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Background: Achilles tendon injuries are common in sports, including football. The purpose of this study was to determine (1) return-to-sport rate in National Football League (NFL) players following Achilles tendon repair, (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. Methods: Publicly available records were used to identify NFL players who underwent Achilles tendon repair and matched controls were identified. Ninety-five players (98 surgeries) were analyzed (mean age 28.2 ± 2.8 years; mean 5.5 ± 2 .8 years in NFL at time of surgery). Demographic and performance data were collected. Comparisons between case and control groups and preoperative and postoperative time points were made using paired-samples Student t tests. Results: Seventy-one (72.4%) players were able to return to sport in the NFL at a mean of 339.8 ± 84.8 days following surgery. Thirty-one (32%) Achilles tendon repairs were performed during training camp or preseason. Controls (3.6 ± 2.1 years) had a significantly longer NFL career ( P < .05) than players who underwent Achilles tendon repair (2.7 ± 2.1 years). There was no significant difference in games per season in subsequent seasons following surgery compared with controls. Postoperative performance scores were significantly worse ( P < .05) for running backs (RBs) (n = 4) and linebackers (LBs) (n = 12) compared to preoperative scores. LBs had significantly worse postoperative performance scores when compared to matched controls ( P < .05). Conclusion: Following Achilles tendon repair, less than 75% of players returned to the NFL. Postoperative career length was 1 season shorter than matched controls. No difference was observed in the number of games per season played compared to matched controls. Postoperative performance scores were significantly worse for RBs and LBs compared to preoperative and LBs had significantly worse postoperative performance when compared to matched controls. Level of evidence: Level III, retrospective comparative series.
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Article
Introduction
Achilles tendon tears are one of the most common foot and
ankle injuries in both contact and noncontact sports.10 These
injuries are a source of significant morbidity with an inci-
dence as high as 18 per 100 000 people.15-17,20 Recent evi-
dence suggests that the incidence is increasing secondary to
an increase in athletic participation that accounts for 68% of
all Achilles tendon tears.21,22
The pathophysiology of Achilles tendon tears involves the
interplay of intrinsic (degenerative changes, hypovascularity,
repetitive microtrauma) and extrinsic (rapid acceleration/
deceleration) factors.22 Elite level athletes required to per-
form explosive changes in direction and extreme loading of
the Achilles tendon are at increased risk for Achilles tendon
tears.17 This explosive acceleration and rapid deceleration
associated with Achilles tendon tears is displayed and often
required by National Football League (NFL) players.
Many elite athletes elect for operative repair of their torn
Achilles tendon secondary to lower rerupture rates,
improved strength, and high return to sport.7 However,
recent studies demonstrated that injuries that are severe
718131FAIXXX10.1177/1071100717718131Foot & Ankle InternationalJack et al
research-article2017
1Houston Methodist Orthopedics and Sports Medicine, Houston, TX,
USA
Corresponding Author:
Joshua Harris, MD, Houston Methodist Orthopedics and Sports
Medicine, 6445 Main Street, Suite 2500, Houston, TX 77030, USA.
Email: Joshuaharrismd@gmail.com
Performance and Return to Sport After
Achilles Tendon Repair in National
Football League Players
Robert A. Jack II, MD1, Kyle R. Sochacki, MD1, Stephanie S. Gardner, MD1,
Patrick C. McCulloch, MD1, David M. Lintner, MD1, Pedro E. Cosculluela, MD1,
Kevin E. Varner, MD1, and Joshua D. Harris, MD1
Abstract
Background: Achilles tendon injuries are common in sports, including football. The purpose of this study was to determine
(1) return-to-sport rate in National Football League (NFL) players following Achilles tendon repair, (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.
Methods: Publicly available records were used to identify NFL players who underwent Achilles tendon repair and matched
controls were identified. Ninety-five players (98 surgeries) were analyzed (mean age 28.2 ± 2.8 years; mean 5.5 ± 2 .8 years
in NFL at time of surgery). Demographic and performance data were collected. Comparisons between case and control
groups and preoperative and postoperative time points were made using paired-samples Student t tests.
Results: Seventy-one (72.4%) players were able to return to sport in the NFL at a mean of 339.8 ± 84.8 days following
surgery. Thirty-one (32%) Achilles tendon repairs were performed during training camp or preseason. Controls (3.6 ± 2.1
years) had a significantly longer NFL career (P < .05) than players who underwent Achilles tendon repair (2.7 ± 2.1 years).
There was no significant difference in games per season in subsequent seasons following surgery compared with controls.
Postoperative performance scores were significantly worse (P < .05) for running backs (RBs) (n = 4) and linebackers (LBs)
(n = 12) compared to preoperative scores. LBs had significantly worse postoperative performance scores when compared
to matched controls (P < .05).
Conclusion: Following Achilles tendon repair, less than 75% of players returned to the NFL. Postoperative career length
was 1 season shorter than matched controls. No difference was observed in the number of games per season played
compared to matched controls. Postoperative performance scores were significantly worse for RBs and LBs compared to
preoperative and LBs had significantly worse postoperative performance when compared to matched controls.
Level of Evidence: Level III, retrospective comparative series.
Keywords: Achilles tendon, NFL, football, surgery, return to sport
2 Foot & Ankle International 00(0)
enough to warrant operative intervention in NFL players
can have a negative effect on postoperative performance,
return to sport (RTS), and length of career.4,18 Given the
increasing revenue and popularity of the NFL, it is impor-
tant to understand operative outcomes in this patient popu-
lation. To our knowledge, there have been no published
studies to date that have compared postoperative perfor-
mance statistics with matched controls following Achilles
tendon repair in NFL athletes.
The purpose of this study was to determine (1) RTS rate
in NFL players following Achilles tendon repair, (2) post-
operative career length and games per season, (3) pre- and
postoperative performance, and (4) postoperative perfor-
mance compared with control players matched by position,
age, years of experience, and performance. The authors
hypothesized that NFL players who underwent Achilles
tendon repair would have (1) a 75% RTS rate, (2) a postop-
erative career length and games per season significantly
less than that of matched controls, (3) significantly worse
postoperative performance compared to preoperative, and
(4) significantly worse performance postoperatively when
compared with matched controls.
Methods
Players in the NFL who sustained an Achilles tendon tear
and underwent repair were evaluated (Figure 1). These play-
ers were identified through NFL team websites, publicly
available Internet-based injury reports, player profiles and
biographies, and press releases. The search was manually
conducted by 2 orthopedic surgery residents with validation
of the findings by the senior author. Searches were per-
formed for all NFL teams and players.
All players identified who met inclusion criteria were
evaluated in this study as it related to RTS rate. A player
was deemed to have RTS if he played in any NFL game
Figure 1. Flowchart illustrating application of exclusion criteria.
Jack et al 3
after surgery. A player did not RTS if he did not play in any
NFL game after surgery. Inclusion criteria were any NFL
athletes on an active roster or listed on injured reserve in the
NFL prior to Achilles tendon tear. Players were included if
they were found to have Achilles tendon repair surgery as
reported by at least 2 separate sources. Athletes who were
injured and underwent procedures before completing their
first NFL regular season were excluded. Players who sus-
tained an Achilles tendon tear and underwent Achilles ten-
don repair in the 2015-2016 season were excluded from
analysis because they had less than a 1-year opportunity to
return to sport. In addition, online reports that were conflict-
ing, incomplete, or did not have a date of surgery were also
excluded from the study. Ninety-eight surgeries in 95 play-
ers were analyzed (Table 1).
Demographic variables including a player’s age, posi-
tion, prior professional experience, and date of surgery
were recorded. Players were categorized by their posi-
tions, including quarterback “QB,” running back “RB,”
tight end “TE,” wide receiver “WR,” offensive lineman
“OL,” defensive lineman “DL,” linebacker “LB,” defen-
sive back “DB,” kicker “K,” or punter “P.” Performance
statistics were collected from profootballreference.com
for each player identified before and after Achilles tendon
repair (Appendix A). Statistics were collected for regular
season NFL games only, with preseason and playoff
games excluded.
A control group was selected to compare data. Controls
were matched to study cases based on position, age, years
of experience, and performance data prior to the surgery
date (Table 2). Each control was given an index date that
matched the case player’s surgery date to compare postop-
erative or postindex performance. For example, if a player
had Achilles repair surgery 3 years into his career, the con-
trol’s index date was 3 years into his career.
Player statistics for cases pre- and postoperative and
controls pre- and postindex were collected and aggregated.
Each statistical category was divided by games played to
account for discrepancies in number of games played per
season. A player’s performance score (Appendix B) was
then calculated by using a previously published and stan-
dardized scoring system based on metrics important to the
player’s specific position.5,18,25 Statistics per game were
used to calculate each performance score per game.
All players were included in RTS, games per season,
and career length analysis. A Kaplan-Meier survivorship
curve with ‘‘retirement’’ as the endpoint was constructed
postoperatively for cases and postindex for controls.
Positions without previously defined performance scores
(punters, kickers, and offensive lineman) were excluded
from performance score analysis. Comparisons between
case and control groups and preoperative and postopera-
tive time points were made using paired-samples Student
t tests (http://in-silico.net/tools/statistics/ttest) using P
less than .05.
Results
One player retore his ipsilateral Achilles tendon within 1
month of surgery and returned to sport. He was counted as
a single event. One player retore his ipsilateral Achilles and
did not return to sport. He was counted as a single event.
One player tore both Achilles 2 years apart and was counted
as 2 separate events. Seventy-one (72.4%) players were
able to return to sport in the NFL. The overall 1-year sur-
vival rate of players undergoing Achilles tendon repair sur-
gery was 67.7% (Figure 2). Players in the control group (3.6
± 2.1 years) were in the NFL significantly longer (P < .001)
than players who underwent Achilles tendon repair surgery
(2.7 ± 2.1 years) (Table 3). Players in the control group
(12.9 ± 2.8 games per season) played in a similar number of
games per season postindex than players who underwent
Table 1. Number of Surgeries With Return to Sport (RTS)
Data by Position.
Position n RTS, n RTS, % Days to RTS
QB 5 5 100.0 326.4 ± 17.5
RB 11 5 45.5 363.6 ± 119.3
TE 5 3 60.0 326.3 ± 74.1
WR 10 8 80.0 317.5 ± 160.4
DB 12 9 75.0 336.2 ± 38.5
LB 19 14 73.7 351.1 ± 42.7
DL 21 17 80.1 328.2 ± 83.4
OL 13 8 61.5 341.9 ± 98.1
K 1 1 100.0 501
P 1 1 100.0 403
Total 98 71 72.4 339.8 ± 84.8
Abbreviations: DB, defensive back; DL, defensive lineman; K, kicker;
LB, linebacker; OL, offensive lineman; P, punter; QB, quarterback; RB,
running back; RTS, return to sport; TE, tight end; WR, wide receiver.
Figure 2. Kaplan-Meier survival analysis for cases and controls.
Zero (0) signifies year of surgery for cases and index year for
controls.
4 Foot & Ankle International 00(0)
Achilles tendon repair surgery (12.6 ± 3.4) postsurgery
(Table 3).
Thirty-two (100%) of the NFL’s teams had at least 1
Achilles tendon repair surgery performed. The team with
the greatest number of players undergoing Achilles tendon
repair was the New York Jets, with 9 (9%) players. The
most common position to undergo Achilles tendon repair
surgery was DL, with 21 (21%) players (Table 1). Sixty-
three (64%) Achilles tendon repairs occurred in the
off-season.
There were no significant (P > .05) differences in demo-
graphic, performance, and games per season data between
cases and matched controls presurgery and preindex
(Tables 2-4). Postoperative performance scores were signifi-
cantly worse for RBs (P = .04) and LBs (P = .03) compared
to preoperative scores (Figure 3). There was a statistically
significant (P = .04) decrease in games per season for DL
cases following surgery (Table 4). LBs had significantly
worse postoperative performance scores when compared to
postindex matched controls (P < .05) (Figure 3). There was
a clinically significant decline in performance statistics fol-
lowing Achilles tendon repair compared to controls for QBs
(5 touchdowns and 60 passing yards per year), RBs (5 touch-
downs per year), TEs (6 touchdowns per year), DBs (2 inter-
ceptions and 1 pass defended per year), and LBs (7 sacks or
28 tackles per year).
Discussion
The authors hypothesized that NFL players who underwent
Achilles tendon repair would have (1) a 75% RTS rate, (2) a
postoperative career length and games per season signifi-
cantly less than that of matched controls, (3) significantly
worse postoperative performance compared to preoperative,
Table 3. Games per Season and Career Length Postsurgery and Postindex for Cases and Controls.
Games per Season, n (Mean ± SD) Career Length, y (Mean ± SD)
Position n Cases Controls P Value Cases Controls P Value
QB 5 10.0 ± 3.2 9.6 ± 4.4 .886 6.2 ± 3.5 5.6 ± 4.1 .671
RB 5 13.0 ± 2.7 12.6 ± 1.6 .808 1.3 ± 0.8 3.2 ± 1.8 .084
TE 3 13.1 ± 3.0 8.4 ± 1.3 .198 2.3 ± 1.5 2.2 ± 1.7 .844
WR 8 10.9 ± 5.4 14.8 ± 1.1 .101 2.7 ± 2.4 4.1 ± 2.0 .195
DB 9 12.7 ± 2.2 13.3 ± 2.3 .361 2.4 ± 1.2 3.9 ± 1.5 .022*
LB 14 14.2 ± 2.4 13.7 ± 2.4 .606 2.5 ± 2.2 3.7 ± 2.2 .001*
DL 17 12.2 ± 4.0 13.4 ± 2.5 .343 2.4 ± 1.6 3.3 ± 2.0 .002*
OL 7 12.8 ± 2.5 12.3 ± 2.5 .775 3.4 ± 1.0 3.1 ± 1.1 .209
K 1 13.0 8.0 1.3 2.0
P 1 16.0 16.0 1.0 4.0
Overall 70 12.6 ± 3.4 12.9 ± 2.8 .513 2.7 ± 2.1 3.6 ± 2.1 <.001*
Abbreviations: DB, defensive back; DL, defensive lineman; K, kicker; LB, linebacker; OL, offensive lineman; P, punter; QB, quarterback; RB, running
back; SD, standard deviation; TE, tight end; WR, wide receiver.
*Statistically significant.
Table 2. Age and Experience for Each Position at Time of Surgery (for Cases) and Index Time (for Controls).
Age, y (Mean ± SD) Experience (Mean ± SD)
Position n Cases Controls P Value Cases Controls P Value
QB 5 30.8 ± 3.7 31.1 ± 4.2 .531 8.1 ± 3.8 7.7 ± 5.0 .587
RB 5 27.9 ± 3.5 27.4 ± 2.9 .352 4.4 ± 2.7 4.4 ± 3.1 1.000
TE 3 28.5 ± 3.4 28.4 ± 3.9 .792 6.1 ± 3.6 6.1 ± 3.6 1.000
WR 8 25.9 ± 2.5 25.8 ± 2.5 .876 3.1 ± 2.4 3.0 ± 2.4 .351
DB 9 27.3 ± 2.1 27.5 ± 2.3 .399 4.9 ± 2.5 4.8 ± 2.2 .347
LB 14 28.1 ± 2.1 27.9 ± 2.4 .607 5.8 ± 2.1 5.8 ± 2.1 1.000
DL 17 28.5 ± 3.2 28.2 ± 3.4 .317 5.6 ± 3.2 5.6 ± 3.1 .332
OL 7 29.4 ± 1.7 29.4 ± 2.3 .957 6.3 ± 2.0 6.3 ± 2.0 1.000
K 1 27.3 27.2 5.2 5.2
P 1 29.5 29.1 6.3 6.3
Overall 70 28.2 ± 2.8 28.0 ± 3.0 .309 5.5 ± 2.8 5.4 ± 2.9 .199
Abbreviations: DB, defensive back; DL, defensive lineman; K, kicker; LB, linebacker; OL, offensive lineman; P, punter; QB, quarterback; RB, running
back; SD, standard deviation; TE, tight end; WR, wide receiver.
Jack et al 5
and (4) significantly worse performance postoperatively
when compared with matched controls. The first study
hypothesis was confirmed because there was a 72.4% RTS
rate. The remaining hypotheses were partially confirmed in
that the postoperative career length was significantly less
than matched controls, postoperative games per season was
not significantly different, RBs and LBs had significantly
worse postoperative performance, and LBs had significantly
worse postoperative performance when compared to matched
controls.
One previous study investigated RTS and postoperative
performance for players who underwent Achilles tendon
repair in the NFL.18 The prior study demonstrated an RTS of
72.5% in 80 NFL athletes.18 The RTS from this prior study is
nearly identical to the results of the present study with an
RTS of 72.4% in 95 NFL athletes. However, this study did
not evaluate performance scores for specific position groups
and did not compare the outcomes of Achilles tendon repair
against matched controls. By using controls that were age-,
NFL experience-, and performance-matched, the current
study was able to improve performance data comparisons
for case players against controls at the same point in their
career. By simply comparing a player to himself, rapid
improvements (or regressions) in performance that are prev-
alent among similar players in the league may otherwise not
be accounted for. Furthermore, there may be the same
pathology present on the contralateral side similar to that of
the operative side, with recent studies demonstrating a con-
tralateral Achilles tendon rupture rate as high as 6.4%.11,21,26
Despite an RTS of 72.4%, there was a large number of
players who retire within the next few seasons after surgery
and index year. By year 3 postsurgery, only 28.1% of play-
ers who underwent Achilles tendon repair surgery remained
in the NFL. The average career length in the NFL is reported
as 6 years for players making an opening day roster in their
rookie season and 3.3 years for all NFL players overall.24
The average experience for players in this investigation was
5.5 years, already surpassing the overall career length aver-
age. The average career length after Achilles tendon repair
surgery has previously been described as 1.6 years.18 The
current investigation found an average career length of 2.7
years after Achilles tendon repair surgery. The increase in
career length in this investigation is likely due to more
recent seasons included in the current study (an additional 2
NFL seasons). The current investigation also found a sig-
nificant difference in career length after surgery when com-
paring cases (2.7 years) to controls (3.6 years), which has
not previously been described.
The highest number of Achilles tendon repair surgeries
occurred in DL (21), LB (19), and OL (13). This is a similar
distribution to a previous study looking at the effect of
injury on a career in the NFL in which DL and OL had the
highest and third highest incidence of injury, respectively.4
Interestingly, offensive (37.1 ± 1.9) and defensive (34.6 ±
1.4) linemen have the highest body mass index (BMI) in
NFL players.14 With recent studies demonstrating a signifi-
cantly increased incidence of Achilles tendon pathology in
patients with elevated BMI, the increased number of
Achilles tendon injuries in these players could be secondary
to the elevated BMI.12,13,23
Prior studies have also failed to comment on perfor-
mance and RTS differences between position groups fol-
lowing Achilles tendon repair. The RBs’ and LBs’
performance significantly regressed postoperatively, and
the LBs had significantly worse performance postopera-
tively compared to matched controls. There was an average
performance score difference per game of 1.9 for RBs and
1.8 for LBs. Extrapolated over a 16-game season, this
results in a performance score difference of 30.4 and 28.8
for RBs and LBs, respectively. Using the performance
score, RBs had 5 fewer touchdowns and LBs had 7 fewer
sacks and 28 fewer tackles compared to matched controls,
indicating both clinically and statistically significant results.
Furthermore, the TE and DB positions regressed postop-
eratively while their controls remained similar or improved.
There is an average performance score difference per game
of 2.3 and 0.7 for TEs and DBs, respectively. Extrapolated
over a 16-game season, the result is a performance score
difference of 36.8 for TEs and 11.2 for DBs, which equates
to 6 touchdowns per season for TEs and 2 interceptions and
1 pass defended per season for DBs. The QBs’ performance
scores decreased postoperatively and postindex in the con-
trols resulting in a performance score difference per game
of 1.4 between the cases and controls. Using the same logic,
this results in 5 touchdowns and 60 passing yards per
Table 4. Mean Games per Season for Cases and Controls
Presurgery and Preindex as well as Cases Postsurgery.
Presurgery and
Preindex
(Mean ± SD)
Postsurgery
(Mean ± SD)
Position Cases Controls P ValueaCases P Valueb
QB 10.9 ± 4.4 10.4 ± 3.3 .494 10.0 ± 3.2 .715
RB 12.9 ± 4.7 12.9 ± 2.8 .999 13.0 ± 2.7 .982
TE 13.9 ± 1.4 14.4 ± 1.8 .725 13.1 ± 3.0 .667
WR 12.4 ± 2.7 13.1 ± 1.6 .264 10.9 ± 5.4 .514
DB 14.1 ± 1.6 14.1 ± 3.0 .993 12.7 ± 2.2 .219
LB 14.4 ± 1.7 14.5 ± 1.2 .899 14.2 ± 2.4 .797
DL 14.4 ± 2.0 14.1 ± 1.7 .619 12.2 ± 4.0 .040*
OL 13.3 ± 1.6 14.2 ± 1.5 .243 12.8 ± 2.5 .646
K 13.2 10.8 13.0
P 12.0 16.0 16.0
Abbreviations: DB, defensive back; DL, defensive lineman; K, kicker;
LB, linebacker; OL, offensive lineman; P, punter; QB, quarterback; RB,
running back; SD, standard deviation; TE, tight end; WR, wide receiver.
aStudent t test comparing case presurgery and control preindex games/
season.
bStudent t test comparing case presurgery and case postsurgery games/
season.
6 Foot & Ankle International 00(0)
season fewer than controls. Although these differences in
performance are not statistically significant, they are clearly
clinically significant.
Interestingly, the RBs, OLs, and LBs also had the worst
RTS, with only 45.5% of RBs, 61.5% of OL, and 73.7% of
LBs returning to sport postoperatively. On the other hand,
QBs and special team players had an RTS of 100%. This
trend is similar to that found in a previous study looking at
the effect of injury on a career in the NFL in which LBs,
RBs, and OL were the most negatively affected by injury
and QBs and specialists were the least negatively affected
by injury.4
The majority (64%) of NFL players in the present study
sustained Achilles tendon rupture and underwent Achilles
tendon repair surgery during the offseason training camps.
No study has directly compared Achilles tendon ruptures
between the offseason training camps and regular season.
However, a prior study by Feeley et al demonstrated signifi-
cantly more injuries occurred during the first 2 weeks of
training camp compared to the final 3 weeks, with the
severity of injuries decreasing as the training camp
progressed.9 Additionally, a study of professional rugby
players found there to be significantly increased injuries in
the preseason compared to the regular season.3 Askling et al
found that a preseason program improved function and
decreased injury rate in professional soccer players, indicat-
ing that the addition of preseason strength and conditioning
training may be beneficial to elite professional athletes.2
These findings may have significant implications in the
occasional recreational athlete who may have limited
conditioning.
Figure 3. Performance scores by position before and after surgery compared to controls pre- and postindex.
, significant difference between pre- and postsurgery performance scores for cases; , significant difference between postsurgery and postindex
performance scores.
There are several limitations of this study. The use of
publicly available data to identify Achilles tendon tears
and repairs is prone to selection, reporting, and observer
bias. However, this method of data acquisition has been
used in multiple previous studies.1,6,8,18,19 Additionally,
the use of public data limits the ability to obtain the sever-
ity of the injury and the exact operative procedure (open
or percutaneous) being performed for Achilles tendon
repair. In this study, career length was not adjusted for
“time missed” for players who underwent surgery. Their
time in the league was in fact longer than reported; how-
ever, their seasons spent playing (ie, career length) after
surgery is accurate. Inherent to this type of study, there
are multiple unknown confounding variables such as pre-
surgical course and no direct physical contact or medical
records access to corroborate diagnosis. Other limitations
include the absence of patient-reported outcomes, incom-
plete follow-up and career length for players still in the
NFL, and inability to compare offensive lineman or spe-
cialist with performance scoring.
Conclusion
Following Achilles tendon repair, less than 75% of players
returned to the NFL. Postoperative career length was 1 sea-
son shorter than matched controls. No difference was
observed in the number of games per season played com-
pared to matched controls. Postoperative performance
scores were significantly worse for RBs and LBs compared
to preoperative, and LBs had significantly worse postopera-
tive performance when compared to matched controls.
Jack et al 7
Appendix A
Position Variables Collected
Quarterback Demographic: Age, experience
Presurgery and postsurgery (and index) variables:
Number of seasons, games
Total, per game, and per season variables
collected pre- and postsurgery (and
index): Completions, attempts, completion
percentage, passing yards, passing touchdowns,
interceptions, sacks, fumbles, rushing yards,
rushing touchdowns
Running back Demographic: Age, experience
Presurgery and postsurgery (and index) variables:
Number of seasons, games
Total, per game, and per season variables
collected pre- and postsurgery (and index):
Rushing attempts, rushing yards, rushing yards
per attempt, rushing touchdowns, receptions,
receiving yards, receiving touchdowns, fumbles
Tight end / wide
receiver
Demographic: Age, experience
Presurgery and postsurgery(and index) variables:
Number of seasons, games
Total, per game, and per season variables collected
pre- and postsurgery (and index): Receptions,
receiving yards, receiving yards per reception,
receiving touchdowns, fumbles
Offensive lineman
/ punter / kicker
Demographic: Age, experience
Presurgery and postsurgery (and index) variables:
Number of seasons, games
Defensive back
/ linebacker
/ defensive
lineman
Demographic: Age, experience
Presurgery and postsurgery (and index) variables:
Number of seasons, games
Total, per game, and per season variables collected
pre- and postsurgery (and index): Tackles,
assisted tackles, total tackles, sacks, safeties,
interceptions, forced fumbles, touchdowns,
passes deflected
Appendix B
Position Performance Score Formula
Quarterback (Passing yards ÷ 25) +(Passing
touchdowns × 4) + (Rushing yards ÷
10) + (Rushing touchdowns × 6)
Running back /
wide receiver /
tight end
(Receiving yards ÷ 10) + (Receiving
touchdowns × 6) + (Rushing yards ÷
10) + (Rushing touchdowns × 6)
Defensive players (Tackles) + (Assists ÷ 2) + (Sacks × 4) +
(Passes defended) + (Interceptions ×
5) + (Interceptions / Fumbles returned
for touchdowns × 6) + (Forced fumbles
× 3) + (Fumbles recovered × 2) +
(Safeties × 2)
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article. ICMJE forms for all authors available online.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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... Prior work has demonstrated that they are associated with rates of failure to return to play (RTP) of 20.5%, 17 29.2%, 24 and 2% 34 in National Basketball Association (NBA) players; 34.4%, 34 27.6%, 15 and 38.7% 37 in National Football League (NFL) players; 0% 34 in Major League Baseball (MLB) players; 7.5% 36 in National Collegiate Athletics Association (NCAA) football players; and 13% 12 and 29.2% 35 in professional soccer players. In NFL players, failure to RTP has been shown to be associated with fewer preinjury games played per season and declining performance in the season prior to injury. ...
... In NFL players, failure to RTP has been shown to be associated with fewer preinjury games played per season and declining performance in the season prior to injury. 37 Achilles tendon ruptures in professional athletes have been shown to be associated with decreased career duration, 15 fewer games played, 17,24 fewer minutes played, 35 and decreased performance. 15 Prior work assessing outcomes following Achilles tendon ruptures in National Hockey League (NHL) players has demonstrated a 78.9% RTP rate with no significant change in performance as measured by traditional statistics including goals scored, assists, plus minus, penalty minutes, shots, and games played. ...
... 37 Achilles tendon ruptures in professional athletes have been shown to be associated with decreased career duration, 15 fewer games played, 17,24 fewer minutes played, 35 and decreased performance. 15 Prior work assessing outcomes following Achilles tendon ruptures in National Hockey League (NHL) players has demonstrated a 78.9% RTP rate with no significant change in performance as measured by traditional statistics including goals scored, assists, plus minus, penalty minutes, shots, and games played. 20 Although traditional statistics does paint a general picture of the effect of Achilles tendon ruptures on NHL performance, these statistics can be influenced by randomness, strategy, usage, teammate performance, and game script and have been shown to be a poor predictor of future team performance. ...
Article
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Background Few studies assess rates of return to play and postinjury performance in National Hockey League (NHL) players who sustain Achilles tendon ruptures. Our objective was to determine the rate of return to play and performance impact among NHL players who undergo surgical repair of Achilles tendon tears. Methods NHL players who sustained an Achilles tendon rupture between 2001 and 2021 were identified using a publicly available injury database. Demographic and outcome data were collected for the 1-year period preceding and the 2-year period following surgery. Our primary outcome was expected wins above replacement per 60 minutes played. A position, draft year, and index season performance matched cohort was created. Pre- and postinjury outcomes were compared between cases and controls with a paired t test. Results We identified 15 cases (9 forwards, 5 defencemen, 1 goaltender). Fourteen of 15 (93%) players returned to play. Preinjury, postinjury year 1, and postinjury year 2 expected wins above replacement were 0.05, 0.05, 0.05 respectively ( P > .05). There was no significant difference in performance between cases and controls at any time point. Conclusion Achilles tendon tears are associated with a high rate of return to play in the NHL and are not associated with a significant change in offensive, defensive, or overall performance-based metrics. Level of Evidence Level III, case-control study.
... However, if the return to professional play took place 2-3 years after the event, athletes more often return to their original level of play, and the number of matches played is the same as the period before the Achilles tendon rupture. Nonetheless, the estimated duration of their NFL career is shorter than that of healthy individuals [64,66]. A meta-analysis by John et al. based on 15 studies, showed a 76% return to play (RTP) rate among professional athletes, while the average time to achieve it is approximately 11 months [67]. ...
... It is the highest in the European group of football players and is approximately 96%, as shown by the research of Grassi et al. [69]. There is a large discrepancy in the results of the RTP index among football players (NFL), which, depending on the study, ranges from 61.3 to 92.5% [63,64,66,70,71]. In basketball (NBA), the RTP rate varies from 68.0% to 79.5% depending on the study [69,72,73]. ...
... In basketball (NBA), the RTP rate varies from 68.0% to 79.5% depending on the study [69,72,73]. In studies by have shown that this phenomenon is most common among sports such as athletics, football, and basketball [66,72,73]. This correlation is probably due to the characteristics of the styles of these games, which involve series of jumps, short sprints, and frequent stopping and resuming movement. ...
Article
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The Achilles tendon is the most powerful and longest in our body. 20% of all serious tendon ruptures involve the Achilles tendon (AT). An AT rupture can be a career-ending injury. Proven risk factors predisposing and preventing tendon rupture are presented, as well as epidemiological data on the incidence of this disease in the population. In addition, it illustrates currently used diagnostic methods and presents the benefits they bring. Achilles tendon ruptures have a detrimental impact on athletic performance, and the most appropriate treatment method and return-to-play recommendations remain controversial. Recent studies show that operative intervention improves strength and functional results and is more effective compared to non-operative treatment combined with rehabilitation. Currently, according to the latest research, surgical intervention should be used, especially in athletes and very physically active people, because it shortens the time to return to full fitness and allows for better sports achievements in the future. However, you should remember about the complications that may result from such treatment. Nevertheless, the benefits of surgery outweigh the possible losses, especially to the athletic population. The purpose of this study is to comprehensively review the relationship between surgical repair of a ruptured AT and future athletic performance in an athlete population. The available research shows the effectiveness, side effects, complications, and benefits of surgical correction of a ruptured tendon in the athlete population, as well as the quality of performance they are able to achieve after recovery. Materials and methods: Materials used in this study were found in the PubMed database, using the following keywords: Achilles tendon”, Achilles tendon rupture”, Return to play’’, Athletes injury”, Athletic population”.
... Six of the studies included in this review were case reports or case series (Uchiyama et al, 2007;Byrne et al, 2017;Fanchini et al, 2018;Rungprai and Phisitkul, 2018;Hagen and Pandya, 2019;Morimoto et al, 2021), one was a case-control study (Sánchez et al, 2007), one was an observational cross-sectional study (Jallageas et al, 2013), four were prospective cohort studies (Kakiuchi, 1995;Jennings et al, 2004;Lansdaal et al, 2007;Saxena et al, 2021), ten were retrospective cohort studies (Gajhede-Knudsen et al, 2013;McCullough et al, 2014;Jack et al, 2017;Schipper et al, 2018;Grassi et al, 2020;2022;Khalil et al, 2020;Siu et al, 2020;Chauhan et al, 2021;Tramer et al, 2021), one was a retrospective comparative study (Zayni, 2017) and one was a randomised controlled trial (Makulavičius et al, 2020). ...
... Studies were published between 1995 and 2021, including 947 patients and covering basketball, soccer, American football, volleyball, racket sports, running, aerobics, bobsled, handball, rugby, Japanese fencing, martial arts, swimming and gymnastics. Eighteen studies included only elite athletes (Lansdaal et al, 2007;Sánchez et al, 2007;Gajhede-Knudsen et al, 2013;Jallageas et al, 2013;McCullough et al, 2014;Byrne et al, 2017;Jack et al, 2017;Fanchini et al, 2018;Rungprai and Phisitkul, 2018;Schipper et al, 2018;Hagen and Pandya, 2019;Grassi et al, 2020;2022;Khalil et al, 2020;Siu et al, 2020;Chauhan et al, 2021;Morimoto et al, 2021;Tramer et al, 2021), and five included only non-elite athletes (Kakiuchi, 1995;Jennings et al, 2004;Zayni, 2017;Makulavičius et al, 2020;Saxena et al, 2021). The case series by Uchiyama et al (2007) included both elite and non-elite athletes. ...
... However, they all Review © 2023 MA Healthcare Ltd included younger patients with a mean age close to 28 years old, which is on the younger end of the scale of the studies included in this review (the median age being 29.8 years). Studies reporting data from older athletes, such as Fanchini et al (2018), Jack et al (2017) and Jennings et al (2004), reported shorter return to sport times of 4, 5.1 and 4 months respectively, the reasons for which are difficult to determine. One explanation may be that older athletes function at a lower baseline of what is considered a return to sport, whereas younger athletes are more likely to be professionals who require much more rigorous recovery of their Achilles tendon to be fit enough to play once more, as they place much greater strain on their tendon than older athletes. ...
Article
Achilles tendon rupture is among the most common sports injuries. In patients with high functional demands, surgical repair is preferred to facilitate early return to sporting function. This article reviews the literature and provides evidence-based guidance for return to sport after operative management of Achilles tendon rupture. A search was performed using PubMed, Embase and Cochrane Library for all studies reporting on return to sport after operative management of Achilles tendon rupture. The review included 24 studies reporting on 947 patients, and found that 65-100% of patients were able to return to sport between 3 and 13.4 months post-injury, with incidence of rupture recurrence 0-5.74%. These findings will help patients and healthcare professionals plan a recovery timeline, discuss athletic functionality post-recovery, and understand complications of repair and risk of tendon re-rupture.
... Calf strength asymmetry, observed in many patients after ATR, likely contributes to the challenges athletes face to RTP [58,59]. This has been found to be most prevalent in athletic competitions, including basketball and football, where the nature of the games demands a stop/start playing style, repetitive jumping, and short sprints [3,[60][61][62]. Muscle weakness, decreased endurance, and other functional deficits observed after ATR, which ultimately limit athletes' abilities to execute the physical demands of sport, in some cases persist for 10 years following injury [57]. ...
... For NFL players, in their first year returning from ATR, studies demonstrate that athletes play in significantly fewer games, with reduced play time, and worse performance compared to age-matched controls and their preinjury baseline [11,40,64]. At 2 to 3 years after surgery, athletes recover to their baseline performance levels and numbers of games played; however, the duration of their NFL career is significantly shorter than controls (3.6 ± 2.1 years, p<0.05) [60,64]. ...
Article
Full-text available
Purpose of Review Achilles tendon ruptures (ATR) are detrimental to sports performance, and optimal treatment strategy and guidelines on return to play (RTP) remain controversial. This current review investigates the recent literature surrounding nonoperative versus operative management of ATR, clinical outcomes, and operative techniques to allow the athlete a successful return to their respective sport. Recent Findings The Achilles tendon (AT) is crucial to the athlete, as it is essential for explosive activities such as running and jumping. Athletes that sustain an ATR play in fewer games and perform at a lower level of play compared to age-matched controls. Recent studies also theorize that ATRs occur due to elongation of the tendon with fatigue failure. Biomechanical studies have focused on comparing modes of fixation under dynamic loading to recreate this mechanism. Summary ATRs can be career-ending injuries. Fortunately, the recent incorporation of early weight-bearing and functional rehabilitation programming for non-operative and operative patients alike proves to be beneficial. Especially for those treated nonoperatively, with the incorporation of functional rehabilitation, the risk of re-rupture among non-operative patients is beginning to approach the historical lower risk of re-rupture observed among patients treated operatively. Despite this progress in decreasing risk of re-rupture particularly among non-operative patients, operative managements are associated with unique benefits that may be of particular interest for athletes and active individuals. Recent studies demonstrate that operative intervention improves strength and functional outcomes with more efficacy compared to nonoperative management with rehabilitation. The current literature supports operative intervention in elite athletes to improve performance and shorten the duration to RTP. However, we acknowledge that surgical intervention does have inherent risks. Ultimately, most if not all young and/or high-level athletes with an ATR benefit from surgical repair, but it is crucial to take a stepwise algorithmic approach and consider other factors, which may lead towards nonoperative intervention. These factors include age, chronicity of injury, gap of ATR, social factors, and medical history amongst others in this review.
... Several studies reporting outcomes of ATRs in elite athletes are based on publicly available information [11,13,15,24,26,30,33,34]. In soccer, one notable source is transfermarkt.com ...
Article
Purpose: Achilles tendon ruptures (ATR) are career-threatening injuries in elite soccer players due to the decreased sports performance they commonly inflict. This study presents an exploratory data analysis of match participation before and after ATRs and an evaluation of the performance of a machine learning (ML) model based on pre-injury features to predict whether a player will return to a previous level of match participation. Methods: The website transfermarkt.com was mined, between January and March of 2021, for relevant entries regarding soccer players who suffered an ATR while playing in first or second leagues. The difference between average minutes played per match (MPM) 1 year before injury and between 1 and 2 years after the injury was used to identify patterns in match participation after injury. Clustering analysis was performed using k-means clustering. Predictions of post-injury match participation were made using the XGBoost classification algorithm. The performance of this model was evaluated using the area under the receiver operating characteristic curve (AUROC) and Brier score loss (BSL). Results: Two hundred and nine players were included in the study. Data from 32,853 matches was analysed. Exploratory data analysis revealed that forwards, midfielders and defenders increased match participation during the first year after injury, with goalkeepers still improving at 2 years. Players were grouped into four clusters regarding the difference between MPMs 1 year before injury and between 1 and 2 years after the injury. These groups ranged between a severe decrease (n = 34; - 59 ± 13 MPM), moderate decrease (n = 75; - 25 ± 8 MPM), maintenance (n = 70; 0 ± 8 MPM), or increase (n = 30; 32 ± 13 MPM). Regarding the predictive model, the average AUROC after cross-validation was 0.81 ± 0.10, and the BSL was 0.12, with the most important features relating to pre-injury match participation. Conclusion: Most players take 1 year to reach peak match participation after an ATR. Good performance was attained using a ML classifier to predict the level of match participation following an ATR, with features related to pre-injury match participation displaying the highest importance. Level of evidence: I.
Article
Acute rupture of the Achilles tendon is a frequently encountered injury that occurs most commonly in people who participate in recreational athletics into their thirties and forties. For many years, the injury has been treated either nonsurgically or surgically using a standard open approach. More recently, a variety of new surgical techniques have emerged in the literature aiming to improve surgical outcomes while decreasing the potential complications associated with standard open repair. Nonsurgical treatment plans using early weight bearing and accelerated functional rehabilitation have also proven to be excellent management options. Achilles rupture treatment plans can include the use of orthobiologics, such as platelet-rich plasma, with mixed results. Accelerated functional rehabilitation protocols have shown to improve patient outcomes, whether used in conjunction with surgery or nonsurgical management modalities, and reduce the disparity between the injured tendon and the native Achilles.
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Background Injury incidence is higher in the National Football League (NFL) than in other collision sports. Although previous research has identified that scheduling variations, including overseas games and bye week timing, does not affect concussion risk, data are currently lacking regarding the effects of scheduling variation on season-long musculoskeletal injury incidence. Purpose To determine whether higher cumulative travel distance, overseas play, an early season bye week, and an expansion of the regular season is associated with higher injury rates in the NFL. Study Design Descriptive epidemiology study. Methods All 1275 injuries across 5 NFL seasons from 2017 to 2018 through 2021 to 2022 were reviewed retrospectively. Injury data and travel distances were extracted from publicly available sources, which were cross-referenced for validation. Injury rates were calculated per 1000 athletic-exposures (AEs). Cumulative team travel distances were compared statistically using a linear regression. Single factor analysis of variance was used to compare categorical variables. Results Travel distance did not significantly predict injury rates ( P = .47), and there was no difference in injury rates between teams that played a game overseas versus teams that did not (19.3 injuries per 1000 AEs for both; P = .96). In addition, no difference was found in injury rates ( F[109,2100[ = 0.704; P = .73) or players placed on the injured reserve list ( F[99,778] = 1.70; P = .077) between various bye weeks ( P = .73). Injury rates did not differ between the new 17-game regular season (18.4 per 1000 AEs) versus the previous four 16-game regular seasons (19.7 per 1000 AEs; P = .12). However, teams that did not qualify for the playoffs had a significantly higher injury rate (19.9 per 1000 AEs) as well as players on injured reserve (8.0 per 1000 AEs) than playoff-qualifying teams (18.4 and 6.8 per 1000 AEs, respectively; P < .05 for both). Conclusion Over 5 NFL seasons, cumulative travel distance, overseas play, bye week timing, and adding 1 regular season game were not associated with increased injury rates in NFL players. However, a lack of regular season success was associated with higher injury rates and more players on injured reserve.
Article
Achilles tendon ruptures are the most common tendinous lesions in the adult population. The incidence has been rising, and it is more common between men and athletes. Achilles tendon rupture is a very relevant injury for athletes as it can threaten their career, with 20% to 40% not returning to elite sport. With the advent of better rehabilitation programs and new options available, the conservative treatment has become more popular and recent studies demonstrated similar outcomes compared with surgery. The conservative option is based on the principle of cast splint immobilization or functional braces, early weight-bearing and physical rehabilitation. The surgical treatment is based in open, mini-open and percutaneous approaches, with the goal to restore length and tension of the tendon. Percutaneous and mini-open techniques seem to have some benefit, as they reduce the risk of complications and an earlier return to physical activities.
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Background: Anterior cruciate ligament (ACL) rupture is a significant injury in male Major League Soccer (MLS) players in the United States. Purpose: To determine (1) return-to-sport (RTS) rate in MLS following ACL reconstruction (ACLR), (2) timing of RTS, (3) performance upon RTS, and (4) the difference in RTS and performance between players who underwent ACL reconstruction (ACLR) and controls. Study Design: Case-control study; Level of evidence, 3. Methods: MLS players undergoing ACLR between 1996 and 2012 were evaluated. Player data were extracted from publically available sources. All demographic data were analyzed. A control group of players matched by age, body mass index (BMI), sex, position, performance, and MLS experience (occurred at 2.6 years into career, designated ‘‘index year’’) was selected from the MLS during the same years as those undergoing ACLR. The RTS and performance in the MLS were analyzed and compared between cases and controls. Student t tests were performed for analysis of within- and between-group variables. Results: A total of 52 players (57 knees) that met inclusion criteria underwent ACLR while in the MLS. Mean player age was 25.6+/- 3.98 years. Forty players were able to resume play (77%). Of the 40 players (45 knees), 38 (43 knees; 95%) resumed play the season following ACLR (mean, 10+/-2.8 months after surgery). Mean career length in the MLS after ACLR was 4.0+/-2.8 years. The revision rate was 10%. There was a significant increase in the incidence of ACL tears in the MLS by year (P < .001), and there was a significantly (P = .002) greater number of ACL tears on the left knee as opposed to the right. Performance in the MLS upon RTS after ACLR was not significantly different versus preinjury. There was no significant difference in survival in the MLS between cases and controls after ACLR or index year. The only significant performance differences between cases and controls were that cases had significantly greater shots taken per season (P = .005) and assists (P = .005) than did controls after the index year. Conclusion: There is a high RTS rate in the MLS following ACLR. Nearly all players resumed play the season after surgery. Performance was not significantly different from preinjury. Only 2 performance measures (shots taken and assists) were significantly different between cases and controls. A significantly greater number of ACL tears occur in the left versus the right knee. Keywords: anterior cruciate ligament; Major League Soccer; return to sport; knee
Article
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Background: A complete rupture of the Achilles tendon is a devastating injury. Variables affecting return to competition and performance changes for National Basketball Association (NBA) players are not readily evident. Hypothesis: Players in the NBA who ruptured their Achilles tendons and who underwent surgical repair would have more experience in the league, and the performance of those who were able to return to competition would be decreased when compared with their performance before injury and with their control-matched peers. Study design: Cohort study; Level of evidence, 3. Methods: Data for 18 basketball players with Achilles tendon repair over a 23-year period (1988-2011) were obtained from injury reports, press releases, and player profiles. Variables included age, body mass index (BMI), player position, and number of years playing in the league. Individual season statistics were obtained, and the NBA player efficiency rating (PER) was calculated for 2 seasons before and after injury. Controls were matched by playing position, number of seasons played, and performance statistics. Univariate and multivariate analyses were performed to assess the effect of each factor. Results: At the time of injury, the average age was 29.7 years, average BMI was 25.6, and average playing experience was 7.6 years. Seven players never returned to play an NBA game, whereas 11 players returned to play 1 season, with 8 of those players returning for ≥2 seasons. Players who returned missed an average of 55.9 games. The PER was reduced by 4.57 (P = .003) in the first season and by 4.38 (P = .010) in the second season. When compared with controls, players demonstrated a significant decline in the PER the first season (P = .038) and second season (P = .081) after their return. Conclusion: The NBA players who returned to play after repair of complete Achilles tendon ruptures showed a significant decrease in playing time and performance. Thirty-nine percent of players never returned to play.
Article
Background: Injuries are inherent to the sport of American football and often require operative management. Outcomes have been reported for certain surgical procedures in professional athletes in the National Football League (NFL), but there is little information comparing the career effect of these procedures. Purpose: To catalog the postoperative outcomes of orthopaedic procedures in NFL athletes and to compare respective prognoses and effects on careers. Study design: Case series; Level of evidence, 4. Methods: Athletes in the NFL undergoing procedures for anterior cruciate ligament (ACL) tears, Achilles tendon tears, patellar tendon tears, cervical disc herniation, lumbar disc herniation, sports hernia, knee articular cartilage repair (microfracture technique), forearm fractures, tibial shaft fractures, and ankle fractures were identified through team injury reports or other public records. Game and performance statistics during the regular season were collected before and after surgery. Statistical analysis was performed with significance accepted as P < .05. Results: A total of 559 NFL athletes were included. Overall, 79.4% of NFL athletes returned to play after an orthopaedic procedure. Forearm open reduction and internal fixation (ORIF), sports hernia repair, and tibia intramedullary nailing (IMN) led to significantly higher return-to-play (RTP) rates (90.2%-96.3%), while patellar tendon repair led to a significantly lower rate (50%) (P < .001). Athletes undergoing ACL reconstruction (ACLR), Achilles tendon repair, patellar tendon repair, and ankle fracture ORIF had significant declines in games played at 1 year and recovered to baseline at 2 to 3 years after surgery. Athletes undergoing ACLR, Achilles tendon repair, patellar tendon repair, and tibia IMN had decreased performance in postoperative season 1. Athletes in the Achilles tendon repair and tibia IMN cohorts recovered to baseline performance, while those in the ACLR and patellar tendon repair cohorts demonstrated sustained decreases in performance. Conclusion: ACLR, Achilles tendon repair, and patellar tendon repair have the greatest effect on NFL careers, with patellar tendon repair faring worst with respect to the RTP rate, career length after surgery, games played, and performance at 1 year and 2 to 3 years after surgery.
Article
Background and Aims: There have been reports about the increasing number of Achilles tendon ruptures. The most of the reports are based on records in a few hospitals only. We wanted to verify the increasing trend by investigating the epidemiology of Achilles tendon rupture in a very large population. Material and Methods: The retrospective data was collected from 1987 to 1999 in Finnish National Hospital Discharge Register. The study includes 7 375 tendon rupture patients. We recorded their age, gender, home district and the date of admission in a hospital. Results: The incidence of operatively treated Achilles tendon rupture was 11.2/10(5). The number of the patients was increasing particularly in the old age-groups. The change during the study period was statistically significant (p = 0.015). The females with a tendon rupture were on average 2-3 years older than men (p < 0.01). The urban areas around the capital city had a higher occurrence of tendon ruptures than the rural areas (p < 0.05). Conclusion: The number of Achilles tendon ruptures is increasing, but the reasons for this remain unknown. The geographical variations in rupture rate might indicate the role of the urban life-style as a risk factor. One reason for the differences between the men and the women might be the different level of the sport activities, especially ball-games.
Article
Unlabelled: With this study we intend to determine if there is a correlation between body mass index (BMI) and Achilles tendon pathology. A retrospective chart review of 197 patients was performed with CPT codes of Achilles tendinosis/tendonitis. These 197 patients were then compared with 100 random new patient encounters excluding Achilles pathology, plantar fasciitis, and surgical consults. Statistical analysis was then performed to identify correlation of BMI to incidence of Achilles tendinosis compared with patients without Achilles pathology. A total of 197 Achilles tendon pathology patients (113 male, 84 female) were analyzed and had a mean age of 52.77 ± 11.8 years (21-82) with a BMI of 34.69 ± 7.54 (17.9-75.9). The control group had a mean age of 42.74 ± 12.1 years (21-78) and mean BMI of 30.56 ± 7.55 (19.7-61.5). A significant difference was found in mean BMI between the Achilles tendinopathy group versus the control group (P < .001). There was a very significant difference in age noted between the 2 cohorts (52.77 years vs 42.74 years, P < .001), perhaps reenforcing the involvement of age-related degenerative changes. In this study, patients with Achilles pathology exhibited a significantly higher BMI than non-Achilles patients (P < .001) even after accounting for age. Levels of evidence: Prognostic Level II.
Article
Introduction: High body mass index (BMI) has been implicated as an etiologic agent in Achilles tendonitis (AT) and may contribute to poorer treatment outcomes. The purpose of this study was to better elucidate the role of BMI in both the development and treatment of AT. Methods: A matched case-control (1:1) study design was used. Matching criteria were age, gender, and year of presentation. Consecutive patients who presented with a diagnosis of AT between 2002 and 2011 at a single foot and ankle specialty clinic were identified. Patients who presented with other foot pain at the same clinic served as controls (CG). The AT group was further stratified into treatment responders and nonresponders. The main effect measure for both analyses was an adjusted odds ratio. Results: A total of 944 patients (472 AT; 472 CG) were included. AT patients had higher BMI than those in the CG (30.2 ± 6.5 vs 25.9 ± 5.3, P < .001). Overweight and obese patients were 2.6 to 6.6 times more likely than those with a normal BMI to present with Achilles tendonitis (P < .001). There was also elevated risk of presenting with AT at higher BMI categories (Mantel-Haenszel χ (2) = 8.074, P = .004). However, only age, not BMI, correlated with having failed conservative treatment among the AT group, with patients older than 65 years at the greatest risk (odds ratio = 2.4, 95% confidence interval = 1.5 to 4.1, P < .001). Conclusion: BMI plays a role in the development of AT but does not appear to influence patient response to conservative treatment. Levels of evidence: Prognostic, Level II.
Article
Background: Most studies on Achilles tendon ruptures involved US military or European populations, which may not translate to the general US population. The current study reviews 406 consecutive Achilles tendon ruptures occurring in the general US population for patterns in a tertiary care subspecialty referral setting. Methods: An institutional review board-approved, retrospective review of the charts of 331 (83%) males (6 bilateral, nonsimultaneous) and 69 (17%) females diagnosed with Achilles tendon ruptures over a 10-year period was undertaken. Average age was 46.4 years with 310 (76%) ruptures diagnosed and managed acutely (less than 4 weeks), whereas 96 (24%) were chronic (more than 4 weeks since the injury). Patients were assessed for mechanism of injury and previously described underlying risk factors. Results were assessed according to age (greater or less than 55 years), body mass index (BMI), and time to diagnosis. Results: Sporting activity was responsible for 275 ruptures (68%). This was higher in patients younger than 55 years of age (77%) than those older than 55 years (42%). Basketball was the most commonly involved sport, accounting for 132 ruptures (48% of sports ruptures, 32% of all ruptures), followed by tennis in 52 ruptures (13%, 9%), and football in 32 ruptures (12%, 8%). In all, 20 ruptures were reruptures of the same Achilles tendon, of which 17 had previously been treated nonsurgically. In this study, recent quinolone use (2%) and African American race (31%) were not major risk factors for rupture as described in other studies. Older patients and patients with a BMI greater than 30 were more likely to be injured in nonsporting activities and more likely to have their diagnosis initially not recognized resulting in their presentation more than 4 weeks following the injury. Conclusion: In this study, sports participation was the most common mechanism, but not to the same extent seen in the European or US military studies. Basketball was the most commonly involved sport, as compared to soccer in Europe. Age and BMI had a directly proportional correlation with time to diagnosis.
Article
This study reports on the demographics of acute Achilles tendon rupture in our region and compares the results of a selective approach to operative and nonoperative treatment using an identical rehabilitation program with functional bracing. A consecutive series of 363 patients, aged 15 to 60 years, treated over 8.5 years by either open operative repair (143) or nonoperatively (220) were compared with respect to demographics, re-rupture rate, and major wound complication. There was an almost equal number of males (159) and females (152) up to age 50 years but males comprised 73% of patients aged 51 to 60 years. Netball was the most common cause of injury and explains the relatively high incidence in females. In the 143 patients treated surgically there were two re-ruptures (1.4%) and two reoperations for wound complications (1.4%). In the 220 patients treated nonoperatively there were 19 re-ruptures (8.6%), 13 of 113 males (11.5%) and six of 107 females (5.6%). There was a significantly lower re-rupture rate, and reoperation rate in the surgical group (p < 0.05). In the nonoperative group there was a significantly lower rate of re-rupture in patients over 40 (six of 119) (4.1%) compared with those 40 years and under (13 of 99, 13.1%) and between females over 40 when compared with males 40 years and under. In our region there is a high incidence of Achilles tendon rupture among women due to netball and results in a younger age of injury than previously reported. Our results support surgery in patients less than 40 years, particularly males, if there are no contraindications. Functional bracing as part of nonoperative treatment can result in low re-rupture rates in patients over 40, especially in females.
Article
Retrospective cohort study. To determine the performance-based outcomes in National Football League (NFL) athletes after discectomy for a lumbar disc herniation (LDH). Long-term outcomes following surgical treatment in elite athletes in the NFL are unknown. Postoperative outcomes may be significantly different from the general population due to the exceptional physical demands imposed by the sport. National Football League players diagnosed with a lumbar disc herniation were identified using information from press releases, team injury reports, and newspaper archives. Demographic, treatment, and performance data based on vital statistics to each position were recorded for each player over the length of his career. Using a modification of a previously published scoring system (Carey et al, Am J Sports Med 2006;34:1911-7) based on game statistics, a "Performance Score" was calculated for each player both before and after diagnosis of LDH. A total of 137 National Football League players were identified as having an LDH necessitating treatment. Ninety-six players underwent surgical treatment with a lumbar discectomy, and 34 athletes were treated nonoperatively. Seventy-eight percent of athletes treated surgically for an LDH returned to play in at least 1 NFL game. Players treated surgically played in statistically more games post-treatment (36) than those treated nonoperatively (20) (P < 0.002). There was no significant difference between the Performance Score preoperatively and postoperatively over the length of the players' careers. Age at diagnosis, body mass index, Pro Bowl appearances, and position played did not significantly affect outcome. The data in this study suggests that even though a lumbar discectomy has career-threatening implications, a large percentage of NFL athletes return to play at competitive levels. Despite the general opinion of many NFL general managers, players who are able to complete the rigorous rehabilitation required to return to play after lumbar discectomy can expect excellent performance-based outcomes after surgery.
Article
Surgical treatment for chondral defects of the knee in competitive running and jumping athletes remains controversial. This study evaluated the performance outcomes of professional basketball players in the National Basketball Association (NBA) who underwent microfracture. Data from 24 professional basketball players from 1997 to 2006 was obtained and analyzed. NBA player efficiency ratings (PER) were calculated for two seasons before and after injury. A control group of 24 players was used for comparison. Study group and control group demographics including age, NBA experience, and minutes per game demonstrated no statistical difference. Mean time to return to an NBA game was 30.0 weeks from the time of surgery. The first season after returning to competition PER and minutes per game decreased by 3.5 (P < 0.01) and 4.9 min (P < 0.05), respectively. The 17 players who continued to play two or more seasons after surgery, the average reduction in their PER and minutes per game was 2.7 (P > 0.05) and 3.0 min (P < 0.26), respectively. A multivariant comparison versus controls demonstrated that power rating during the 2 years after surgery decreased by 3.1 (P < 0.01); while minutes per game decreased by 5.2 (P < 0.001). Twenty-one percent (n = 5 of 24) of the players treated with microfracture did not return to competition in an NBA game. On return to competition player performance and minutes per game are diminished.