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Kuhn AW, Coughlin MJ, McGonegle SJ, Herzog MM, Weir N, Meade Spratley E, O'Cain CM, Anderson RB. Distal Tibiofibular Syndesmosis Injuries in the National Football League (NFL): A Spectrum of Pathology That Correlates With Time to Return to Full Participation. Sports Health 2024:19417381241253223. [PMID: 38804171 DOI: 10.1177/19417381241253223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Studies routinely evaluate high ankle sprains in isolation, but recent data suggest that these injuries are often associated with concomitant pathology, potentially influencing return to full participation. HYPOTHESIS In National Football League (NFL) players, isolated high ankle sprains are rare and syndesmosis injuries with concomitant pathology will result in increased time to return to full participation. STUDY DESIGN Cross-sectional study. LEVEL OF EVIDENCE Level 3. METHODS Distal tibiofibular syndesmosis injuries sustained by NFL players between 2017 and 2019 were identified through NFL Injury Surveillance Database queries and verified with video analysis. Each injury underwent a comprehensive magnetic resonance imaging (MRI) review. Regression modeling was utilized to explore the influence of numerous imaging findings on time to return to full participation. RESULTS There were 83 external rotation ankle injuries involving the syndesmosis. Isolated distal tibiofibular syndesmosis injuries were rare (n = 11; 13%) and more often associated with other ligamentous injury (deltoid ligament and lateral ligamentous complex) and/or fractures. Regression modeling resulted in clustering of 3 injury pattern groups for time to return to full participation across numerous imaging findings: syndesmosis injury-fracture combinations (250 days [interquartile range [IQR,] 142-266 days]), syndesmosis injury with complete deep deltoid tear or acute diastasis (175 days [IQR, 20-248 days]), and all other syndesmosis injuries (27 days [IQR, 18-46 days]). CONCLUSION In NFL athletes with external rotation ankle injuries, isolated distal tibiofibular syndesmosis injuries were rare and more often associated with concomitant pathology. Time to return to full participation was affected by an associated fracture and complete deep deltoid ligament tear or diastasis but no other relevant MRI variables such as lateral ligament complex involvement or the presence of osteochondral lesions or bone contusions.
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Affiliation(s)
- Andrew W Kuhn
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
- Gem State Radiology, Boise, Idaho
- IQVIA, Durham, North Carolina
- Green Bay Packers, Green Bay, Wisconsin
- Biocore LLC, Charlottesville, Virginia
- Biocore LLC, Charlottesville, Virginia
- Green Bay Packers, Green Bay, Wisconsin, Bellin Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin, and OrthoCarolina, Charlotte, North Carolina
| | - Michael J Coughlin
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
- Gem State Radiology, Boise, Idaho
- IQVIA, Durham, North Carolina
- Green Bay Packers, Green Bay, Wisconsin
- Biocore LLC, Charlottesville, Virginia
- Biocore LLC, Charlottesville, Virginia
- Green Bay Packers, Green Bay, Wisconsin, Bellin Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin, and OrthoCarolina, Charlotte, North Carolina
| | - Shane J McGonegle
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
- Gem State Radiology, Boise, Idaho
- IQVIA, Durham, North Carolina
- Green Bay Packers, Green Bay, Wisconsin
- Biocore LLC, Charlottesville, Virginia
- Biocore LLC, Charlottesville, Virginia
- Green Bay Packers, Green Bay, Wisconsin, Bellin Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin, and OrthoCarolina, Charlotte, North Carolina
| | - Mackenzie M Herzog
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
- Gem State Radiology, Boise, Idaho
- IQVIA, Durham, North Carolina
- Green Bay Packers, Green Bay, Wisconsin
- Biocore LLC, Charlottesville, Virginia
- Biocore LLC, Charlottesville, Virginia
- Green Bay Packers, Green Bay, Wisconsin, Bellin Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin, and OrthoCarolina, Charlotte, North Carolina
| | - Nate Weir
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
- Gem State Radiology, Boise, Idaho
- IQVIA, Durham, North Carolina
- Green Bay Packers, Green Bay, Wisconsin
- Biocore LLC, Charlottesville, Virginia
- Biocore LLC, Charlottesville, Virginia
- Green Bay Packers, Green Bay, Wisconsin, Bellin Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin, and OrthoCarolina, Charlotte, North Carolina
| | - E Meade Spratley
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
- Gem State Radiology, Boise, Idaho
- IQVIA, Durham, North Carolina
- Green Bay Packers, Green Bay, Wisconsin
- Biocore LLC, Charlottesville, Virginia
- Biocore LLC, Charlottesville, Virginia
- Green Bay Packers, Green Bay, Wisconsin, Bellin Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin, and OrthoCarolina, Charlotte, North Carolina
| | - Cody M O'Cain
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
- Gem State Radiology, Boise, Idaho
- IQVIA, Durham, North Carolina
- Green Bay Packers, Green Bay, Wisconsin
- Biocore LLC, Charlottesville, Virginia
- Biocore LLC, Charlottesville, Virginia
- Green Bay Packers, Green Bay, Wisconsin, Bellin Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin, and OrthoCarolina, Charlotte, North Carolina
| | - Robert B Anderson
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
- Gem State Radiology, Boise, Idaho
- IQVIA, Durham, North Carolina
- Green Bay Packers, Green Bay, Wisconsin
- Biocore LLC, Charlottesville, Virginia
- Biocore LLC, Charlottesville, Virginia
- Green Bay Packers, Green Bay, Wisconsin, Bellin Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin, and OrthoCarolina, Charlotte, North Carolina
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Robbins JB, Jupiter DC, Panchbhavi VK, Weiss WM, Hagedorn JC, Chen J. Return to Play Rates Following Operative Ankle Fractures Differ Between High- and Low-Performing National Football League Athletes. Orthopedics 2024; 47:22-27. [PMID: 37216567 DOI: 10.3928/01477447-20230517-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This study investigated predictive factors for return to play among National Football League athletes after operative treatment of ankle fractures and the impacts of these injuries on career longevity and player performance. Athletes who underwent surgery to repair ankle fractures from the 2013 to 2017 seasons were identified from injury reserve lists and press releases. Demographics and season metrics were collected before and after the injury. Statistical analysis assessed for differences in recorded variables between injured and uninjured players. Thirty-one players met study inclusion criteria. Twenty-two (71%) athletes successfully returned to play. Players who did not return showed no significant differences (P>.05) in position, age, body mass index, number of games or seasons played preinjury, or snaps per game the season prior to injury and had a significantly lower (42.6%, P=.013) preinjury season approximate value (SAV) compared with returning players. Returning athletes showed no significant differences (P>.05) in SAV or snaps per game compared with their preinjury season or with uninjured controls. A high preinjury SAV is associated with successful return to play. No difference in game time or performance metrics was detectable between returning players and uninjured controls, or between preinjury and postinjury seasons. [Orthopedics. 2024;47(1):22-27.].
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Cho D, Kukadia S, Drakos M. Common Football Foot and Ankle Injuries: Non-Surgical and Surgical Management. HSS J 2023; 19:322-329. [PMID: 37435125 PMCID: PMC10331273 DOI: 10.1177/15563316231160458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/13/2022] [Indexed: 07/13/2023]
Affiliation(s)
- David Cho
- Hospital for Special Surgery, New York, NY, USA
| | | | - Mark Drakos
- Hospital for Special Surgery, New York, NY, USA
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Sinha A, Robertson G, Maffulli N. Doctor, I fractured my ankle. When can I return to play? An updated systematic review. Br Med Bull 2022; 143:35-45. [PMID: 35511134 PMCID: PMC9494256 DOI: 10.1093/bmb/ldac016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Ankle fractures in sport are common. Their optimal management is unclear, as is when patients can return to their sports activities. This systematic review provides a contemporary assessment of the literature on return to sports following acute traumatic ankle fractures managed both operatively and non-operatively. SOURCES OF DATA We systematically searched Pubmed, Google Scholar, the Cochrane Library, EMBASE and CINAHL using the terms 'ankle fractures', 'ankle injuries', 'athletes', 'sports', 'return to sport', 'return to activity', 'operative management', 'non-operative management'. AREAS OF AGREEMENT Thirteen retrospective studies fulfilled the inclusion criteria. The methodological quality of the studies was generally poor. The proportion of patients returning to sporting activity was high. In some studies, a quicker return to sporting activity was demonstrated in patients managed non-operatively. AREAS OF CONTROVERSY The time to return to sporting activity and level of performance post-treatment are not universally recorded, and the optimal time to return to sport remains to be confirmed. GROWING POINTS Conservative management for stable or undisplaced fracture may result in a higher proportion of patients returning to sport more quickly. AREAS TIMELY FOR DEVELOPING RESEARCH Randomized controlled trials should compare conservative to surgical treatment for appropriately chosen fracture patterns. Future studies should routinely report the timing of return to sport, the level of performance reached, and the time to achieve this.
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Affiliation(s)
- Amit Sinha
- Department of Trauma and Orthopaedic Surgery, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW, UK.,Department of Trauma and Orthopaedic Surgery, Wales Deanery, Ty Dysgu, Cefn Coed, Nantgarw CF15 7QQ, UK
| | - Greg Robertson
- Department of Orthopaedic Surgery, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow G51 4TF, UK
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Salerno, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent ST4 7QB, UK.,Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK
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5
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Burke J, Geller JS, Perez JR, Naik K, Vidal AF, Baraga MG, Kaplan LD. Effect of Passing Plays on Injury Rates in the National Football League. J Strength Cond Res 2021; 35:S1-S4. [PMID: 34846327 DOI: 10.1519/jsc.0000000000004172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
ABSTRACT Burke, J, Geller, JS, Perez, JR, Naik, K, Vidal, AF, Baraga, MG, and Kaplan, LD. The effect of passing plays on injury rates in the national football league. J Strength Cond Res 35(12S): S1-S4, 2021-The National Football League (NFL) has one of the highest all-cause injury rates in sports, yet our understanding of extrinsic injury risk factors is limited. The objective of this study was to assess the effect of play type on injury incidence in the NFL. We obtained data for every regular season game played during the 2013-2016 seasons from the official NFL game books. There were 2,721 in-game injuries during the 4 seasons examined, with an overall rate of 1.33 injuries per team per game. For statistical analysis, p < 0.05 was considered significant. Passing plays conferred significantly higher odds of injury than running plays (odds ratio [OR] 1.4, 95% confidence interval [CI]: 1.3-1.5, p < 0.0001). This primarily stems from increased risks in quarterbacks (OR 6.9, 95% CI: 3.6-13.3, p < 0.0001), receivers (OR 5.0, 95% CI: 3.7-6.6, p < 0.0001), and defensive backs (OR 2.3, 95% CI: 1.9-2.7, p < 0.0001). Our study suggests that passing plays confer a greater risk of overall injuries in the NFL when compared with running plays, specifically regarding concussions and core or trunk injuries.
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Affiliation(s)
- Jonathan Burke
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Joseph S Geller
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Miami, Florida; and
| | - Jose R Perez
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Miami, Florida; and
| | - Kunal Naik
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Miami, Florida; and
| | | | - Michael G Baraga
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Miami, Florida; and
| | - Lee D Kaplan
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Miami, Florida; and
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Canton G, Sborgia A, Maritan G, Fattori R, Roman F, Tomic M, Morandi MM, Murena L. Fibula fractures management. World J Orthop 2021; 12:254-269. [PMID: 34055584 PMCID: PMC8152440 DOI: 10.5312/wjo.v12.i5.254] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/01/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.
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Affiliation(s)
- Gianluca Canton
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Andrea Sborgia
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Guido Maritan
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Roberto Fattori
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Federico Roman
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Marko Tomic
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Massimo Max Morandi
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, LA 71103, United States
| | - Luigi Murena
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
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7
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Kluczynski MA, Kelly WH, Lashomb WM, Bisson LJ. A Systematic Review of the Orthopaedic Literature Involving National Football League Players. Orthop J Sports Med 2019; 7:2325967119864356. [PMID: 31457068 PMCID: PMC6702781 DOI: 10.1177/2325967119864356] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Melissa A Kluczynski
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, Buffalo, New York, USA
| | - William H Kelly
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, Buffalo, New York, USA
| | - William M Lashomb
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, Buffalo, New York, USA
| | - Leslie J Bisson
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, Buffalo, New York, USA
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Grashow RG, Roberts AL, Zafonte R, Pascual-Leone A, Taylor H, Baggish A, Nadler L, Courtney TK, Connor A, Weisskopf MG. Defining Exposures in Professional Football: Professional American-Style Football Players as an Occupational Cohort. Orthop J Sports Med 2019; 7:2325967119829212. [PMID: 30746383 PMCID: PMC6360475 DOI: 10.1177/2325967119829212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Studies of professional American football players have shown that football-related activities lead to acute injuries and may have long-term adverse health outcomes including osteoarthritis, neurocognitive impairment, and cardiovascular disease. However, the full complement of what constitutes professional football exposure has yet to be effectively articulated. Most likely, professional football exposure encompasses a multifaceted array of experiences including head impacts and joint stresses, long-term pain medication use, dietary restrictions, and strenuous training regimens. To study the health of professional American football players, characterizing the group as an occupational cohort and taking advantage of methods established within the discipline of occupational epidemiology may be beneficial. We conducted a narrative review of existing football research, occupational epidemiological methods papers, and occupational medicine studies. Here we describe the traditional occupational epidemiological approach to assessing exposure in a novel cohort and show how this framework could be implemented in studies of professional football players. In addition, we identify the specific challenges associated with studying an elite athletic occupational group, including the healthy worker effect and other types of selection and information biases, and explore these in the context of existing studies of football-related health. The application of well-established occupational epidemiological methods to professional football players may yield new insights into the effects of playing exposure and may provide opportunities for interventions to reduce harm.
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Affiliation(s)
- Rachel G Grashow
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Football Players Health Study, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea L Roberts
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ross Zafonte
- Football Players Health Study, Harvard Medical School, Boston, Massachusetts, USA.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alvaro Pascual-Leone
- Football Players Health Study, Harvard Medical School, Boston, Massachusetts, USA.,Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Herman Taylor
- Football Players Health Study, Harvard Medical School, Boston, Massachusetts, USA.,Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Aaron Baggish
- Football Players Health Study, Harvard Medical School, Boston, Massachusetts, USA.,Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lee Nadler
- Football Players Health Study, Harvard Medical School, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Theodore K Courtney
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Football Players Health Study, Harvard Medical School, Boston, Massachusetts, USA.,Environmental and Occupational Medicine and Epidemiology Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ann Connor
- Football Players Health Study, Harvard Medical School, Boston, Massachusetts, USA.,Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc G Weisskopf
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Football Players Health Study, Harvard Medical School, Boston, Massachusetts, USA.,Environmental and Occupational Medicine and Epidemiology Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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