, but no study has reviewed functional performance after an isolated partial meniscectomy.

HYPOTHESIS/PURPOSE

To compare the performance of elite-level basketball players after a partial meniscectomy to a control group of players with no previous reported knee injury. We believe that there is no difference between the two groups in functional performance.

STUDY DESIGN

Case Series.

METHODS

Functional performance results from the National Basketball Association (NBA) combine were reviewed between 2000 and 2015. Twelve out of 1092 players were found to have undergone a partial meniscectomy prior to competing in the NBA combine. The partial meniscectomy group was compared to an age-, size-, and position-matched control group with respect to functional performance testing such as the shuttle run test, lane agility test, ¾ court sprint, vertical jump (no step), and vertical jump (max).

RESULTS

The meniscectomy and the control groups that there was no significant difference between the two groups in agility, quickness, sprinting, and jumping ability. However, there was a - 0.596 spearman correlation between months after surgery and agility (p = 0.041), while there was a + 0.690 and + 0.650 spearman correlation between both months after surgery and standing vertical and max vertical (p = 0.013 and p = 0.022).

CONCLUSIONS

Athletes competing in the NBA combine who have undergone a partial meniscectomy perform as well as uninjured athletes in all NBA combine performance testing. Furthermore, as athletes are further out from surgery, they have an improvement in both standing and max vertical jump.

A Systematic Review of the Orthopaedic Literature Involving National Football League Players

Background

Orthopaedic injuries of National Football League (NFL) players can have a deleterious effect on their health, with minimal to no high-level evidence on the management of these injuries.

Purpose

To summarize all data published between January 1980 and March 2018 on orthopaedic injuries experienced by NFL candidates and professional players in the NFL.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search of studies examining orthopaedic injuries in the NFL was performed through the PubMed, Embase, and CINAHL databases. The review included studies of orthopaedic injuries in college football recruits attending the NFL Combine as well as professional NFL players. Excluded were studies of nonorthopaedic injuries, such as concussions, traumatic brain injury, facial injuries, and vascular injuries, as well as case reports.

Results

A total of 147 articles met the inclusion criteria and were divided into 11 topics based on anatomic site: general (16%), spine (13%), shoulder (13%), elbow (3%), hand and wrist (3%), trunk (0.7%), hip and pelvis (7%), thigh (3%), knee (24%), ankle (5%), and foot (12%). Of these studies, 74% were of level 4 evidence. Most studies obtained data from the NFL Combine database (26%), by searching the internet (24%), and via the NFL Injury Surveillance System (22%). Studies using internet search methods to identify injuries consistently found fewer participants than studies using the NFL Injury Surveillance System.

Conclusion

This systematic review provides National Collegiate Athletic Association and NFL team physicians with a single source of the most current literature regarding orthopaedic injuries in NFL players. Most research was published on knee, spine, shoulder, and foot injuries and consisted of level 4 evidence. A substantial portion of the published literature was based on data obtained from internet searches and may not accurately represent the NFL population.

Impact of Anterior Cruciate Ligament Reconstruction on NCAA FBS Football Players: Return to Play and Performance Vary by Position

Background:

Anterior cruciate ligament (ACL) injuries are devastating for college football players. Although the change in functional performance of National Collegiate Athletic Association (NCAA) football players after reconstruction has been shown to be negligible, studies have failed to analyze the statistical performance of these players upon their return.

Purpose/Hypothesis:

The purpose of this study was to quantify the impact of ACL reconstruction on the statistical performance of collegiate football players. We hypothesized that statistical performance would vary by position and that running backs, wide receivers, and defensive backs, compared with preinjury and controls, would experience the largest decline in performance after returning from ACL reconstruction.

Study Design:

Descriptive epidemiology study.

Methods:

NCAA Football Bowl Subdivision (FBS) football players who experienced ACL tears between the years 2010 and 2015 were identified. The rates of return to play after surgery were determined for each position. Preinjury and postoperative performance statistics of each running back, receiver, defensive lineman, linebacker, and defensive back who met inclusion criteria were compared. A t-test analysis was used to compare the performance changes experienced by these players versus the performance changes of matched controls.

Results:

A total of 349 players were identified. Only 63.64% of eligible offensive linemen returned to play. Upon return, running backs experienced significant performance decreases compared with controls in carries (mean ± SD, –2.4 ± 2.7 vs 2.8 ± 1.6; P = .003), yards (–12.3 ± 15.5 vs 13.8 ± 7.8; P = .006), and receptions (–0.22 ± 0.32 vs 0.32 ± 0.23; P = .011) per game. Receivers displayed significant performance decreases compared with controls in number of touchdowns (–0.019 ± 0.110 vs 0.18 ± 0.06; P = .004), receptions (–0.11 ± 0.79 vs 1.2 ± 0.4; P = .004), and yards (–3.2 ± 10.6 vs 18.6 ± 5.4; P = .0009) per game. Linebackers demonstrated less improvement than controls in tackles for loss (0.007 ± 0.115 vs 0.31 ± 0.11; P = .0003) and sacks (0.001 ± 0.061 vs 0.10 ± 0.06; P = .026).

Conclusion:

Although offensive linemen were the least likely to return to play, running backs and receivers returned to play at a lower level of performance. The performance of defensive players was less affected by ACL reconstruction.

Athletes With Musculoskeletal Injuries Identified at the NFL Scouting Combine and Prediction of Outcomes in the NFL: A Systematic Review

Background:

Prior to the annual National Football League (NFL) Draft, the top college football prospects are evaluated by medical personnel from each team at the NFL Scouting Combine. On the basis of these evaluations, each athlete is assigned an orthopaedic grade from the medical staff of each club, which aims to predict the impact of an athlete’s injury history on his ability to participate in the NFL.

Purpose:

(1) To identify clinical predictors of signs, symptoms, and subsequent professional participation associated with football-related injuries identified at the NFL Combine and (2) to assess the methodological quality of the evidence currently published.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We reviewed all studies that examined musculoskeletal injuries identified among athletes at the NFL Combine and associated outcomes. Data on signs, symptoms, and subsequent NFL participation were collected, and the methodological quality of the studies was assessed.

Results:

Overall, 32 studies, including 30 injury-specific studies, met the inclusion criteria. Twenty studies analyzed data collected at the NFL Combine from 2009 and later. When compared with matched controls, athletes with a history of a cervical or lumbar spine injury, rotator cuff repair, superior labrum anterior-posterior repair, anterior cruciate ligament reconstruction, full-thickness chondral lesions of the knee, or Lisfranc injury played in significantly fewer games early in their NFL careers. Additionally, athletes with a history of a cervical or lumbar spine injury, rotator cuff repair, and navicular injury had decreased career lengths versus controls. Defensive players and linemen were found to have decreased participation in the NFL for several injuries, including prior meniscectomy, anterior cruciate ligament reconstruction, and shoulder instability. Career length follow-up, measures of athletic participation, and matching criteria were highly variable among studies.

Conclusion:

For medical professionals caring for professional football athletes, this information can help guide orthopaedic grading of prospects at the NFL Combine and counseling of athletes on the potential impact of prior injuries on their professional careers. For future studies, improvements in study methodology will provide greater insight into the efficacy of current treatments and areas that require further understanding.

Return to Sport-Specific Performance After Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review

BACKGROUND

Physicians counseling athletes on the prognosis of sport-specific performance outcomes after anterior cruciate ligament reconstruction (ACLR) depend on the published literature. However, critical appraisal of the validity and biases in these studies is required to understand how ACLR affects an athlete's ability to return to sport, the athlete's sport-specific performance, and his or her ability to achieve preinjury levels of performance.

PURPOSE

This review identifies the published prognostic studies evaluating sport-specific performance outcomes after ACLR. A risk of bias assessment and summaries of return to sport and career longevity results are provided for each included study.

STUDY DESIGN

Systematic review.

METHODS

Electronic databases (Ovid MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and PUBMED) were searched via a defined search strategy with no limits, to identify relevant studies for inclusion in the review. A priori defined eligibility criteria included studies measuring sport-specific performance within an athlete's sport, before and after primary ACLR. Reference lists of eligible studies were hand-searched for additional relevant studies. Data extraction was performed by use of a standardized spreadsheet. Each included study was assessed by use of 6 bias domains of the Quality in Prognosis Studies tool to critically appraise study participation, study attrition, prognostic factors, outcome measurement, confounders, and statistical analysis and reporting. Two authors independently performed each stage of the review and reached consensus through discussion.

RESULTS

Fifteen pertinent prognostic studies evaluated sport-specific performance outcomes and/or return to play after ACLR for athletes participating in competitive soccer, football, ice hockey, basketball, Alpine ski, X-Games ski and snowboarding, and baseball. Twelve of these studies were considered to have a high level of bias.

CONCLUSION

This review demonstrated that most high-performance or professional athletes returned to their preinjury level of sport after ACLR. The bulk of evidence suggests there was a measurable decrease in performance statistics, although this is highly sport-specific. A paucity of literature is available that addresses sport-specific performance in athletes after ACLR. This review has determined that the available literature is highly biased and must be read with caution.

CLINICAL RELEVANCE

By better understanding the validity and biases in the published literature, physicians can provide more informed prognoses about return to sport-specific performance after ACLR while considering risk factors relevant to their patients.

REGISTRATION

CRD42016046709 (International Prospective Register of Systematic Reviews, https://www.crd.york.ac.uk/prospero/ ).

A History of Anterior Cruciate Ligament Reconstruction at the National Football League Combine Results in Inferior Early National Football League Career Participation

PURPOSE

To evaluate whether players with a history of an anterior cruciate ligament reconstruction (ACLR) before the National Football League (NFL) Combine played or started fewer games and/or participated in fewer eligible snaps compared with NFL Combine participants without a history of knee injury or surgery.

METHODS

We performed a retrospective review of all players who participated in the NFL Combine between 2009 and 2015 and who had a history of an ACLR. NFL Combine participants were included if they had a previous ACLR or combined anterior cruciate ligament (ACL) injury and nonoperatively managed medial collateral ligament injury. The number of games started, number of games played, draft number, overall draft pick, and snap percentage for each position were determined. The mean value of each outcome metric was compared between case and control players.

RESULTS

We identified 110 players who had an ACL injury (n = 76) or a combined ACL and medial collateral ligament injury (n = 34). Players in the ACLR group had a significantly worse mean draft pick number (difference of 30.2, P = .002) and mean draft round (difference of 0.8, P = .019) versus controls. Compared with control players, players in the ACLR group started and played significantly fewer games in both season 1 (difference of 2.7 games started, P < .001; difference of 2.7 games played, P < .001) and season 2 (difference of 7.4 games started, P < .001; difference of 3.0 games played, P = .003) and had a significantly lower snap percentage in both season 1 (difference of 23.1%, P < .001) and season 2 (difference of 24.0%, P < .001).

CONCLUSIONS

Athletes at the NFL Combine who previously underwent an ACLR had significantly lower early-career NFL player metrics, including fewer games started, fewer games played, and a lower snap percentage, than uninjured controls. Defensive linemen, defensive backs, and linebackers were the 3 most affected positions. Players with a prior ACLR and combined meniscal-chondral pathology had significantly lower numbers of games started and games played in seasons 1 and 2 and a significantly lower season 2 snap percentage.

LEVEL OF EVIDENCE

Level III, case-control study.

Return to Play After Multiligament Knee Injuries in National Football League Athletes

Background:

Return to play (RTP) of National Football League (NFL) athletes after isolated anterior cruciate ligament (ACL) tears has been reported. However, no studies have reported on RTP of NFL athletes after multiligament knee injuries.

Hypotheses:

NFL athletes with multiligament knee injuries have lower RTP rates and longer recoveries than athletes with isolated ACL tears. Second, athletes with ACL and medial collateral ligament (MCL) injuries will have higher RTP rates and shorter time to RTP than athletes with an ACL tear and posterolateral corner involvement.

Study Design:

Retrospective cohort study.

Level of Evidence:

Level 4.

Methods:

Publicly available NFL injury data were reviewed for all multiligament knee injuries incurred between 2000 and 2016 with RTP information. Athletes were excluded if RTP was limited for reasons unrelated to the injury. Extracted data included type of injury, RTP, time to RTP (days), number and percentage of games played, and performance.

Results:

A total of 50 NFL athletes with multiligament knee injuries met inclusion and exclusion criteria. The overall RTP rate was 64.0%. Athletes with ACL/MCL tears had an RTP rate of 70.8%, whereas athletes with ACL and posterior collateral ligament/lateral collateral ligament (PCL/LCL) tears had an RTP rate of 55.6% (P = 0.26). Mean time to RTP for all 50 athletes was 388.71 ± 198.52 days. The mean time to RTP for athletes with ACL/MCL injuries was 305.1 ± 58.9 days, compared with 459.2 ± 245.1 days (P = 0.004) and 609.3 ± 183.1 days (P < 0.0001) for those with combined ACL and PCL/LCL injuries and frank knee dislocations, respectively. Athletes with ACL/MCL injuries were more likely to return to prior performance level (43.5%) than those with ACL and PCL/LCL injuries (18.5%) (P < 0.001).

Conclusion:

The RTP rate for athletes with multiligament knee injuries is significantly less than the RTP rate for athletes with isolated ACL tears. In addition, athletes with ACL and MCL tears have a higher RTP rate, a significantly shorter time to RTP, and a greater likelihood of returning to prior performance than athletes with ACL and PCL/LCL tears.

Clinical Relevance:

Multiligament knee injuries significantly affect the ability of a football player to return to sport. ACL and MCL tears are associated with better RTP prognosis compared with ACL and PCL/LCL tears.

Anterior Cruciate Ligament Injury: Return to Play, Function and Long-Term Considerations

Anterior cruciate ligament tears are common and affect young individuals who participate in jumping and pivoting sports. After injury many individuals undergo ligament reconstruction (ACLR) but do not return to play, suffer recurrent injury and osteoarthritis. Outcome studies show that after ACLR, 81% of individuals return to sports, 65% return to their preinjury level and 55% return to competitive sports. Systematic reviews place the risk of ipsilateral retears at 5.8% and contralateral injuries at 11.8%, with recent reports of over 20% failure rate. Approximately 20% to 50% of patients will have evidence of OA within 10 to 20 yr. Factors important in reducing complications include timing of surgery, individualized return to play protocols, and prevention programs for injury. Further understanding of the factors that increase return to play percentages, reduce the risk of recurrent injury and improve long-term outcomes after ACL injury is needed to reduce the burden of these injuries on society.

National Football League Skilled and Unskilled Positions Vary in Opportunity and Yield in Return to Play After an Anterior Cruciate Ligament Injury

BACKGROUND

Anterior cruciate ligament (ACL) injuries pose a significant risk to the careers of players in the National Football League (NFL). The relationships between draft round and position on return to play (RTP) among NFL players are not well understood, and the ability to return to preinjury performance levels remains unknown for most positions.

PURPOSE

To test for differences in RTP rates and changes in performance after an ACL injury by position and draft round. We hypothesized that skilled positions would return at a lower rate compared to unskilled positions. We further hypothesized that early draft-round status would relate to a greater rate of RTP and that skilled positions and a lower draft round would correlate with decreased performance for players who return to sport.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Utilizing a previously established database of publicly available information regarding ACL tears among NFL players, athletes with ACL tears occurring between the 2010 and 2013 seasons were identified. Generalized linear models and Kaplan-Meier time-to-event models were used to test the study hypotheses.

RESULTS

The overall RTP rate was 61.7%, with skilled players and unskilled players returning at rates of 64.1% and 60.4%, respectively (P = .74). Early draft-round players and unskilled late draft-round players had greater rates of RTP compared to skilled late draft-round players and both unskilled and skilled undrafted free agents (UDFAs). Skilled early draft-round players constituted the only cohort that played significantly fewer games after an injury. Unskilled UDFAs constituted the only cohort to show a significant increase in the number of games started and ratio of games started to games played, starting more games in which they played, after an injury.

CONCLUSION

Early draft-round and unskilled players were more likely to return compared to their later draft-round and skilled peers. Skilled early draft-round players, who displayed relatively high rates of RTP, constituted the only cohort to show a decline in performance. Unskilled UDFAs, who exhibited relatively low rates of RTP, constituted the only cohort to show an increase in performance. The significant effect of draft round and position type on RTP may be caused by a combination of differences in talent levels and in opportunities given to returning to play.

Epidemiology of Injuries Identified at the NFL Scouting Combine and Their Impact on Performance in the National Football League: Evaluation of 2203 Athletes From 2009 to 2015

Background:

At the annual National Football League (NFL) Scouting Combine, the medical staff of each NFL franchise performs a comprehensive medical evaluation of all athletes potentially entering the NFL. Currently, little is known regarding the overall epidemiology of injuries identified at the combine and their impact on NFL performance.

Purpose:

To determine the epidemiology of injuries identified at the combine and their impact on initial NFL performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

All previous musculoskeletal injuries identified at the NFL Combine from 2009 to 2015 were retrospectively reviewed. Medical records and imaging reports were examined. Game statistics for the first 2 seasons of NFL play were obtained for all players from 2009 to 2013. Analysis of injury prevalence and overall impact on the draft status and position-specific performance metrics of each injury was performed and compared with a position-matched control group with no history of injury or surgery.

Results:

A total of 2203 athletes over 7 years were evaluated, including 1490 (67.6%) drafted athletes and 1040 (47.2%) who ultimately played at least 2 years in the NFL. The most common sites of injury were the ankle (1160, 52.7%), shoulder (1143, 51.9%), knee (1128, 51.2%), spine (785, 35.6%), and hand (739, 33.5%). Odds ratios (ORs) demonstrated that quarterbacks were most at risk of shoulder injury (OR, 2.78; P = .001), while running backs most commonly sustained ankle (OR, 1.39; P = .040) and shoulder injuries (OR, 1.55; P = .020) when compared with all other players. Ultimately, defensive players demonstrated a greater negative impact due to injury than offensive players, with multiple performance metrics significantly affected for each defensive position analyzed, whereas skilled offensive players (eg, quarterbacks, running backs) demonstrated only 1 metric significantly affected at each position.

Conclusion:

The most common sites of injury identified at the combine were (1) ankle, (2) shoulder, (3) knee, (4) spine, and (5) hand. Overall, performance in the NFL tended to worsen with injury history, with a direct correlation found between injury at a certain anatomic location and position of play. Defensive players tended to perform worse compared with offensive players if injury history was present.

Return to Play After Revision Anterior Cruciate Ligament Reconstruction in National Football League Players

Background:

National Football League (NFL) players who undergo anterior cruciate ligament (ACL) reconstruction have been shown to have a lower return to play (RTP) than previously expected. However, RTP in the NFL after revision ACL reconstruction (RACLR) is not well defined.

Purpose/Hypothesis:

The purpose of this study is to determine the RTP of NFL players after RACLR and evaluate factors that predict RTP. Our hypothesis was that more experienced and established players would be more likely to RTP after RACLR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 24 NFL players who underwent RACLR between 2007 and 2014 were reviewed and evaluated. Return to NFL play, time to return, seasons and games played prior to and after revision surgery, draft status, and demographic data were collected. Overall RTP was determined, and players who did RTP were compared with those unable to RTP. Data were also compared with control players matched for age, position, size, and experience.

Results:

After RACLR, 79% (19/24) of NFL players returned to NFL regular-season play at an average of 12.6 months. All players who were drafted in the first 4 rounds, played in at least 55 games, or played 4 seasons of NFL play prior to injury were able to RTP. Players drafted in the first 4 rounds of the NFL draft were more likely to RTP than those who were not (odds ratio, 0.1; 95% CI, 0.01-1.00; P = .05). Those who returned to NFL play played in significantly less games and seasons after their injury than before (P = .01 and P = .01, respectively). However, these values did not differ when compared with matched controls (P = .67 and P = .33).

Conclusion:

NFL players who RTP after RACLR do so at a similar rate but prolonged time period compared with after primary ACL reconstruction. Athletes who were drafted in earlier rounds were more likely to RTP than those who were not. Additionally, player experience prior to injury is an important factor when predicting RTP after RACLR.

Return to Play Following Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstructions are commonly performed in an attempt to return an athlete to sports activities. Accelerated rehabilitation has made recovery for surgery more predictable and shortened the timeline for return to play. Despite success with and advancements in anterior cruciate ligament reconstructions, some athletes still fail to return to play.

Athletic Performance at the National Basketball Association Combine After Anterior Cruciate Ligament Reconstruction

Background:

Anterior cruciate ligament (ACL) injuries are significant injuries in elite-level basketball players. In-game statistical performance after ACL reconstruction has been demonstrated; however, few studies have reviewed functional performance in National Basketball Association (NBA)–caliber athletes after ACL reconstruction.

Purpose:

To compare NBA Combine performance of athletes after ACL reconstruction with an age-, size-, and position-matched control group of players with no previous reported knee injury requiring surgery. We hypothesized that there is no difference between the 2 groups in functional performance.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 1092 NBA-caliber players who participated in the NBA Combine between 2000 and 2015 were reviewed. Twenty-one athletes were identified as having primary ACL reconstruction prior to participation in the combine. This study group was compared with an age-, size-, and position-matched control group in objective functional performance testing, including the shuttle run test, lane agility test, three-quarter court sprint, vertical jump (no step), and maximum vertical jump (running start).

Results:

With regard to quickness and agility, both ACL-reconstructed athletes and controls scored an average of 11.5 seconds in the lane agility test and 3.1 seconds in the shuttle run test (P = .745 and .346, respectively). Speed and acceleration was measured by the three-quarter court sprint, in which both the study group and the control group averaged 3.3 seconds (P = .516). In the maximum vertical jump, which demonstrates an athlete’s jumping ability with a running start, the ACL reconstruction group had an average height of 33.6 inches while the controls averaged 33.9 inches (P = .548). In the standing vertical jump, the ACL reconstruction group averaged 28.2 inches while the control group averaged 29.2 inches (P = .067).

Conclusion:

In athletes who are able to return to sport and compete at a high level such as the NBA Combine, there is no significant difference in any combine performance test between players who have had primary ACL reconstruction compared with an age-, size-, and position-matched control group.

Clinical Relevance:

Athletes with previous ACL reconstruction who are able to return to high-level professional basketball have equivalent performance measures with regard to speed, quickness, and jumping ability as those athletes who have not undergone knee surgery.