Evolving Treatment Patterns of NFL Players by Orthopaedic Team Physicians Over the Past Decade, 2008-2016

Return to Play After Surgical Treatment of High-Grade Acromioclavicular Joint Injuries in the Australian Football League

Background:

Acromioclavicular joint (ACJ) injuries are the second most common upper limb injuries in the Australian Football League (AFL); however, there is little evidence on the return-to-sport results after surgical stabilization of the ACJ in this sporting population.

Purpose:

To investigate the return-to-sport time, on-field performance, and patient-reported outcomes in a series of professional AFL players after undergoing ACJ stabilization.

Study Design:

Case series; Level of evidence, 4.

Methods:

We conducted a retrospective case series of all AFL players who had undergone open twin-tailed dog-bone ACJ stabilization by a single surgeon between September 2013 and April 2017. Outcome measures included time to return to sport, on-field performance indicators (handballs, tackles, kicks, and AFL Fantasy and Supercoach scores), the Nottingham Clavicle Score, Oxford Shoulder Score, and the Specific Acromioclavicular Score. Patient-reported outcomes were evaluated at a minimum follow-up of 12 months.

Results:

Of 13 senior listed AFL players who underwent twin-tailed dog-bone surgery, 9 players were included. Mean follow-up was 24.8 months (range, 5-41 months) postoperatively. Mean return-to-sport time was 8.6 weeks for injuries that occurred within the season. The number of kicks, marks, handballs, and tackles as well as AFL Supercoach and Fantasy scores did not significantly change after surgery ( P > .05). Outcome measures showed a high level of patient satisfaction after surgery, with a mean Nottingham Clavicle Score of 92.2, Oxford Shoulder Score of 47.7, and the Specific Acromioclavicular Score of 7.5.

Conclusion:

In a collective of professional AFL players with ACJ injury, our twin-tailed dog-bone technique revealed return to competitive play could be achieved at a mean of 8.6 weeks without compromising on-field performance or patient-reported pain, function, and satisfaction.

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.

ACL Tears in the National Football League From 2013 to 2020: Analysis of the 2020 Season After Delays and Schedule Changes From the Early COVID-19 Pandemic Relative to Prior Seasons

Background:

The impact of fatigue and preseason preparation on anterior cruciate ligament (ACL) tears in the National Football League (NFL) are not well described. The 2020 NFL season did not include the standard preseason in response to changes secondary to the coronavirus disease-2019 (COVID-19) pandemic.

Purpose:

To evaluate the association of game play on ACL tears in NFL athletes and to determine if differences in ACL tear epidemiology were present based on season of play from 2013 to 2020.

Study Design:

Descriptive epidemiology study.

Methods:

ACL tears in NFL athletes were identified using publicly available data. Games played and snap counts at the time of injury were recorded for each athlete sustaining game-related injuries. Tear rates were determined, and injuries were also calculated per 1000 athlete-exposures. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated.

Results:

Overall, 379 ACL tears were identified, including 256 (67.6%) during game play and 118 (31.1%) during practice. Practice-based injuries were significantly higher in the preseason versus the remainder of the season. Games and snaps at the time of injury did not differ by year. The incidence rate of preseason injuries was significantly greater relative to in-season injuries (IRR = 2.68; 95% CI, 2.18-3.29; P < .00001). There was an elevated incidence rate of in-season injuries in 2020 relative to 2014-2019 combined (IRR = 1.49; 95% CI, 0.98-2.19; P = .048). In 2013 to 2019, the most frequent month of injury was the first month of the preseason in August (119/334 tears; 35.6%), whereas in 2020, the most frequent month was September (13/41 tears, 31.7%). The proportion of tears in September 2020 was not different from the proportion of tears in August 2013 to 2019.

Conclusion:

There was an increased proportion of in-season ACL tears in the 2020 NFL season relative to 2014 to 2019; this is attributable to a frameshift in the consistent trend of injuries in the 1st month to return of competitive play, with 2020 being in the regular season in September as opposed to the preseason in August.

Editorial Commentary: Large-Diameter Quadrupled Hamstring Autografts Are an Acceptable Option for National Collegiate Athletic Association Division I College Football Players: We Must Challenge Our Comfort Zone to Be Successful in the End Zone

The majority of surgeons caring for elite American football teams choose bone-patellar tendon-bone (BTB) autograft for anterior cruciate ligament reconstruction. As we strive to continue to improve currently favorable outcomes, we need to consider all options regarding graft choice, surgical technique, and postoperative rehabilitation. Advantages of BTB include an excellent track record, potential for faster incorporation with bone-to-bone healing. Disadvantages include risk of patellar fracture/tendon rupture and anterior knee pain. The pros of quadrupled hamstring (QH) graft include stronger graft (higher ultimate load to failure) and less anterior knee pain and stiffness, and the cons include loss of flexion/hamstring strength and slower healing in the tunnels. Several studies have shown that smaller grafts have higher failure rates, and recent research shows that QH grafts >9 mm had decreased risk of revision compared to BTB. We can now quadruple the semitendinosus tendon to provide elite athletes with even more robust grafts. Large-diameter QH autografts are an acceptable option for National Collegiate Athletic Association Division I college football players.

High Return to Play and Low Reinjury Rates in National Collegiate Athletic Association Division I Football Players Following Anterior Cruciate Ligament Reconstruction Using Quadrupled Hamstring Autograft

PURPOSE

The purpose of this study was to examine the outcomes of anterior cruciate ligament (ACL) reconstruction using quadrupled hamstring (QH) autograft in a cohort of National Collegiate Athletic Association (NCAA) Division I football players.

METHODS

A retrospective analysis was performed on NCAA Division I football players at a single institution who had transtibial ACL reconstruction using QH autograft between 2001 and 2016. Primary outcomes were ACL reinjury and return to play (RTP). Secondary outcomes were position, percent of eligibility used after surgery, graft diameter, Tegner-Lysholm scores, concomitant injuries/surgeries, and postcollegiate professional play.

RESULTS

Between 2001 and 2016, 34 players had QH autograft ACL reconstruction, and 29 players achieved RTP. Of the 29, 2 (6.9%) sustained ACL reinjuries. The average RTP was 318 days (range 115-628) after surgery. Players used 79.5% of their remaining collegiate eligibility after surgery. Nine players sustained multiligamentous knee injuries. This did not have a significant effect on RTP (P = 0.709; mean 306±24 days for isolated ACL, mean of 353±51 for 2 ligaments, mean of 324±114 for 3 + ligaments) and none sustained reinjury. Associated meniscal injuries were sustained by 28, and 8 sustained chondral injuries. The mean postoperative Tegner-Lysholm score was 90.7 of 100, with mean follow-up of 102 months. Of these players, 18 went on to play professionally, with 17 joining National Football League rosters and 1 an arena team roster.

CONCLUSION

QH demonstrated an ACL reinjury and RTP rates similar to those in previously published, predominantly bone-patella tendon-bone ACL reinjury data in elite athletes. This study demonstrates that QH autograft may be a viable option in elite athletes.

LEVEL OF EVIDENCE

IV, case series.

Analgesia in Athletes: A Review of Commonly Used Oral and Injectable Modalities

Pain is common among athletes at all levels and the treatment of pain can be a challenging and frustrating task. The team physician needs a fundamental knowledge of analgesic strategies as it relates to athletes. It is important to understand the mechanism of action, side effect profile/associated complications, incidence of and indications for use, as well as the controversies associated with the most common analgesic medications used in sports medicine. Several "in vogue" treatment modalities, including cannabidiol, are also becoming more commonly used and are worth discussion.

Evolving Expectations of the Orthopedic Team Physician: Managing the Sidelines and Landmines

ABSTRACT

The role of orthopedic team physicians has evolved greatly over the past decade having been influenced by advances in sports science and performance, new surgical and biologic technologies, social media, medicolegal liability, marketing, and sexual misconduct cases by some team physicians. The great variety of events and sports that are covered from high school and collegiate to the Olympic and professional levels requires a myriad of skills outside of the traditional medical training curriculum. In the current climate of increasing media scrutiny from a 24-h news cycle it is imperative for orthopedic team physicians, whether operative or nonoperative, to continually adapt to the needs and expectations of athletes who also are patients. This is especially true in the wake of the COVID-19 pandemic. Orthopedic team physicians' responsibilities continue to evolve ensuring their relevance and necessity on the sidelines and in the training room as well as in the operative suite.

Foot and Ankle Injections in Athletes

CONTEXT

Injections are commonly used by health care practitioners to treat foot and ankle injuries in athletes despite ongoing questions regarding efficacy and safety.

EVIDENCE ACQUISITION

An extensive literature review was performed through MEDLINE, Google Scholar, and EBSCOhost from database inception to 2021. Keywords searched were injections, athletes, sports, foot and ankle, corticosteroids, platelet-rich plasma, and placental tissue. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Corticosteroids, platelet-rich plasma/autologous blood, anesthetic, and placental tissue injections are commonly used in the treatment of foot and ankle injuries. Primary indications for injections in athletes include plantar fasciitis, Achilles tendinosis, isolated syndesmotic injury, and ankle impingement with varying clinical results.

CONCLUSIONS

Despite promising results from limited case series and comparative studies, the data for safety and efficacy of injections for foot and ankle injuries in athletes remain inconclusive.

Return to Play Rates in NFL Wide Receivers and Running Backs After ACL Reconstruction: An Updated Analysis

Background:

Anterior cruciate ligament (ACL) ruptures are potentially career-threatening injuries to National Football League (NFL) skill position players. A 2006 study showed a return-to-play (RTP) rate of 79% for NFL running backs (RBs) and wide receivers (WRs). Since then, a number of factors affecting RTP, including style of play as well as rules regarding hits to the head, have changed how defensive players tackle offensive ball carriers.

Purpose/Hypothesis:

To determine whether the RTP rate for RBs and WRs in the NFL has changed since data were collected in the 2000s. Additionally, we evaluated player performance before and after ACL reconstruction (ACLR). We hypothesized that there will be a lower RTP rate than previously reported as well as a decrease in performance statistics after ACLR.

Study Design:

Descriptive epidemiology study.

Methods:

Publicly available NFL injury reports between the 2009-2010 and 2015-2016 seasons were utilized for RBs and WRs who underwent ACLR. Successful RTP was indicated by playing in at least 1 NFL game after reconstruction. Position-specific performance statistics from before and after reconstruction were gathered for these players, and the RTP players were compared against the players who did not RTP (dnRTP group). Pre- and postinjury performance measures were also compared against a matched control group of NFL RBs and WRs who had not sustained an ACL injury.

Results:

Overall, 61.8% of players (64.5% of RBs, 60% of WRs) returned to play at a mean of 13.6 months. Prior to injury, the RTP group had played in significantly more career games and had significantly more rushes and receptions per game than the dnRTP group; however, there was no significant difference in performance after ACLR. The WR RTP group had significantly decreased performance in all measured categories when compared with the control group.

Conclusion:

Our study found a lower RTP rate in RBs and WRs than previous studies conducted in the early 2000s. WRs who achieved RTP had decreased performance when compared with noninjured controls.

Use and Outcome of Local Anesthetic Painkilling Injections in Athletes: A Systematic Review

BACKGROUND

The use of local anesthetic painkilling injections to improve player availability is common practice in elite-level sport.

OBJECTIVE

To document the published use of local anesthetic injections in sport, according to number of injections, sites of injections, and complications reported.

DATA SOURCES

A systematic search of MEDLINE, Embase, CINAHL, AMED, Cochrane Database of Systematic reviews, SportDiscus, EBSCO Host, and Google Scholar.

RESULTS

One thousand nine hundred seventy local anesthetic injections reported on 540 athletes in 10 studies (from rugby league, American football, Australian football, and soccer) were reviewed. The most common areas of injection were as follows: the acromioclavicular (AC) joint; hand (including fingers); sternoclavicular joint (including sternum); rib injuries; and iliac crest contusions.

DISCUSSION

This review found some evidence of long-term safety for a limited number of injection sites (eg, AC joint) and some evidence of immediate complications and harmful long-term consequences for other sites. The quality of evidence is not high, with little long-term data and a lack of independent verification of the effects of the injections. Ideally, long-term follow-up should be conducted to determine whether these injections are safe, with follow-up undertaken independently of the treating physician and team.

CONCLUSIONS

Based on limited publications, there is some evidence of long-term safety; however, there is a lack of clear proof of either absolute safety or long-term harm for many of these procedures. Physicians and players in professional sport should proceed with caution in using local anesthetic injections.

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

Background

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

Purpose

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

Study Design

Systematic review; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

Injectable Ketorolac and Corticosteroid Use in Athletes: A Systematic Review

CONTEXT

The use of injectable medications to help athletes quickly return to the field of play after injury is common. Understanding the effects and risks of these medications will help providers make informed decisions regarding their use in this patient population.

OBJECTIVE

To evaluate the utilization, efficacy, and adverse effects of injectable ketorolac and corticosteroids in athletes.

DATA SOURCES

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic search of the literature was performed using multiple databases (PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov). Secondary references were appraised for relevant articles. No randomized controlled trials or other prospective studies were identified. Articles included retrospective database reviews and physician survey studies.

STUDY SELECTION

A total of 6 studies met the inclusion and exclusion criteria and were reviewed by 2 independent reviewers with a third consulted in the case of disagreement, which was not needed.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 5.

DATA EXTRACTION

Two reviewers recorded rate of use, effectiveness of treatment, and reported side effect data.

RESULTS

Most studies centered around the football athlete, either professional or collegiate. Professional football game day use of intramuscular ketorolac declined from 93.3% (28/30) in 2002 to 48% in 2016. Collegiate football game day use of intramuscular ketorolac declined from 62% in 2008 to 26% in 2016. Game day corticosteroid injection was far lower than ketorolac usage. Both medications were reported to be effective with few adverse events.

CONCLUSION

Use of injectable ketorolac is common but declining in professional and college football. Pain control efficacy is good, and risk of adverse events is low. The incidence of injectable corticosteroid use in athletes is unknown. Use of injectable corticosteroids in athletes allows for early return to sport activities with no reported complications.

Return to Play and Career Length After Anterior Cruciate Ligament Reconstruction Among Canadian Professional Football Players

BACKGROUND

For many athletes, a tear of the anterior cruciate ligament (ACL) represents a significant injury that requires a prolonged period away from the sport with substantial rehabilitation.

HYPOTHESIS

There will be no difference in return to play (RTP) and career length after hamstring tendon (HT) ACL reconstruction in a group of Canadian Football League professional players as compared with what has been already been reported in the literature among professional football players.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data on athletes who sustained an ACL injury were collected by team physicians and head athletic trainers from 2002 to 2017 from 2 Canadian Football League teams. Patient details included age at the time of injury, initial injury date, position, practice versus game injury, and primary versus rerupture with injury-specific data, such as affected limb, concomitant injuries, graft choice, and procedure performed. RTP rates and career length data were collected through publically available internet sources. Comparisons between the non-RTP and RTP groups were made with independent-sample t tests. Binomial logistic regression was performed to determine variables (ie, games preinjury, graft type, meniscal injury, collateral ligament injury) that contributed to players not being able to RTP.

RESULTS

A total of 44 ACL reconstructions were performed over the study period (HT, n = 32 [72.7%]; bone-patellar tendon-bone [BPTB], n = 8 [18.2%]; allograft, n = 4 [9.1%]). Overall, 69.8% (n = 30) were able to RTP in at least 1 game, while 30.2% (n = 13) did not return. Mean time to return was 316.1 days (range, 220-427 days), or 10.4 months. For those players who did RTP, mean career length after ACL reconstruction was 2.8 seasons, or 34.4 games. The majority (56.8%) of injuries occurred early in the season. Breakdown by graft type demonstrated RTP rates among HT, BPTB, and allograft of 64.5% (n = 20), 87.5% (n = 7), and 75% (n = 3), respectively. Career length among HT, BPTB, and allograft was 2.9, 2.4, and 3 seasons. Logistic regression analysis found only concomitant medial collateral ligament (MCL) injuries to be a negative predictor for RTP. Meniscal injuries were associated with a decreased RTP rate and career length, but this was not statistically significant.

CONCLUSION

The RTP rates after ACL reconstruction in this study are similar to those reported in National Football League players. A concomitant injury to the MCL injury was a negative predictor of RTP. Meniscal injuries demonstrated a trend for decreased RTP rate and career length, but this was not a significant predictor. A large portion of injuries occur early in the season, and further study should be done to examine potential preventative strategies to reduce ACL injuries.

Epidemiology of Hand and Wrist Injuries in NCAA Men's Football: 2009-2010 to 2013-2014

Background:

Participation in National Collegiate Athletic Association (NCAA) football is at an all-time high. This population of athletes experiences a substantial injury burden, with many injuries affecting the upper extremities.

Purpose/Hypothesis:

The purpose of this study was to describe the epidemiology of hand and wrist injuries in college football players from the academic years 2009–2010 to 2013–2014. We hypothesized that variables such as event type (practice vs game), mechanism of injury, and player position would have an effect on the injury incidence.

Study Design:

Descriptive epidemiological study.

Methods:

An epidemiological study utilizing the NCAA Injury Surveillance Program was performed to investigate rates and patterns of hand and wrist injuries in participating varsity football teams from 2009–2010 to 2013–2014.

Results:

A total of 725 hand and wrist injuries were captured in 899,225 athlete-exposures. The observed practice injury rate was 0.51 injuries per 1000 athlete-exposures, compared with a game injury rate of 3.60 (P < .01). Player-on-player contact was the most common injury mechanism reported, with blocking being the most common activity at the time of injury. Offensive linemen were most likely to experience an injury. Of all injuries sustained, 71.4% resulted in no time loss from competition, whereas 9.8% of injuries resulted in longer than 7 days of time loss. A fracture resulted in the greatest time loss from competition (mean ± SD, 8.3 ± 24.0 days; median, 0 days [range, 0-148 days] for injuries sustained in a practice setting) (mean ± SD, 7.7 ± 15.8 days; median, 0 days [range, 0-87 days] for injuries sustained in a game setting).

Conclusion:

Hand and wrist injuries were found to be significantly more common in games when compared with practices. This study provides valuable prognostic data regarding expected time loss on a per-injury pattern basis. Further investigation on specific injury subtypes and expected time loss as a result of these injures would provide trainers, players, and coaches with useful information on an expected postinjury recovery and rehabilitation timeline.

Previous foot injuries associated with a greater likelihood of Achilles tendon ruptures in professional American football players

OBJECTIVES

The purpose of this study was to build on current understanding of Achilles tendon (AT) ruptures in football through the examination of lower extremity injury rates (IR) in the season prior to AT rupture.

METHODS

An online review was conducted to document AT ruptures in the National Football League (NFL) from the 2010-11 through 2016-17 seasons. Player-specific information was gathered through the online search, injury reports, or video analysis. Injury incidence was recorded for each season. Descriptive statistics were calculated for all variables. IRs per 1000 athlete-exposures with 95% confidence intervals (CI) were established. Injury rate ratios (IRR) with 95% CI were calculated to evaluate differences in IR with statistical significance established at p < 0.05.

RESULTS

From the 2010-11 to 2016-17 NFL seasons, 109 AT ruptures were identified. 36 athletes participated in the NFL the season prior and sustained a total of 40 injuries. Thirty-two (32/40, 80%) of the injuries involved the lower extremity. The most frequent body parts injured in the NFL season prior to AT rupture were the knee (n = 8, 22.5%), upper leg and thigh (n = 7, 17.5%), lower leg and shin (n = 5, 12.5%), and ankle (n = 5, 12.5%). The overall IR for the AT rupture group was not significantly different than the NFL group (IRR: 0.94, 0.68-1.31 95% CI, p = 0.73). The AT rupture group demonstrated a significantly increased rate of foot injuries compared to the NFL cohort (IRR: 2.58, 1.16-5.77 95% CI, p = 0.02).

CONCLUSION

There was an increased identified incidence of AT ruptures in the NFL from 2010 to 2017 compared to AT ruptures reported from 1997 to 2002. There was no significant difference in lower extremity IR the season prior to AT rupture. Only foot injuries demonstrated an increased IR the season prior to AT rupture compared to an NFL cohort. Eleven athletes sustained 2 AT ruptures and all 11 players sustained the subsequent AT rupture to the contralateral limb.