Return to Play and Performance After Jones Fracture in National Basketball Association Athletes

Auditing the Representation of Female Athletes in Sports Medicine Research: Fifth-Metatarsal Fractures

Background

Female representation within athletics has increased as a result of Title IX, rising popularity, demand for equal compensation, and greater participation in multiple sports. Despite this, gender disparities in sports medicine research are apparent. This project serves to review the literature available on fifth-metatarsal fractures and assess the representation of female athletes in current literature.

Methods

We used a standardized protocol to audit the representation of female athletes in sports science and sports medicine research for fifth-metatarsal fractures. Primary factors included population, athletic caliber, menstrual status, research theme, sample of males and females, journal impact factor, and Altmetric score.

Results

Thirty articles met the inclusion criteria. A total of 472 fifth-metatarsal fractures were identified, with 373 of 472 fractures (79%) occurring in males and 99 of 472 (21%) in females. The majority of studies (18/30, 60%) were mixed cohort, followed by 10 male only (33.33%), 1 female only (3.33%), and 1 male vs female (3.33%). Out of 831 total patients in the 18 mixed-cohort studies, 605 of 831 patients (72.8%) were male and 226 of 831 patients (27%) were female. All 18 mixed-sex cohorts investigated health outcomes. Male-only studies evaluated health outcomes and performance metrics. No studies investigated female performance. The one female-only study investigated health outcomes and was the only study to account for menstrual status. There was a single metatarsal fracture in this study population.

Conclusion

Females are underrepresented in research regarding sports science and sports medicine research for fifth-metatarsal fractures. Research focused on female-only fifth-metatarsal fracture studies exploring the potential impact of female sex-specific factors such as menstrual status in study design are needed.

The Impact of Wrist Fractures on Long-Term Basketball Performance

Background

Wrist joint fractures may present challenging obstacles for the rehabilitating athlete upon return to play. Although current literature has examined the effects of specific injuries to the upper extremity for basketball athletes, little is known about long-term performance outcomes following wrist joint fractures.

Methods

Review of all National Basketball Association players who sustained wrist joint fractures was conducted. Player characteristics, preinjury and postinjury performance, and overall efficiency were analyzed.

Results

A total of 31 players were deemed appropriate for inclusion, with an average age of 26.2 ± 4.3 years and a mean of 5.2 ± 3.6 years played before injury and 4.1 ± 3.1 years played upon return. Operative management was pursued in 48.4% of players. Players demonstrated a significant decrease in win shares before injury (mean: 24.3 ± 31.5) compared to after return from injury (mean: 9.6 ± 19.6) (p < 0.032). Multivariate regression demonstrated that increased points per game before injury (standardized β: 0.71; 95% confidence interval [CI]: 1.2-8.5, p < 0.011) and increased win shares before injury (β: 1.0; 95% CI: 1.4-9.5, p < 0.001) were both independently predictive with increased win shares after return to play. Player position, age, management type, and all other statistics were not significantly associated with any other findings upon return.

Conclusion

Overall efficiency following return to play in the setting of basketball-associated wrist joint fractures appears to be decreased in athletes. However, preinjury performance as captured through win share efficiency and points per game appears to be predictive of increased productivity after successful return.

Performance Outcomes and Return to Sport Following Metacarpal Fractures in Major League Baseball Players

BACKGROUND

Major League Baseball (MLB) players are at risk for metacarpal fractures; however, little is known regarding the impact of these injuries on future performance. The purpose of this study was to determine whether MLB players who sustain metacarpal fractures demonstrate decreased performance on return to competition in comparison to the performance of control-matched peers.

METHODS

Data for MLB position players with metacarpal fractures incurred over 17 seasons were obtained from injury reports, press releases, and player profiles. Age, position, career experience, body mass index (BMI), injury mechanism, handedness, and treatment were recorded. Individual season statistics for the 2 seasons immediately before injury and the 2 seasons after injury were obtained. Controls matched by player position, age, BMI, career experience, and performance statistics were identified. A performance comparison of the cohorts was performed.

RESULTS

Overall, 24 players met inclusion criteria. Eleven players with metacarpal fractures were treated with surgery (46%) and 13 (54%) were treated nonoperatively. Players treated nonoperatively missed significantly fewer games following injury compared with those treated operatively (35.5 vs 52.6 games, P = .04). There was no significant difference in postinjury performance when compared with preinjury performance among the fracture cohorts. Players with metacarpal fractures treated nonoperatively had a significant decline in their Wins Above Replacement (WAR) 2 seasons postinjury (1.37 point decline) in comparison to matched controls (0.84 point increase) (P = .02). There was no significant difference in WAR 1 or 2 seasons postinjury for players with metacarpal fractures treated operatively in comparison to the control cohort.

CONCLUSIONS

Major League Baseball players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. However, players treated nonoperatively may witness a decline in their performance compared with peers over the long term. Orthopedic surgeons treating professional athletes with metacarpal fractures should consider these outcomes when counseling their patients and making treatment recommendations.

Short-Term Outcomes of Jones-Specific Implant Versus Intramedullary Screw and Plate Fixation for Proximal Fifth Metatarsal Fractures

Although intramedullary screw fixation is commonly performed for proximal fifth metatarsal fractures, high rates of nonunion, refracture, and hardware prominence have been reported. The Jones Specific Implant (JSI) is a novel surgical implant which contours to the native curvature of the fifth metatarsal allowing for a more anatomic fixation. The purpose of this study was to compare short-term complication rates and outcomes of patients treated with the JSI to other fixation types such as plates and intramedullary screws. Electronic records were queried for adult patients with proximal fifth metatarsal fractures who underwent primary fixation from 2010 to 2021. All patients were treated by a foot and ankle fellowship-trained surgeon with intramedullary screws, plates, or JSI (Arthrex Inc., Naples, FL). Visual analog scale (VAS) and the American Orthopedic Foot and Ankle Score (AOFAS) were recorded and compared using univariate statistics. Eighty-five patients underwent fixation using intramedullary screw (n = 51, 60%), plate (n = 22, 25.9%), or JSI (n = 12, 14.1%) with a mean follow-up of 11.1 ± 14.6 months. The total cohort demonstrated a significant improvement in VAS pain (p < .0001) as well as AOFAS (p < .0001) scores. When comparing the cohort treated with JSI and the cohort treated with all other types of fixation, there were no significant differences in postoperative VAS or AOFAS scores. Only 3 complications, one with JSI (3.5%) required removal of the symptomatic hardware. The JSI is a novel treatment for proximal fifth metatarsal fractures, with similar early outcomes and complication rates when compared with intramedullary screw and plate fixation.

Return to play and performance in the National Basketball Association after undergoing operative or nonoperative treatment for foot fracture

Background

The incidence of distal lower extremity fractures in National Basketball Association (NBA) athletes continues to increase. There is a paucity of data regarding return-to-play (RTP) rates and performance after sustaining foot fractures in these athletes. The purpose of this study is to quantify RTP rates and performance in NBA players after sustaining a foot fracture.

Methods

Sixty-two NBA athletes suffered foot fractures between 2005 and 2021 according to publicly accessible online data. Each athlete was matched to a control player based on age at start of career, age at index injury year, body mass index (BMI), and position played. Performance statistics from 3 seasons prior and 3 seasons following the index injury season were recorded.

Results

We found that players who suffered foot fracture injuries are expected to make a full recovery and reach their previous level of performance within three years. 100% of players treated nonoperatively returned to play; meanwhile only 90% of players who were treated operatively returned to play. This difference is statistically significant.

Conclusion

NBA athletes have a high RTP rate after sustaining a foot fracture. Players may experience an initial decrease in playing time and performance when returning to play, however, these variables were found to return to baseline over time. After three seasons, player statistics returned to baseline in mostly every category, including player efficiency rating (PER). We found that players are expected to make a full recovery and return to their previous level of performance, regardless of whether they were treated operatively or not. Players treated nonoperatively returned to play at a rate of 100% meanwhile those treated operatively returned at a rate of 90%. Therefore, it is our recommendation that players opt for nonoperative treatment when possible.

Performance Is Regained Within 2 Seasons After Quadriceps Tendon Tears in National Basketball Association Players

Purpose

To characterize quadriceps tendon injuries over 30 National Basketball Association (NBA) seasons and assess the effects on player performance upon return to play.

Methods

Partial and complete quadriceps tendon tears in NBA players between the 1990-1991 and 2021-2022 seasons were queried from a publicly available database. The primary outcomes were changes in player performance statistics obtained from each player's preindex season and first 2 postindex seasons. These interseason changes were compared with the changes of a healthy control cohort. Each injured player was matched with 2 controls using position, career length and win shares by season. The secondary measure of this study was the rate of return to play.

Results

Nine quadriceps tendon tears (6 partial, 3 complete) were identified in NBA players. Seven (78%) of the players returned to play in NBA games, missing 50 ± 30 games and 214 ± 112 calendar days on average. Comparisons between these player's preindex and first postindex seasons revealed significant declines in games played (73.2 ± 6.6 vs 41.8 ± 10.8, P = .009) and minutes per game (27.2 ± 2.9 vs 23.0 ± 3.7, P = .042). When compared with controls, only the decrease in games played was significant (-31.3 ± 7.6 vs 1.4 ± 8.2, P = .004). These findings were consistent when comparing preindex and second postindex seasons (games played: 79.6 ± 1.9 vs -28.4 ± 5.4, P = .006; minutes per game: 29.3 ± 2.6 vs 51.2 ± 4.6, P = .003). All other player performance metrics including player efficiency rating returned to near-baseline levels in the first 2 seasons after injury.

Conclusion

NBA players with quadriceps tendon tears return to play in 78% of cases. These athletes achieved preinjury levels of performance within 1 to 2 seasons, but with reduced games played per season.

Level of Evidence

IV, therapeutic case series.

Surgical Management of Jones Fractures in Athletes: Orthobiologic Augmentation: A Systematic Review and Meta-analysis of 718 Fractures

BACKGROUND

The use of orthobiologics is expanding. However, the use of orthobiologic augmentation in primary fracture fixation surgery remains limited. Primary fracture fixation of the fifth metatarsal (Jones) in athletes is one of the rare situations where primary orthobiologic augmentation has been advocated.

PURPOSE

To determine the effect of orthobiologic augmentation on the outcome of surgically managed Jones fractures in athletes.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through March 2021 to identify studies reporting on surgically managed Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the return to play (RTP) rate and time to RTP, whereas the secondary outcomes were time to union, union rate, and refractures. Data were presented by type of treatment (biologically augmented fixation or fixation alone).

RESULTS

In the biologically augmented fixation group, successful RTP was reported in 195 (98.98%) of 197 fractures (odds ratio [OR], 97.5%; 95% CI, 95.8%-100%; I² = 0), with a mean time to RTP of 10.3 weeks (95% CI, 9.5-11.1 weeks; I² = 99%). In the group that received fixation without biological augmentation, successful RTP was reported in 516 (99.04%) of 521 fractures (OR, 98.7%; 95% CI, 97.8%-99.7%; I² = 0], with a mean time to RTP of 9.7 weeks (95% CI, 7.84-11.53 weeks; I² = 98.64%]. In the biologically augmented fixation group, fracture union was achieved in 194 (98.48%) of 197 fractures (OR, 97.6%; 95% CI, 95.5%-99.7%; I² = 0%), with a mean time to fracture union of 9.28 weeks (95% CI, 7.23-11.34 weeks; I² = 98.18%). In the group that received fixation without biological augmentation, fracture union was achieved in 407 (93.78%) of 434 fractures (OR, 97.4%; 95% CI, 96%-98.9%; I² = 0%), with a mean time to fracture union of 8.57 weeks (95% CI, 6.82-10.32 weeks; I² = 98.81%).

CONCLUSION

Orthobiologically augmented surgical fixation of Jones fractures in athletes is becoming increasingly common, despite the lack of comparative studies to support this practice. Biologically augmented fixation of Jones fractures results in higher fracture union rates than fixation alone but similar rates of RTP and time to RTP. Although the current evidence recommends primary surgical fixation for the management of Jones fractures in athletes, further high quality comparative studies are required to establish the indication for orthobiologic augmentation.

Systematic Review of Injuries in the Men's and Women's National Basketball Association

BACKGROUND

Numerous studies have reported the incidence and outcomes of injuries in the men's and women's National Basketball Association (NBA and WNBA, respectively).

PURPOSE

To synthesize published data regarding the incidence and outcomes of all injuries in the NBA and WNBA in a comprehensive review.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched 3 electronic databases (PubMed, MEDLINE, Embase) for studies of all levels of evidence since 1990 pertaining to injuries sustained by active players in the NBA and WNBA. Studies were excluded if the cohort of interest included ≤3 active players.

RESULTS

The initial search of the 3 databases yielded 1253 unique studies, of which 49 met final inclusion criteria for this review. Only 4 studies included athletes in the WNBA. Based on the mean annual incidence, the 5 most common orthopaedic sports injuries sustained in the NBA were concussions (9.5-14.9 per year), fractures of the hand (3.5-5.5 per year), lower extremity stress fractures (4.8 per year), meniscal tears (2.3-3.3 per year), and anterior cruciate ligament tears (1.5-2.6 per year). Cartilage defects treated using microfracture, Achilles tendon ruptures, and anterior cruciate ligament injuries were 3 injuries that led to significant reductions in performance measurements after injury.

CONCLUSION

With advances in sports technology and statistical analysis, there is rapidly growing interest in injuries among professional basketball athletes. High-quality prospective studies are needed to understand the prevalence and effect of injuries on player performance and career length. This information can inform preventative and treatment measures taken by health care providers to protect players and guide safe return to play at a high level.

Performance After Concussion in National Basketball Association Players

Background:

Concussions have received national attention in collision sports such as football, soccer, and hockey, but less focus has been placed on basketball.

Purpose:

To determine return-to-play (RTP) and player performance in the first and second season after concussion in National Basketball Association (NBA) players.

Study Design:

Descriptive epidemiology study.

Methods:

An online database of publicly available NBA athlete injuries was queried for instances of “concussion” between 2010 and 2018. The age at injury, team, position, height, weight, body mass index, NBA experience, date of concussion, date of return, and seasons played postconcussion was recorded for each player. Regular-season statistics (games started, games played, minutes played, and player efficiency rating [PER]) were compiled for the season before, and 2 seasons immediately after, injury. Kaplan-Meier survivorship plots were computed for athlete RTP and retirement endpoints.

Results:

A total of 81 injuries were identified from 2010 to 2018, with a rate of 2.0 concussions per 100 player-years. Overall RTP was 100% after concussion, with nearly all (88%) returning in the season of injury; 12% of players experienced a season-ending concussion. RTP averaged 37.3 days after injury, varying widely (range, 2-291 days). Compared with preinjury season (78.0%), athletes played in significantly fewer overall games in the season of injury (36.6%; P < .0001), as well as 1 (69.5%; P = .0229) and 2 seasons postinjury (73.2%; P = .3192). PER scores were not significantly different across the study period. Each point increase in a player’s preinjury PER score was associated with a 2.4% decrease in PER from the preinjury season to season of injury (P = .0016) and a 3.1% decrease from preinjury to season after injury (P = .0053). Each increasing year of age or year of experience was associated with 5% decline in PER score at 1 season after injury.

Conclusion:

NBA players had a high RTP after concussion, with most returning in the same season as the injury. Players sustaining concussions played significantly fewer games for at least 2 seasons after injury. Performance via PER did not change across the entire cohort; however, players with higher preinjury PER, and older players were more likely to sustain a greater decline in performance after injury.

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.

Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis

BACKGROUND

Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population.

PURPOSE

To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures.

STUDY DESIGN

Meta-analysis.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures.

RESULTS

Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%).

CONCLUSION

The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.

Outcomes of Surgically Treated Fifth Metatarsal Fractures in Major League Soccer Athletes

BACKGROUND

Sports-related fractures of the fifth metatarsal are common in professional athletes. Data regarding outcomes of surgical management including refracture, complications, and return-to-play statistics are available for other professional American sports with a notable exception of soccer.

PURPOSE

To quantify the burden of operative fifth metatarsal fractures in Major League Soccer (MLS) athletes, to compare outcomes as well as refracture and complication rates with other professional sports, to analyze factors that may contribute to treatment failure, and to report on return-to-play characteristics for affected players.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We searched all injuries in the prospectively collected HealtheAthlete database for MLS for operative fifth metatarsal fractures for seasons 2013 to 2017. Additional information regarding each fracture including demographics, treatment, postoperative course, and return-to-play statistics were compiled from HealtheAthlete and supplemented by teams' chief medical officers, coaches, trainers, and online sources.

RESULTS

There were 21 fractures in 18 players during the study period. Mean time to radiographic healing was 8.5 weeks (n = 17). Mean time to return to play was 11.1 weeks (n = 19). Of 21 fractures, 20 (95%) players returned to sport. Of 18 players, 4 (22.2%) experienced refracture. Of 18 players, 5 (27.8%) and 2 (11.1%) reported previous stress injuries on the contralateral and ipsilateral limb, respectively. Player performance characteristics showed small declines in the first year of return that improved by the second year.

CONCLUSION

MLS athletes who sustain a sports-related fifth metatarsal fracture can expect a high rate of return to sport with time to radiographic healing and return to play as well as risk of refracture similar to other professional cohorts.

Return to play, performance, and value of National Basketball Association players following Achilles tendon rupture

Background: Achilles tendon ruptures are devastating injuries for National Basketball Association (NBA) players: prior studies have demonstrated decreased performance following return-to-play, but none have evaluated the effect of injury on rate-adjusted contextual statistics to assess the true change in performance. Additionally, there exists a paucity of data on the independent impact on defensive performance following return.Hypothesis: Compared to both control-matched peers and preoperative careers, we hypothesize that player production based on rate-adjusted contextual statistics will significantly decline following Achilles tendon rupture.Study design: Retrospective Cohort StudyMethods: Publicly available NBA injury data on Achilles tendon rupture were reviewed from the 1996 -1997 to the 2016-2017 seasons. Controls were matched based on height, position, age, and rate-adjusted statistics. Extracted data included Value over Replacement Player Rating, Box Plus-Minus, Win Shares, offensive rating, defensive rating, and time to return-to-play, and was collected for the season before and two seasons following injury.Results: Twenty-five NBA players with surgically treated complete Achilles ruptures met inclusion and exclusion criteria. The return-to-play rate from Achilles tendon ruptures from 1996-1997 to 2016-2017 was 80%, with a mean recovery period of 311.0 ± 100.9 days. After 2 years, performance significantly declined for Value over Replacement Player Rating, Box Plus-Minus, and offensive rating compared to controls and cases. However, there was no significant effect on defensive rating (P = 0.38). After two seasons, returning players had a Value over Replacement Player Rating that was 24.1% below pre-injury levels, contributed 1.4 fewer points per 100 possessions by Box Plus-Minus, and yielded 2.4 fewer wins by Win Shares.Conclusions: Achilles tendon rupture results in significant decreases in offensive production and career longevity. The injury does not have a significant impact on defensive production.Clinical relevance: Achilles tendon ruptures significantly affect basketball players ability to return-to-play, and their in-game performance.Level of evidence: 3.

Fifth Metatarsal Fractures in Professional Soccer Players: Case Series

OBJECTIVE

Fifth metatarsal fractures occur mainly in young athletes, with an estimated incidence of 1.8 per 1000 individuals per year. This study aims to evaluate the functional outcome of professional soccer players undergoing surgical treatment of fifth metatarsal base fractures.

METHODS

We appraised 34 soccer players operated on from July 2001 to June 2016. All individuals were assessed by the American Orthopedic Foot and Ankle Score (AOFAS) and Visual Analog Scale (VAS) before and after surgery, with a mean 23-month follow-up. The need for grafting, fracture healing, Torg classification, and return to sports were also evaluated.

RESULTS

There were 10 attackers, 7 offensive-defensive midfielders, 6 side defenders, 5 central defensive midfielders, 3 defenders, 2 goalkeepers, and 1 defensive midfielder, at an average age of 19 years. Preoperative and postoperative AOFAS averaged 42 and 99 points, respectively, whereas VAS scores were 6 and 0. The longer the time to get operated on, the greater was the need for grafting (P = .011). In our study, all fractures have consolidated. Return to sports occurred, on average, 73 days after surgical treatment, and it was not influenced by the time to get operated on, fracture healing, Torg classification, and grafting.

CONCLUSION

Surgical treatment of the fifth metatarsal base fracture in professional soccer players presents good clinical results. Getting back to activities after surgery is not influenced by surgery time, fracture healing, Torg classification, and grafting.Levels of Evidence: Level IV: Therapeutic studies, Case series.

Management of ankle injuries in professional basketball players: Prevalence and rehabilitation

Basketball is a popular internationally played sport. With the physical requirements the game has on athletes, players are at risk of injury. Ankle injuries are the most common injury type suffered by basketball players. In this comprehensive review, we present an analysis and overview of the most common ankle injuries among basketball players, including sprains, fractures, impingement, and Achilles tendon pathology. The review includes treatment modalities for such injuries. More research is warranted regarding prevention strategies.

Epidemiology of Sports-Specific Foot and Ankle Injuries

The epidemiology of any given topic sometimes is overlooked. This is true particularly with sports physicians and sports injuries. The identification of sports-specific injury patterns by collection and examination of data can help prevent injuries. Thus, as a physician involved in any sport, it is essential to have this knowledge because understanding it and imparting it may allow a valuable contribution to the health and safety of the athletes and success of the teams.

Performance After Anterior Cruciate Ligament Reconstruction in National Basketball Association Players

Background:

Anterior cruciate ligament (ACL) injury in National Basketball Association (NBA) players can have a significant impact on player longevity and performance. Current literature reports a high rate of return to play, but there are limited data on performance after ACL reconstruction (ACLR).

Purpose/Hypothesis:

To determine return to play and player performance in the first and second seasons after ACLR in NBA players. We hypothesized that players would return at a high rate. However, we also hypothesized that performance in the first season after ACLR would be worse as compared with the preinjury performance, with a return to baseline by postoperative year 2.

Study Design:

Case series; Level of evidence, 4.

Methods:

An online database of NBA athlete injuries between 2010 and 2019 was queried using the term ACL reconstruction. For the included players, the following data were recorded: name; age at injury; position; height, weight, and body mass index; handedness; NBA experience; dates of injury, surgery, and return; knee affected; and postoperative seasons played. Regular season statistics for 1 preinjury season and 2 postoperative seasons were compiled and included games started and played, minutes played, and player efficiency rating. Kaplan-Meier survivorship plots were computed for athlete return-to-play and retirement endpoints.

Results:

A total of 26 athletes underwent ACLR; of these, 84% (95% CI, 63.9%-95.5%) returned to play at a mean 372.5 days (95% CI, 323.5-421.5 days) after surgery. Career length after injury was a mean of 3.36 seasons (95% CI, 2.27-4.45 seasons). Factors that contributed to an increased probability of return to play included younger age at injury (odds ratio, 0.71 [95% CI, 0.47-0.92]; P = .0337) and fewer years of experience in the NBA before injury (odds ratio, 0.70 [95% CI, 0.45-0.93]; P = .0335). Postoperatively, athletes played a significantly lower percentage of total games in the first season (48.4%; P = .0004) and second season (62.1%; P = .0067) as compared with the preinjury season (78.5%). Player efficiency rating in the first season was 19.3% less than that in the preinjury season (P = .0056). Performance in the second postoperative season was not significantly different versus preinjury.

Conclusion:

NBA players have a high rate of RTP after ACLR. However, it may take longer than a single season for elite NBA athletes to return to their full preinjury performance. Younger players and those with less NBA experience returned at higher rates.

Systematic Review of Orthopaedic and Sports Medicine Injuries and Treatment Outcomes in Women's National Basketball Association and National Basketball Association Players

Background:

Athletes in the Women’s National Basketball Association (WNBA) and National Basketball Association (NBA) are subject to high injury rates given the physical demands of the sport. Comprehensive data regarding injury patterns and rates in these athletes are limited.

Purpose:

To summarize available data on orthopaedic and sports medicine–related injuries through 2020 in professional female and male basketball players.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A search was conducted using PubMed and Embase through April 5, 2020, to identify injury studies regarding WNBA and NBA players. Studies were included if the injury or surgery was considered a direct consequence of game play including musculoskeletal/orthopaedic, concussion, ophthalmologic, and craniomaxillofacial injuries. Systematic reviews, screening studies, or studies without sufficient WNBA or NBA player subgroup analysis were excluded.

Results:

A total of 49 studies met inclusion criteria, 43 (87.8%) of which detailed musculoskeletal injuries. The lower extremity represented 63.3% of studies. A majority (59.2%) of studies were level 4 evidence. The source of data was primarily comprehensive online search (n = 33; 67.3%), followed by official databases (n = 11; 22.4%). Only 3 studies concerned WNBA athletes compared with 47 that concerned NBA athletes. The lowest return-to-play rates were cited for Achilles tendon repairs (61.0%-79.5%). Variability in return-to-play rates existed among studies even with similar seasons studied.

Conclusion:

The majority of literature available on orthopaedic and sports medicine–related injuries of NBA and WNBA athletes is on the lower extremity. The injuries that had the greatest effect on return to play and performance were Achilles tendon ruptures and knee cartilage injuries treated using microfracture. The reported outcomes are limited by heterogeneity and overlapping injury studies. There are limited available data on WNBA injuries specifically.

Optimizing Return to Play for Common and Controversial Foot and Ankle Sports Injuries

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Surgical decision-making should consider factors to help optimize return to play for athletes with foot and ankle injuries, including injuries to the syndesmosis, the Achilles tendon, the fifth metatarsal, and the Lisfranc complex. Understanding influential factors on return to play may help orthopaedic surgeons counsel athletes and coaches on expectations for a timeline to return to play and performance metrics.

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Outcomes after rigid and flexible fixation for syndesmotic injuries are generally favorable. Some data support an earlier return to sport and higher functional scores with flexible fixation, in addition to lower rates of reoperation and a decreased incidence of malreduction, particularly with deltoid repair, if indicated.

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Minimally invasive techniques for Achilles tendon repair have been shown to have a decreased risk of wound complications. Athletes undergoing Achilles repair should expect to miss a full season of play to recover.

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Athletes with fifth metatarsal fractures have better return-to-play outcomes with surgical management and can expect a high return-to-play rate within approximately 3 months of surgery.

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Percutaneous treatment of Lisfranc injuries may expedite return to play relative to open procedures.

Sports Performance and Injury Research: Methodologic Limitations and Recommendations for Future Improvements

Evidence-based research has resulted in incredible advances in sports medicine and is an important component of minimizing injury risk. Such research is similarly important when applied to care delivery to athletes after injury. For research into injury reduction and treatment outcomes to be most impactful, however, the methods must be of sufficient rigor to generate high-quality evidence. Two recent trends in sports injury research have led to specific concerns about evidence quality: 1) use of athletic performance metrics as an injury or treatment outcome and 2) use of publicly available data for injury or treatment research.

Jones Fracture Management in Athletes

Jones fractures in both elite and recreational athletes are best treated with surgical fixation, given superior results as compared to nonoperative management. While screw specifics remain controversial, intramedullary screw fixation is established as the standard surgical technique. Plate fixation also has shown excellent outcomes. Complications of refracture, nonunion, and delayed union require careful evaluation for contributions of early return to play, implant characteristics, and anatomic/metabolic abnormality. Revision fixation with autograft and biologic augmentation is supported in the literature, with ongoing inquiry to optimizing specific implants and adjuvants.

MODIFYING MIDSOLE STIFFNESS of BASKETBALL FOOTWEAR AFFECTS FOOT and ANKLE BIOMECHANICS

Background

There is a growing incidence of foot injuries in basketball, which may be from the sport's repetitive, forceful multi-directional demands. Modifying midsole stiffness of the basketball shoe has been reported to alter ankle motion and plantar forces to reduce the risk of injury; however, the effects on anatomical, in-shoe foot (metatarsal), motion is not well understood.

Purpose

The purpose of this study was to identify differences in foot and ankle biomechanics between basketball shoes with differing midsole stiffness values during single-leg jump landings. It was hypothesized that a stiffer midsole would elicit lower 1^st metatarsophalangeal joint (MTPJ) dorsiflexion angles, higher ankle dorsiflexion angles, and higher plantar forces and relative loading in the distal foot.

Study Design

Experimental cross-sectional study.

Methods

Twenty high school and collegiate-aged basketball players performed a single-leg side drop jump and a single-leg cross drop jump in a pair of standard basketball shoes and a pair of shoes modified with a fiberglass plate to increase midsole stiffness. Three-dimensional motion analysis and flexible insoles quantified foot and ankle kinematics and plantar force distribution, respectively. Separate 2 (footwear) × 2 (task) repeated measures ANOVA models were used to analyze differences in 1) ankle kinematics, 2) 1^st metatarsophalangeal kinematics, 3) maximal regional plantar forces, and 4) relative load.

Results

The stiffer shoe elicited decreased peak ankle plantarflexion (mean difference = 5.8 °, p = 0.01) and eversion (mean difference = 6.6 °, p = 0.03) and increased peak ankle dorsiflexion angles (mean difference = 5.0 °, p = 0.008) but no differences were observed in 1^st MTPJ motion (p > 0.05). The stiffer shoe also resulted in lower peak plantar forces (mean difference = 24.2N, p = 0.004) and relative load (mean difference = 1.9%, p = 0.001) under the lesser toes.

Conclusions

Altering the midsole stiffness in basketball shoes did not reduce motion at the MTPJ, indicating that added stiffness may reduce shoe motion, but does not reduce in-shoe anatomical motion. Instead, a stiffer midsole elicits other changes, including additional ankle joint motion and a reduction in plantar forces under the lesser toes. Collectively, this indicates that clinicians need to account for unintended compensations that can occur throughout the kinetic chain when altering a shoe property to alleviate a musculoskeletal injury.

Level of Evidence

2b.

Femoroacetabular Impingement in Professional Basketball Players: Return to Play, Career Length, and Performance After Hip Arthroscopy

BACKGROUND

Previous studies have demonstrated that hip arthroscopy is an effective treatment for symptomatic femoroacetabular impingement (FAI) in professional athletes across a variety of sports. However, the return-to-play rates and postoperative performance of elite basketball players after hip arthroscopy are currently unknown.

PURPOSE

To determine return-to-play rates and postoperative performance among professional basketball athletes after hip arthroscopy.

STUDY DESIGN

Case series; Level of evidence, 3.

METHODS

Eighteen professional basketball players underwent hip arthroscopy (24 hips) for symptomatic FAI between 2001 and 2016 by a single surgeon. Return to play was defined as competing in a single professional game of equal level after surgery. Data were retrospectively obtained for each player from basketball-reference.com , ESPN.com , eurobasket.com, and individual team websites. Matched controls were selected from the websites to compare performances.

RESULTS

The mean age at the time of surgery was 25.6 years, and the mean body mass index was 24.4 kg/m². All players returned to their previous levels of competition, with a mean number of 4 seasons played after surgery (median, 3; range, 1-12). The mean ± SD time between the date of surgery and return to a professional game was 7.1 ± 4.4 months. There was no change in player efficiency rating when pre- and postinjury performance were compared. When compared with controls, players undergoing surgery also had no significant decline in player efficiency rating.

CONCLUSION

Elite basketball athletes who undergo hip arthroscopy for the treatment of FAI return to their presurgical levels of competition at a high rate. These athletes demonstrate no significant overall decrease in performance upon their return to play.

A Comprehensive Return-to-Play Analysis of National Basketball Association Players With Operative Patellar Tendon Tears

Background:

Patellar tendon tears impart potentially debilitating sequelae among professional basketball athletes.

Hypothesis:

Professional basketball athletes with patellar tendon tears have decreased return-to-play performance in seasons after injury compared with preinjury statistics.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patellar tendon tears among National Basketball Association (NBA) athletes from the 1999-2000 to 2014-2015 seasons were identified. Player performance statistics for players who underwent operative patellar tendon repair were compared from 1 season before injury to 1 season after injury and 2 seasons before injury to 2 seasons after injury using the primary outcome of player efficiency rating (PER). Secondary performance outcomes were also analyzed.

Results:

A total of 13 patellar tendon tears (10 complete, 3 partial) were identified among 12 NBA athletes. Three players (25%) did not return to play in the NBA. No significant differences were found in PER in comparisons of 1 season before and after injury (16.6 ± 1.5 vs 14.3 ± 1.7; P = .20) or in comparisons of 2 seasons before and after injury (15.8 ± 0.8 vs 6.3 ± 2.3; P = .49). Diminished performance outcomes were noted for total minutes played (2598 ± 100 vs 1695 ± 78; P = .01), games played (74.8 ± 1.9 vs 60.5 ± 1.4; P = .04), and minutes per game (34.8 ± 1.5 vs 28.2 ± 1.8; P = .02) in comparisons of 1 season before and after injury. Total minutes played per season (2491 ± 190 vs 799 ± 280; P = .045) decreased in comparisons of 2 seasons before and after injury.

Conclusion:

Patellar tendon tears were not associated with diminished efficiency-adjusted performance, as measured by PER, games played, minutes per game played, points per 36 minutes, and rebounds per 36 minutes. However, decreases in total minutes played were observed following patellar tendon tear. Orthopaedic surgeons may be better prepared to counsel basketball athlete patients with patellar tendon tear given these findings.

Performance, Return to Play, and Career Longevity After Ulnar Collateral Ligament Reconstruction in Professional Catchers

PURPOSE

The purpose of our study was to evaluate return to play and postinjury performance of professional catchers who sustained an ulnar collateral ligament (UCL) rupture requiring surgical reconstruction. We looked to evaluate these players to determine the rate of return to play, the level of return to play, and career longevity after surgery as well as how statistical performance is affected by reconstruction.

METHODS

Twenty-five professional catchers who underwent UCL reconstruction between 1985 and 2015 were identified and compared with an age-, position-, and competition-matched control group. Priority was placed on level of play, year of injury, age, and years played prior to injury in matching controls. Injury information and demographic data (age at injury, level of play, and career length) were collected from publicly available team websites and press releases. Offensive and defensive performance statistics were collected for 3 years prior to injury and 3 years after return. Return to play, return to level of play, and career after return were also analyzed.

RESULTS

The average age at time of UCL injury was 24.4 (standard deviation, 4.5) years old. Return to play for all catchers was 80% (20/25), with only one player not returning to the same previous level of play (95%). Average years in Major League Baseball (MLB) after return was 2.3 years versus 2.6 years in the control group (P = .07), with 4.3 years total (MLB and minors) versus 3.8 years total in the control group (P = .28). There were no changes in offensive or defensive performance before and after injury.

CONCLUSIONS

UCL reconstruction in professional catchers can lead to successful outcomes. Catchers can expect a high rate of return to play with high rate of return to previous level of play, similar performance, and no change in career longevity following return from UCL reconstruction.

STUDY DESIGN

Level III, case-control series.

Performance outcomes after medial ulnar collateral ligament reconstruction in Major League Baseball positional players

BACKGROUND

We sought to determine whether professional baseball positional players who underwent medial ulnar collateral ligament (MUCL) reconstruction demonstrate decreases in performance on return to competition compared with preoperative performance metrics and their control-matched peers.

METHODS

Data for 35 Major League Baseball positional players who underwent MUCL reconstruction during 31 seasons were obtained. Twenty-six players met inclusion criteria. Individual statistics for the 2 seasons immediately before injury and the 2 seasons after injury included wins above replacement (WAR), on-base plus slugging (OPS), and isolated power (ISO). Twenty-six controls matched by player position, age, plate appearances, and performance statistics were identified.

RESULTS

Of the 35 athletes who underwent surgery, 7 did not return to their preinjury level of competition (return to play rate of 80%). In comparing preinjury with postinjury statistics, players exhibited a significant decrease in plate appearances, at-bats, and WAR 2 seasons after injury but did not demonstrate declines in WAR 1 season after injury. Compared with matched controls, athletes who underwent MUCL reconstruction did not demonstrate significant decline in statistical performance, including OPS, WAR, and ISO, after return to play from surgery. Of all positional players, catchers undergoing surgery demonstrated lowest rates of return to play (56%) along with statistically significant decreases in home run rate, runs batted in, and ISO.

CONCLUSION

Major League Baseball positional players undergoing MUCL reconstruction can reasonably expect to return to their preinjury level of competition and performance after surgery compared with their peers. Positional players return to play at a rate comparable to that of pitchers; catchers may experience more difficultly in returning to preinjury levels of play.

Epidemiology and Impact on Performance of Lower Extremity Stress Injuries in Professional Basketball Players

Background:

Professional basketball players in the National Basketball Association (NBA) subject their lower extremities to significant repetitive loading during both regular-season and off-season training. Little is known about the incidence of lower extremity bony stress injuries and their impact on return to play and performance in these athletes.

Hypothesis:

Stress injuries of the lower extremity will have significant impact on performance.

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

All bony stress injuries from 2005 to 2015 were identified from the NBA. Number of games missed due to injury and performance statistics were collected from 2 years prior to injury to 2 years after the injury. A linear regression analysis was performed to determine the impact of injury for players who returned to sport.

Results:

A total of 76 lower extremity bony stress injuries involving 75 NBA players (mean age, 25.4 ± 4.1 years) were identified. Fifty-five percent (42/76) involved the foot, and most injuries occurred during the regular season (82.9%, 63/76), with half occurring within the first 6 weeks. Among players who sustained a fifth metatarsal stress fracture, 42.9% were unable to return to professional play. Players who sustained stress injuries had reduced play performance, specifically related to number of games played (P = 0.014) and number of steals per game (P = 0.004). Players who had surgery had significantly better performance at 2 years than those who were managed nonoperatively, independent of the type of injury (β = 4.561; 95% CI, 1.255-7.868).

Conclusion:

Lower extremity bony stress injuries may significantly affect both short- and long-term player performance and career length. Stress injuries result in decreased player performance, and surgical intervention results in improved performance metrics compared with those treated using conservative methods.

Clinical Relevance:

Stress injuries result in decreased player performance, and surgical intervention results in improved performance metrics.

Professional Athletes' Return to Play and Performance After Operative Repair of an Achilles Tendon Rupture

BACKGROUND

Most Achilles tendon ruptures are sports related. However, few studies have examined and compared the effect of surgical repair for complete ruptures on return to play (RTP), play time, and performance across multiple sports.

PURPOSE

To examine RTP and performance among professional athletes after Achilles tendon repair and compare pre- versus postoperative functional outcomes of professional athletes from different major leagues in the United States.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

National Basketball Association (NBA), National Football League (NFL), Major League Baseball (MLB), and National Hockey League (NHL) athletes who sustained a primary complete Achilles tendon rupture treated surgically between 1989 and 2013 were identified via public injury reports and press releases. Demographic information and performance-related statistics were recorded for 2 seasons before and after surgery and compared with matched controls. Statistical analyses were used to assess differences in recorded metrics.

RESULTS

Of 86 athletes screened, 62 met inclusion criteria including 25 NBA, 32 NFL, and 5 MLB players. Nineteen (30.6%) professional athletes with an isolated Achilles tendon rupture treated surgically were unable to return to play. Among athletes who successfully returned to play, game participation averaged 75.4% ( P < .001) and 81.9% ( P = .002) of the total games played the season before injury at 1 and 2 years postoperatively, respectively. Play time was significantly decreased and athletes performed significantly worse compared with preoperative levels at 1 and 2 years after injury ( P < .001). When players were compared with matched controls, an Achilles tendon rupture resulted in fewer games played ( P < .001), decreased play time ( P = .025), and worse performance statistics ( P < .001) at 1 year but not 2 years postoperatively ( P > .05). When individual sports were compared, NBA players were most significantly affected, experiencing significant decreases in games played, play time, and performance.

CONCLUSION

An Achilles tendon rupture is a devastating injury that prevents RTP for 30.6% of professional players. Athletes who do return play in fewer games, have less play time, and perform at a lower level than their preinjury status. However, these functional deficits are seen only at 1 year after surgery compared with matched controls, such that players who return to play can expect to perform at a level commensurate with uninjured controls 2 years postoperatively.

Risk Factors for Reoperation and Performance-Based Outcomes After Operative Fixation of Foot Fractures in the Professional Athlete: A Cross-Sport Analysis

Background:

Professional athletes are predisposed to fractures of the foot due to large stresses placed on the lower extremity. These players are concerned with efficiently returning to play at a high level. Return-to-play rates after operative treatment have been previously reported, yet performance outcomes after such treatment are generally unknown in this population.

Hypothesis:

Overall, professional athletes sustaining a foot fracture would return to play at high rates with little impact on postoperative performance or league participation. However, National Football League (NFL) athletes would have a significantly greater decline in performance due to the high-impact nature of the sport.

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

Athletes in the National Basketball League (NBA), NFL, Major League Baseball (MLB), and National Hockey League (NHL) undergoing operative fixation of a foot fracture were identified through a well-established protocol confirmed by multiple sources of the public record. Return-to-play rate and time to return were collected for each sport. League participation and game performance data were collected before and after surgery. Statistical analysis was performed, with significance accepted as P ≤ 0.05.

Results:

A total of 77 players undergoing 84 procedures met the inclusion criteria. Overall, 98.7% (76/77) of players were able to return to play, with a median time to return across all sports of 137 days. Players returned to preoperative performance levels within 1 season of surgery. Six players (7.8%) sustained refracture requiring reoperation, all of whom were in the NBA. Percentage of games started during the season after primary operative treatment was a predictive factor for reinjury (99% vs 40%, P = 0.001).

Conclusion:

Athletes returned to play at a high rate after foot fracture fixation, with excellent postoperative performance levels, regardless of sport and fracture location. NBA athletes sustaining fifth metatarsal and navicular fractures are at greater risk of reinjury compared with other athletes. Returning to high levels of athletic participation soon after surgery may predispose athletes to refracture and subsequent reoperation.

Clinical Relevance:

Players, coaches, and team physicians should be aware of the impact of foot fractures on career performance and longevity to best guide therapy.

Zone II and III fifth metatarsal fractures in athletes

PURPOSE OF REVIEW

This study aimed to review indications, complications, and outcomes of zone II and III fifth metatarsal fractures based on recent literature.

RECENT FINDINGS

High rates of nonunion, delayed union, and refracture in athletes treated non-operatively. The standard of care is operative treatment in athletes with intramedullary fixation. Operative treatment of zone II and III fractures in athletes will decrease the risk of nonunion and refracture while leading to an earlier return to play.