Performance and Return to Sport After Nonoperative Treatment of Clavicle Fractures in National Football League Players

Getting Athletes Back on the Field: Management of Clavicle Fractures and Return to Play

This chapter provides an overview of the prevalence of clavicle fractures in athletes. The evaluation and management of clavicle fractures in athletes is summarized, including surgical considerations, rehabilitation protocols, and return to sport guidelines. In this population, high rates of union are observed, but careful timing of return to sport is paramount to optimize performance and prevent reinjury.

Return to competition following clavicle fractures in professional road cyclists

Objectives

Clavicle fractures are common injuries sustained by cyclists, but there is little evidence about return to competition times (RTCT) in elite cyclists. Our aim was to investigate this, and risk factors for delayed return.

Method

We identified elite cyclists who sustained clavicle fractures between 2015 and 2020. Freely available records were reviewed to validate data for RTCT. Secondary outcomes included return to outdoor cycling, management, time to surgery, cause of injury, other injuries, and ability to complete the event returned to.

Results

Records were reviewed of 1449 cyclists, identifying 188 clavicle fractures. 44 were recurrent fractures and were excluded. Those with isolated clavicle fractures (111; 92 male, 19 female) had a mean RTCT of 56.7 days, compared with 74.9 for those with multiple injuries (33) (p = 0.048). Those with multiple injuries were excluded from secondary outcome measures. All those with isolated injuries returned to elite competition. 83% were managed surgically with an RTCT of 53.8d, with no significant difference to those managed non-operatively, 59.3d (p = 0.61). RTCT was significantly lower for injuries sustained January-July (46.5d) than August-December (95.8d, p = 0.00). The incidence during Grand Tours was 0.06/1000 h for males (95% C.I 0.03-0.09), and 0.11/1000h (95% C.I 0.00-0.26) for females.

Conclusion

This is the largest study evaluating return to sport in elite cyclists with clavicle fractures. Athletes with isolated clavicle fractures, able to return the same season, took an average 46.5 days to return to competition. Elite cyclists are at high risk of clavicle fractures and the majority are managed surgically. RTCT is longer than often expected by the media, and this data can help plan rehabilitation, and manage expectations in both professional and amateur cyclists.

Level of Evidence

Level V.

Epidemiology of Sports-Related Clavicle Fractures in the United States: Injuries From 2015 to 2019

Background

Clavicle fractures are common orthopaedic injuries that frequently occur during sports and recreational activity.

Purpose

To (1) determine the incidence rate of sports-related clavicle fractures among patients evaluated in emergency departments in the United States over a 5-year period, (2) determine the most common sports and risks associated with clavicle fractures, and (3) update the literature by comparing past and present injury trends.

Study Design

Descriptive epidemiology study.

Methods

The National Electronic Injury Surveillance System (NEISS) database was queried for patients evaluated with clavicle fractures in US emergency departments from 2015 to 2019. The authors evaluated the data by age, sex, race, and sport/recreational activity. Injuries were characterized based on sports-specific mechanism of injury. Using the NEISS weighted multiplier, the authors estimated annual incidence rates based on US Census data. Contingency table comparisons of categorical variables (ie, age groups vs sex distributions) were analyzed using either chi-square or Fisher exact tests as appropriate for the population size, while continuous variable comparisons were performed using 1-way analysis of variance statistical testing.

Results

A total of 2386 athletic-related clavicle fractures were evaluated at participating emergency departments, translating to 304,211 clavicle fractures, with an annual per-year injury rate of 18.72 clavicle fractures per 100,000 persons at risk (95% CI, 15.28-23.67). Male athletes had disproportionately higher injury rates than female athletes (P < .001) for every year of the study and demonstrated a higher incidence of fractures compared with female athletes (injury proportion ratio, 5.54). Patients aged 10 to 19 years accounted for the highest overall incidence of injury (64.5%). The annual incidence rate of athletic-related clavicle fractures was not significantly different during the study period (P = .24). The most common mechanisms of injury were participation in football (26.87%), soccer (15.76%), snowboarding (5.03%), bicycling (3.77%), wrestling (3.65%), and snow skiing (3.52%).

Conclusion

Study findings indicated that clavicle fractures sustained during sports and recreational activity disproportionately affect male athletes. Adolescent populations (10-19 years of age) had the highest overall incidence of injury, and the most common activities associated with clavicle fractures were football and soccer.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Displaced mid-shaft clavicular fractures: state of the art for athletes and young active people

INTRODUCTION

Fractures ofthe clavicle are frequent injuries (between 4 and 10% of adult fractures) and mid-shaft diaphyseal fractures represent more than 80% of clavicle fractures. In a recent study from the USA in 2019, an incidence of 22.4 fractures per year per 100,000 people was reported. Multiple injury mechanisms are recognised, with sport accounting for 50 to 85% of these injuries. There is little or no consensus as to the optimal treatment but in recent years multiple studies have suggested operative management should be favoured in athletes and young active patients.

OBJECTIVES

These are (1) to present the anatomy and the anatomical-pathology of the fractures of the clavicle as well as the mechanisms of injury, (2), (3) to describe non-operative and operative treatment methods, (4) to review the literature around different treatment modalities and (5) to attempt to describe the best treatment for athletes.

METHODS

To collect and analyse the most recent articles of the literature regarding the management of displaced mid-shaft fractures of the clavicle for athletes and young active people.

RESULTS

Looking at studies of the general population, the results tend to favour surgical treatment with a smaller incidence of non-union and faster return to function. These results are mirrored in the athlete population where several studies have shown excellent anatomic restoration and functional recovery after plate fixation.

CONCLUSION

Based on this analysis, with the exception of patients who refuse operative management after an informed discussion, the treatment of choice in displaced clavicle fractures in athletes seems to be operative treatment with a plate and screws. However, prospective randomised studies comparing non-surgical treatment and plate osteosynthesis are missing and it is not possible to state that the latter is the best treatment.

Causes and differentiation of injuries depending on the positions taken on the pitch among American Football players in Poland

BACKGROUND

American Football (AF) players are assigned to positions by specific abilities and responsible for different tasks on the field; this may result into wide differentiation in experienced injuries. The aim of this study was to analyze the causes of injuries and their differentiation depending on the position on the pitch.

METHODS

Original questionnaire was used to investigate 150 Polish amateur AF players who had suffered from 189 injuries. The questionnaire detailed the following positions: offensive line (OL), defensive line (DL), quarterback (QB), running back (RB), wide receiver (WR), linebacker (LB), defensive backs (DB). The results were statistically analyzed by SofaStas v. 1.4.5 (SOFA Statistics, San Jose, CA, USA) and then had been interpreted.

RESULTS

Over 90% of all investigated AF players had self-reported injury history with the injury rate 1.27 injury per player. No statistically significant relationship was stated between position on the pitch and the occurrence rate, type and location of the injury. Significant relationship (P=0.030) was stated between the injury circumstances and position on the pitch - QB were mostly injured in collision with opponent, OL in direct sport fight while WR and RB due to a fall.

CONCLUSIONS

Occurrence and type of injuries in AF players does not depend on position on the pitch in AF. Relationship between the injury location or injury circumstances and position on the pitch requires further studies. The most common location of injury is the knee joint, and the most common type of injury is sprain while the most common causes of injury were collision with opponent and direct sport fight.

A Current Concepts Review of Clavicle Injuries in Ice Hockey From Sternoclavicular to Acromioclavicular Joint

Clavicle injuries are common in ice hockey, and a number of high-profile fractures and dislocations have occurred in elite hockey players in recent years. Acromioclavicular joint injuries, clavicle fractures, and sternoclavicular joint injuries are some of the most frequent hockey-related injuries treated by orthopaedic surgeons, and familiarity with the management of these injuries and sport-specific considerations for treatment and recovery are critical. Injuries involving the clavicle can sometimes be life-threatening, and subtle findings on physical examination and radiographic studies can have profound implications for treatment. The recent literature pertinent to the diagnosis and treatment of clavicle-related injuries in ice hockey players was reviewed and compiled into a clinical commentary. For ice hockey players, the upper extremity was traditionally considered a relatively well-protected area. However, given the evolution of the game and its protective equipment, the upper extremity now accounts for the majority of youth ice hockey injuries, of which clavicle injuries comprise a significant proportion. Acromioclavicular joint injuries are the most common injury in this population, followed closely by clavicle fractures. Sternoclavicular joint injuries are rare but can be associated with serious complications. The treatment of these injuries often differs between athletes and the general population, and surgical indications continue to evolve in both groups. Although the evidence regarding clavicle injuries is ever-increasing and the treatment of these injuries remains controversial, clavicle injuries are increasingly common in ice hockey players. Rule and equipment changes, most notably the increased use of flexible boards and glass, have been shown to significantly decrease the risk of clavicle injuries. We also recommend compulsory use of shoulder pads, even at a recreational level, as well as continued enforcement and evolution of rules aimed at reducing the rate of clavicle injuries. Future research should focus on equipment design changes directed toward clavicle injury prevention, standardized return-to-play protocols, and studies weighing the risks and benefits of nonoperative management of controversial injuries, such as type III acromioclavicular joint dislocations and diaphyseal clavicle fractures.

Performance and Return to Sport After Hip Arthroscopy in the National Basketball Association

PURPOSE

To determine: (1) return to sport (RTS) rate in National Basketball Association (NBA) players following hip arthroscopy, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players.

METHODS

NBA athletes who underwent hip arthroscopy and matched controls were identified. RTS was defined as playing in at least 1 game after surgery. Player efficiency ratings were used for performance evaluation. Continuous variables of each group were compared using a 2-tailed paired samples Student t test for normally distributed data. χ² was used to analyze categorical data. RTS was used as the primary outcome with statistical significance defined by a P value < .05. A Bonferroni correction was used to control for the remaining multiple comparisons with statistical significance defined by a P value ≤.008.

RESULTS

Twenty-three players (24 hips) were analyzed (mean age 27.5 ± 3.1 years; mean experience in the NBA 5.8 ± 2.8 years at time of surgery). Small forwards (n = 8, 33.3%) represented the largest proportion of players that underwent hip arthroscopy. Twenty players (21 surgeries, 87.5%) were able to RTS in NBA at an average of 5.7 ± 2.6 months. The overall 1-year NBA career survival rate of players undergoing hip arthroscopy was 79.2%. Players in the control group (5.2 ± 3.5 years) had a similar career length as (P = .068) players who underwent surgery (4.4 ± 3.0 years). There was no significant (P = .045) decrease in games per season following surgery. There was no significant difference in performance postoperatively compared with preoperatively (P = .017) and compared with matched controls following surgery (P = .570).

CONCLUSIONS

The RTS rate for NBA athletes after hip arthroscopy is high. There was no decrease in games played, career lengths, or performance following hip arthroscopy in NBA players versus preoperatively and matched controls.

LEVEL OF EVIDENCE

Level III case-control study.

Performance and Return to Sport After Femoroacetabular Impingement Surgery in National Football League Players

The purpose of this study was to determine the (1) return-to-sport rate for National Football League (NFL) players following femoroacetabular impingement surgery, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. National Football League athletes who underwent hip arthroscopy for femoroacetabular impingement and matched controls were identified. A Bonferroni correction was used to control for multiple comparisons, with statistical significance set at P≤.007. Fifty-five players (63 surgeries) were analyzed (mean age, 27.5±3.4 years; mean years in NFL at time of surgery, 4.7±2.9). Forty-seven (53 surgeries, 84.1%) NFL players returned to sport at a mean of 6.7±3.8 months following surgery. There was no difference (P>.007) in the mean career length of players in the control group (3.7±2.2 years) vs players who underwent hip arthroscopy (3.5±2.1 years). There was no difference (P>.007) in mean games played per season of players in the control group (12.5±3.1) vs those who underwent hip arthroscopy (12.1±4.0). Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls (P=.007). The return-to-sport rate is high for NFL athletes after hip arthroscopy for femoroacetabular impingement. There were similar games per season and career lengths postoperatively compared with preoperatively and matched controls. Quarterbacks had significantly better postoperative performance when compared with matched controls. All other positions had similar postoperative performance compared with preoperatively and matched controls. [Orthopedics. 2019; 42(5):e423-e429.].

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

Background

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

Purpose

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

Study Design

Systematic review; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

Performance and Return to Sport After Hip Arthroscopic Surgery in Major League Baseball Players

Background

Femoroacetabular impingement (FAI) is a common cause of hip pain that may lead to decreased performance in Major League Baseball (MLB) players.

Purpose

To determine the (1) return-to-sport (RTS) rate in MLB players after hip arthroscopic surgery for FAI; (2) postoperative career length, innings pitched (IP) (pitchers), and plate appearances (PA) (position players); (3) preoperative and postoperative performance; and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance.

Study Design

Cohort study; Level of evidence, 3.

Methods

MLB athletes who underwent hip arthroscopic surgery for FAI and matched controls were identified. Demographic and performance data were collected. RTS was defined as playing in at least 1 MLB game after surgery. Continuous variables of each group were compared using a 2-tailed paired-samples Student t test for normally distributed data. The chi-square test was used to analyze categorical data. The Bonferroni correction was used to control for multiple comparisons, with statistical significance defined by a P value of ≤.007.

Results

A total of 50 players (57 surgeries) were analyzed (mean age, 30.4 ± 3.9 years; mean MLB experience at the time of surgery, 7.0 ± 4.6 years). Pitchers (31 surgeries; 54.4%) represented the largest proportion of players analyzed. Of these players, 42 (47 surgeries; 82.5%) were able to RTS at a mean of 8.3 ± 4.1 months. The overall 1-year MLB career survival rate of players undergoing FAI surgery was 78.9%. Players in the control group were in MLB a similar number of years (4.0 ± 2.9 years) to players who underwent surgery (3.3 ± 2.4 years) (P > .007). There was no significant decrease in IP or PA per season after surgery (P > .007). There was no significant difference in performance for pitchers and nonpitchers compared with matched controls after surgery (P > .007).

Conclusion

The RTS rate for MLB athletes after hip arthroscopic surgery for FAI was high. There were similar IP, PA, and career lengths postoperatively compared with preoperatively and with matched controls. There was no significant difference in performance for pitchers and nonpitchers compared with matched controls after surgery.

Incidence and mechanism of injury of clavicle fractures in the NEISS database: Athletic and non athletic injuries

BACKGROUND

Clavicle fractures are a very common injury due to accidental trauma, specifically during athletics. The purpose of this study was (1) to determine the incidence of clavicle fractures presenting to United States emergency departments; (2) to compare the rate of clavicle injuries from 2012 to 2015 to 2002-2005 (3) to determine the most common mechanisms of injury for clavicle fractures.

METHODS

The National Electronic Injury Surveillance System (NEISS) was queried for the years 2002-2005 and 2012-2015. Examined variables included patient age, sex, and year of admission. Total annual case numbers were estimated using NEISS hospital weights. Annual injury incidence rates by age group and patient sex were calculated based on yearly U.S. Census estimates. Chi square test and logistic regression were used to compare injury rates by sex and age groups. Statistical significance was set at P < 0.05.

RESULTS

During the 8 years studied, the participating emergency departments (EDs) coded 14,795 fracture exposures. Using weighted estimates, this represent 545,663 injuries nationally (95% CL 425,986-665,339). This resulted in an incidence of 22.4 injuries per 100,000 person years (95% CL 17.5-27.3). The most common causes of injury were bicycles (15.1%), football (10.7%), beds/bedframes (6.8%), stairs (5.4%), and floors (4.0%). Fifty percent of clavicle fractures were due to an athletic activity. There was no significant change in injuries from 2002 to 2005 compared to 2012-2015 (23.1 per 100,000, 95% CL 18.5-27.7, and 22.4 per 100,000 person years (95% CL 17.5-27.3), respectively).

CONCLUSION

Clavicle fractures continue to occur at similar rates, with athletics accounting for 50% of injuries. Patients most at risk for clavicle fracture was bimodal in nature, with males aged 0-19 being the most common. Females were most at risk between 0 and 9 years old. We found that clavicle fracture continued to occur at similar rates as compared to 10 years prior, especially in active populations participating in collision sports (bicycle, football, and soccer).

Return to elite-level sport after clavicle fractures

Objective

To determine if return to sport following clavicle fracture occurs earlier in high-level sports than the current standard of care allows for.

Design

Observational study retrospective review of NHL prospective data.

Setting

The study was performed at a university orthopaedic surgery department.

Patients

NHL player with clavicle fracture.

Assessment of independent variables

The independent variable including time on injured reserve and type of treatment.

Main outcome measures

The primary study outcome measure was successful return to NHL play.

Results

15 athletes were identified; 10 were treated operatively and 5 non-operatively. The average return to ice hockey was 10 weeks. If the one outlier is removed, the average is 9.1 weeks. There was one re-fracture in the non-operative group. The average time from injury to return to sport was 65 days in the operative group and 97.6 days in the non-operative group. Two patients were unable to return play during the same season.

Conclusions

High-end athletes safely return to at-risk sports after clavicle fracture much sooner than the average seen with non-elite athletes. Additional study may demonstrate that return to activity can likely be accelerated without significantly increasing complications.