Article

Eighty-two per cent of male professional football (soccer) players return to play at the previous level two seasons after Achilles tendon rupture treated with surgical repair

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Abstract

Objective To evaluate the time to return to playing following acute Achilles tendon rupture (ATR) and surgical repair in professional male football (soccer) players. Methods Professional male football (soccer) players who sustained an ATR and underwent surgical repair were identified through internet-based injury reports from January 2008 to August 2018. Only League 1 and 2 players with injuries who had at least 1 year of follow-up from the search date were included. Injury history and time to return to play were retrieved from the public platform transfermarkt.com . For athletes who competed for at least two seasons after returning to play, re-ruptures and number of matches played were reported. Results 118 athletes (mean age 27.2±7.2 years) were included. 113 (96%) returned to unrestricted practice after a mean of 199±53 days, with faster recovery in players involved in national teams. Return to competition was after a mean of 274±114 days. In the 76 athletes with at least two seasons of follow-up, 14 (18%) did not compete at the pre-injury level during the two seasons following the index injury. Six players (8%) sustained a re-rupture within the first two seasons after return to play; four re-ruptures were in footballers who returned to play <180 days after injury. Age >30 years and re-ruptures had higher odds ratios of not returning to the same level of play. Conclusions 96% of professional male football players who underwent surgery to repair an ATR returned to unrestricted practice and then competition after an average time of 7 and 9 months, respectively. However, 18% did not return to the same level of play within the two seasons following their return, with a higher risk in those experiencing a re-rupture.

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... The RTP rate varies depending on the sport. 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]. ...
... 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 studies by have shown that this phenomenon is most common among sports such as athletics, football, and basketball [66,72,73]. ...
... One of the factors that may influence the value of the RTP index is the age of the athlete when the Achilles tendon was ruptured. As the age at onset of injury increases, the risk of poorer treatment outcomes increases [69] in the study by Carmont et al. It has been shown that the most important risk factor influencing functional results one year after surgery is age. ...
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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”.
... Finally, a recent study by Grassi et al. [104] evaluated the RTP of 118 professional male soccer players of League 1 and League 2 following acute ATR and surgical repair identified through internet-based injury reports. Only soccer players with injuries who had at least 1 year of follow-up from the search date were included and those who competed for at least two seasons after returning to play, re-ruptures and number of matches played were reported. ...
... Of the 118 players, the 96% returned to unrestricted practice and then competition after an average time of 7 and 9 months, respectively [103]. However, 18% did not return to the same level of play within the two seasons following their return, and the 8% sustained a re-rupture within the first two seasons after RTP [104]. ...
... The mean rate of athletes being unable to RTP among the above-mentioned studies was 29.7 ± 6.738 [19,57,101,102], and athletes who did not return to their previous level of sport was 25.5 ± 7.5 [103,104]. ...
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The Achilles tendon is the thickest, strongest and largest tendon in the human body, but despite its size and tensile strength, it frequently gets injured. Achilles tendon ruptures (ATRs) mainly occur during sports activities, and their incidence has increased over the last few decades. Achilles tendon tears necessitate a prolonged recovery time, sometimes leaving long-term functional limitations. Treatment options include conservative treatment and surgical repair. There is no consensus on which is the best treatment for ATRs, and their management is still controversial. Limited scientific evidence is available for optimized rehabilitation regimen and on the course of recovery after ATRs. Furthermore, there are no universally accepted outcomes regarding the return to play (RTP) process. Therefore, the aim of this narrative review is to give an insight into the mechanism of injuries of an ATR, related principles of rehabilitation, and RTP.
... Although our study involves recreational athletes that have fewer functional demands and require less rehabilitation assistance compared to professional athletes, the results obtained do not differ greatly from the studies by Grassi et al. and Jack et al., demonstrating the validity of the percutaneous techniques in returning to sports, at least at a recreational level [51,52]. The first study reported that 96% of professional athletes returned to sports after surgical repair, 82% at the same pre-injury level, and the second described less than 75% of NFL professional athletes returned to pre-injury levels [51,52]. ...
... Although our study involves recreational athletes that have fewer functional demands and require less rehabilitation assistance compared to professional athletes, the results obtained do not differ greatly from the studies by Grassi et al. and Jack et al., demonstrating the validity of the percutaneous techniques in returning to sports, at least at a recreational level [51,52]. The first study reported that 96% of professional athletes returned to sports after surgical repair, 82% at the same pre-injury level, and the second described less than 75% of NFL professional athletes returned to pre-injury levels [51,52]. However, in none of these studies was the return to sports activity in relation to a specific surgical technique analyzed. ...
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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.
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Achilles tendon rupture (ATR) is a rare although very serious injury for football players; currently, studies on ATR in football are scant. This case report intends to firstly describe the situational pattern and three-dimensional mechanism of the ATR injury occurred to a professional football player during the last UEFA 2020 Championship. To reconstruct the full 3D joint kinematics throughout the injury action, the model-based image-matching technique was used. The key findings were: (i) ATR injury combined a sudden ankle dorsiflexion action with an internal plantarflexion moment while performing a crossover cut at high speed; (ii) a multi-planar loading occurred during the push-off phase. Level of evidence V.
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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.
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Background The injury rate in professional soccer players may be influenced by match frequency. Purpose To assess how changes in match frequency that occurred because of coronavirus disease 2019 (COVID-19) influenced training and match injuries in the Italian Serie A league. Study Design Descriptive epidemiology study. Methods Three phases in the Serie A league, each 41 days long, were evaluated: phase A was the beginning of the 2019-2020 season; phase B was a period after the COVID-19 lockdown was lifted, when the remaining matches of the season were played with greater frequency; and phase C was the beginning of the 2020-2021 season. All male professional soccer players who were injured during the 3 phases were included. Player age, height, position, injury history, and return to play (RTP) were retrieved from a publicly available website. Training- and match-related injuries during each of the 3 phases were collected and compared. Moreover, match injuries that occurred after the lockdown phase (phase B), in which there were 12 days designated for playing matches (“match-days”), were compared with injuries in the first 12 match-days of phases A and C. Results When comparing 41-day periods, we observed the injury burden (per 1000 exposure-hours) was significantly lower in phase B (278.99 days absent) than in phase A (425.4 days absent; P < .05) and phase C (484.76 days absent; P < .05). A longer mean RTP period was recorded in phase A than in phase B (44.6 vs 23.1 days; P < .05). Regarding 12–match day periods (81 days in phase A, 41 days in phase B, and 89 days in phase C), there was a significantly higher match injury rate (0.56 vs 0.39 injuries/1000 exposure-hours; P < .05) and incidence (11.8% vs 9.3%; P < .05) in phase B than in phase A and a longer mean RTP period in phase A than in phase B (41.8 vs 23.1 days; P < .05). Finally, the rate and incidence of training-related injuries were significantly higher in phase B (4.6 injuries/1000 exposure-hours and 6.5, respectively) than in phase A (1.41 injuries/1000 exposure-hours and 2.04, respectively) ( P < .05). Conclusion Both training- and match-related injuries were greater during the abbreviated period after the COVID-19 lockdown. These may be linked to the greater match frequency of that period.
Article
Purpose: Anterior cruciate ligament (ACL) ruptures are considered high burden injuries in sports with high pivotal activity, especially for professional footballers. A lack of evidence exists about long-term follow up of professional elite athletes who underwent ACL reconstruction. The purpose of the study is to analyze the return to play and the career of professional footballers who underwent ACL reconstruction with hamstrings, to evaluate re-rupture and reoperation at either indexed and contralateral knee, and to assess the long-term clinical subjective outcomes and satisfaction. Methods: Twenty-eight professional footballers that underwent 33 ACL reconstructions were retrospectively included in the study. All surgical interventions were performed using hamstring tendons graft and an over the top technique. Inclusion criteria were: inability to compete due to joint instability caused by total or subtotal ACL lesion, patients contracted to a professional football team at time of surgery. Exclusion criteria were: multi-ligament reconstruction or concomitant meniscal allograft transplantation. Patients were contacted by phone and a brief questionnaire about surgery was administered. Subsequently, a Lysholm knee scoring scale was obtained. After that, an online research was performed on publicly available websites in order to retrieve information of the patients included after surgery. Results: In all cases, ACL Reconstruction was performed with hamstring tendons using a non-anatomic Double-Bundle technique in 16 cases (49%), an Over-The-Top Single-Bundle technique in 9 cases (27%), and an Over-The-Top Single-Bundle plus Lateral Plasty technique in 8 cases (24%); moreover, a meniscal lesion was present in 20 cases (61%). Three (9%) of the 33 ACL reconstruction failed (2/16 Double-Bundle, 1/9 Single- Bundle, 0/8 Single-Bundle + Lateral Plasty; p = n.s.), with two of them within 12 months from surgery. Other procedures, mainly arthroscopic meniscectomies, were performed in 10 cases (30%). The first official match was played after an average of 8.0 ± 3.6 (4.6-18.2) months in 31 cases (94%). Patients were evaluated after 12.6 ± 3.3 years (6.7-17.5) from the indexed ACL reconstruction. The average Lysholm score was 94.2 ± 8.3. Conclusions: In our small case-series, professional soccer players were able to return to play at a competitive level with a hamstrings over the top technique. Patients with long careers had a high percentage of reoperation on the contralateral knee. Level of evidence: IV.
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Background There is a paucity of information on rate and time to return to play (RTP) in elite-level soccer players who have sustained foot fractures. Purpose To (1) determine the rate and timing of RTP after foot fracture (eg, tarsal, metatarsal, or phalangeal), (2) investigate foot fracture reinjury incidence after RTP, and (3) evaluate performance after foot fracture as compared with matched, uninjured controls. Study Design Descriptive epidemiology study. Methods Athletes sustaining foot fractures were identified across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Injured athletes were matched to controls (1:1) using demographic characteristics and performance metrics from 1 season before injury. The authors recorded RTP rate, reinjury incidence, player characteristics associated with RTP within 2 seasons of injury, player availability, field time, and performance metrics during the 4 seasons after injury. Results A total of 192 elite soccer players sustaining a foot fracture were identified; 40 players (20.8%) underwent operative treatment. Athletes missed an average of 69.41 ± 59.43 days and 5.15 ± 23.28 games. In the 4 seasons after injury, 80% of players returned to play, with 72% returning to play within 1 season of injury. Nine players (5%) sustained a subsequent foot fracture. Athletes with a foot fracture demonstrated significantly longer league retention compared with uninjured controls ( P < .001). Elite soccer players older than 30 years of age were less likely to RTP (odds ratio, 0.67; P = .002), whereas career experience, field position, and baseline performance showed no significant association with RTP rates. Injured athletes demonstrated similar performance to controls during the 4 years after injury, and there were no position-dependent differences on subgroup analysis. The players who underwent operative treatment had more assists per 90 minutes and more team points per game during the first season after injury compared with athletes treated nonoperatively. Conclusion Foot fractures in elite soccer players resulted in moderate loss of play time (69.41 days). RTP rates were high at 80%, although players older than 30 years of age were less likely to RTP. On RTP, athletes who sustained a foot fracture maintained performance similar to preinjury levels and to uninjured controls.
Article
Background : Achilles tendon rupture (ATR) is one of the most frequently encountered injuries in Sports Medicine. ATR can be managed surgically or conservatively followed by early functional rehabilitation or cast immobilization. The aim of the present systematic review and meta-analysis was to provide an update about the role of early weightbearing (WB) versus late WB on the clinical outcomes of adults with acute ATR. Methods : We performed a systematic literature search in Web of Science, Ovid, Medline/PubMed, and CENTRAL. We included randomized controlled trials (RCTs) that compared early WB, defined as weight-bearing within 4 weeks of treatment, to late WB for individuals with acute (<14 days) ATR. We sought to evaluate the following outcomes: re-rupture rate, Achilles Tendon Rupture Score (ATRS), return to pre-injury sport activity, time to return to work, and adverse event rate. The standardized mean difference (SMD) was used to represent continuous outcomes while the risk ratio (RR) was used to represent dichotomous outcomes. Results : A total of 9 RCTs that enrolled 1046 participants were deemed eligible. There was no significant difference between early WB and late WB in terms of re-rupture rate (RR=0.75, 95% CI 0.49 to 1.16), ATRS (SMD=0.06, 95% CI –0.03 to 0.16), return to pre-injury sport activity (RR=1.05, 95% CI 0.86 to 1.28), time to return to work (SMD=0.03, 95% CI –0.20 to 0.26), or adverse event rate (RR=1.87, 95% CI 0.53 to 6.63). Conclusion : This meta-analysis shows no difference in the functional outcomes and patient-reported outcomes between early functional rehabilitation and cast immobilization for conservatively treat individuals with acute ATR.
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Background Meniscal injuries are extremely common in soccer athletes, and little is known about postrecovery performance. Purpose To (1) identify characteristics associated with return to play (RTP) to the same league level and (2) evaluate long-term effects that injury and management approach may have on player performance. Study Design Cohort study; Level of evidence, 3. Methods Using publicly available records, we identified athletes who sustained meniscal tears across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2006 and 2016. Injured athletes were matched to controls 1:2 by demographics and performance. Investigations included rate of RTP to the same league level, reinjury, player characteristics associated with RTP within 2 seasons, long-term availability, field time, and performance metrics standardized to 90 minutes of play during the next 4 seasons. Results A total of 250 players sustaining meniscal tears were included, of which 106 (42%) received surgical management. Median absence was 57.5 days (interquartile range [IQR], 35-92) or 7 games (IQR, 4-12). Rate of RTP was 70%, and the reinjury rate 5% if a player could RTP. Age greater than 30 years was a negative predictor for RTP (odds ratio [OR], 0.62; P = .002), whereas higher preinjury goals per game (OR, 2.80; P = .04) and surgical management (OR, 1.38; P = .002) were positive predictors for RTP. Surgical management was associated with higher long-term availability ( P < .01). As compared with the control, there were no significant differences in field time or performance metrics after RTP, either overall or by player position. As compared with nonoperative management, defenders undergoing surgery demonstrated decreased field time. Attackers and midfielders demonstrated similar field time and performance regardless of management. Conclusion RTP of elite soccer athletes sustaining meniscal tear is contingent on age, preinjury performance, and management approach. Those who RTP to the same league level can be expected to demonstrate equivalent field time, performance, and long-term availability as noninjured athletes.
Article
Objectives It has been claimed that analyses of large datasets from publicly accessible, open-collaborated (“citizen science-based”) online databases may provide additional insight into the epidemiology of injuries in professional football. However, this approach comes with major limitations, raising critical questions about the current trend of utilising citizen science-based data. Therefore, we aimed to determine if citizen science-based health data from a popular online database on professional football players can be used for epidemiological research, i.e. in providing results comparable to other data sources used in previously published studies. Design Retrospective database analysis. Methods Transfermarkt.com (Transfermarkt; Hamburg; Germany) is a publicly accessible online database on various data of professional football players. All information provided in the section “injury history” of football players from the top five European leagues over a period of ten seasons (2009/10–2018/19) were analysed. Frequency, characteristics, and incidence of injuries were reported according to seasons and countries, and results compared with three previously published databases (a scientific injury surveillance, a media-based study, and an insurance database). Results Overall, 21,598 injuries of 11,507 players were analysed from the Transfermarkt.com database. Incidence was 0.63 injuries per player-season (95% CI 0.62 to 0.64) but significant differences between subgroups (countries, years) were found. In comparison to other databases, citizen science-based data was associated with lower injury incidences and higher proportions of severe injuries. Conclusions With few exceptions (e.g., severe injuries), the use of citizen science-based health data on professional football players cannot be recommended at present for epidemiological research.
Article
Objective: To describe the mechanisms, situational patterns and biomechanics (kinematics) of medial collateral ligament (MCL) injuries in professional male soccer. Design: Case series. Methods: 57 consecutive MCL injuries across two seasons of professional soccer matches were identified. We obtained and reviewed 37 (65% of 57 injuries) videos to establish the injury mechanism, and situational pattern and knee flexion angle. We used detailed biomechanical analysis to assess the indirect/non-contact injuries. Injury lay-off times, timing of injuries during the match and location of the injury on the pitch were also reported. Results: 23 (62%) injuries were direct contact, 9 (24%) were indirect contact and 5 (14%) were non-contact. Three main sprain mechanisms were noted: (1) direct contact/blow to the knee (n=16), (2) contact to the leg or foot (lever-like) (n=7), and (3) sliding (n=9). 73% of MCL injuries occurred during two main situations: (1) pressing/tackling (n=14, 38%), and (2) being tackled (n=13, 35%). For indirect/non-contact injuries, knee valgus loading (100% of cases), hip abduction (73% of cases) and external foot rotation (92% of cases) were prominent injury kinematics, often with lateral trunk tilt (median, 10º, 64% of cases) and rotation (65% of cases). Knee flexion angles were higher for indirect/non-contact injuries (median, 100º) than direct contact injuries (median, 22º)(P<0.01). Conclusions: Nearly two-thirds of MCL injuries occurred after direct contact; one in every 4 MCL injuries occurred after indirect contact. Three sprain mechanisms characterized MCL injuries: (1) blow to knee, (2) contact to the leg or foot (lever-like), and (3) sliding. J Orthop Sports Phys Ther, Epub 16 Nov 2021. doi:10.2519/jospt.2022.10612.
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Background Acromioclavicular joint (ACJ) separation injuries are uncommon in professional soccer players, threatening future performance and team contributions. Data regarding return to play (RTP) in professional soccer players after ACJ separation are limited. Purpose To determine the rate, time to RTP, and player performance after ACJ separation in soccer players from the top 5 professional European leagues when compared with a retrospective, matched cohort of uninjured players. Study Design Cohort study; Level of evidence, 3. Methods Professional soccer players suffering ACJ separation injuries between 1999 and 2018 were identified and were matched to uninjured players (2 controls to 1 injured player) by position, height, age, season year, and length of time played. Information on date of injury, timing to RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) were collected from transfermarkt.co.uk, uefa.com , fifa.com , official team websites, public injury reports, and press releases. Change in performance metrics for the 4 seasons after the season of injury were based on metrics 1 season before injury. Univariate comparisons were performed using independent 2-group t tests and Wilcoxon rank-sum tests when normality of distributions was violated. Results A total 59 soccer players with ACJ separation injuries were identified. Mean age at injury was 24.6 ± 5.3 years. Of these, 81% of the players returned to play, with 69% returning within postinjury season 1. Mean time to RTP was 49.8 ± 24.3 days (5.9 ± 4.1 games). Two players suffered recurrent ACJ separation injuries in their professional soccer careers. There were no significant differences between athletes who sustained ACJ injuries versus control athletes in the number of games played, minutes per game per season, goals scored, assists, or points in the 4 seasons after injury. Defenders played fewer minutes and recorded fewer assists during postinjury season 1 when compared with control athletes. Conclusion Of the 59 elite soccer players who sustained ACJ separation injuries during the study period, 81% returned to elite competition. Performance metrics were similar to preinjury levels and matched, uninjured control players.
Article
Background The purpose of this study was to determine the return-to-play (RTP) rate and postinjury performance after Achilles tendon (AT) ruptures in National Football League (NFL) skill position players. Methods The study included NFL skill positions with an AT rupture between the 2009-2010 and 2015-2016 seasons. Performance data were collected and compared against a matched control group. RTP was defined as playing in at least 1 game after repair. Results RTP rate was 57% for the study cohort. The tight ends (TEs) had the highest RTP rate at 71% while the wide receivers (WRs) had the lowest RTP rate at 38%. Compared with the control group, WRs with successful RTP had significantly less receptions per game ( P = .01). For defensive players with RTP there were significant decreases in postrepair performance in tackles, passes defended, and fumbles forced/recovered compared with the control group. Conclusion A total of 57% of players achieved RTP with WRs and running backs (RBs) having the lowest RTP rates and TEs and linebackers (LBs) having the highest RTP rates. RBs, defensive backs (DBs), and LBs with successful RTP had decreased performance in all categories. This updated information may be helpful for athletes, physicians, scouts, and coaches in evaluating players with a history of AT rupture. Levels of Evidence Analytic, level 3, retrospective cohort study, Epidemiologic study
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Background Participation in elite-level soccer predisposes athletes to injuries of the medial collateral ligament (MCL), resulting in variable durations of time lost from sport. Purpose To (1) determine the rate of return to play (RTP) and timing after MCL injuries, (2) investigate MCL reinjury incidence after RTP, and (3) evaluate the long-term effects of MCL injury on future performance. Study Design Descriptive epidemiology study. Methods Using publicly available records, we identified athletes who had sustained MCL injury between 2000 and 2016 across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A). Injured athletes were matched to controls using demographic characteristics and performance metrics from the season before injury. We recorded injury severity, RTP rate, reinjury incidence, player characteristics associated with RTP within 2 seasons of injury, player availability, field time, and performance metrics during the 4 seasons after injury. Results A total of 59 athletes sustained 61 MCL injuries, with 86% (51/59) of injuries classified as moderate to severe and surgical intervention performed in 14% (8/59) of athletes. After injury, athletes missed a median of 33 days (range, 3-259 days) and 4 games (range, 1-30 games). Overall, 71% (42/59) of athletes returned successfully at the same level, with multivariable regression demonstrating no athlete characteristic predictive of RTP. MCL reinjury was reported in 3% (2/59) of athletes. Midfielders demonstrated decreased field time after RTP when compared with controls ( P < .05). No significant differences in player performance for any position were identified out to 4 seasons after injury. Injured athletes had a significantly higher rate of long-term retention ( P < .001). Conclusion MCL injuries resulted in a median loss of 33 days in elite European soccer athletes, with the majority of injuries treated nonoperatively. RTP remained high, and few athletes experienced reinjury. While midfielders demonstrated a significant decrease in field time after RTP, player performance and long-term retention were not compromised. Future studies are warranted to better understand athlete-specific and external variables predictive of MCL injury and reinjury, while evaluating treatment and rehabilitation protocols to minimize time lost and to optimize athlete safety and health.
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Background Achilles tendon rupture (ATR) is a potentially career-ending injury in professional athletes. Limited information exists regarding return to play (RTP) in professional soccer players after this injury. Purpose To determine the RTP rate and time in professional soccer players after ATR and to evaluate player performance relative to matched controls. Study Design Cohort study; Level of evidence, 3. Methods We evaluated 132 professional soccer players who suffered an ATR between 1999 and 2018. These athletes were matched 2:1 to uninjured controls by position, age, season of injury, seasons played, and height. We collected information on the date of injury, the date of RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) from official team websites, public injury reports, and press releases. Changes in performance metrics for the 4 years after the season of injury were compared with metrics 1 season before injury. Univariate comparisons were performed using independent-sample, 2-group t tests and Wilcoxon rank-sum tests when normality of distributions was violated. Results The mean age at ATR was 27.49 ± 4.06 years, and the mean time to RTP was 5.07 ± 2.61 months (18.19 ± 10.96 games). The RTP rate was 71% for the season after injury and 78% for return at any timepoint. Overall, 9% of the injured players experienced a rerupture during the study period. Compared with controls, the injured players played significantly less (-6.77 vs -1.81 games [ P < .001] and -560.17 vs -171.17 minutes [ P < .05]) and recorded fewer goals (-1.06 vs -0.29 [ P < .05]) and assists (-0.76 vs -0.02 [ P < .05]) during the season of their Achilles rupture. With the exception of midfielders, there were no significant differences in play time or performance metrics between injured and uninjured players at any postinjury timepoint. Conclusion Soccer players who suffered an ATR had a 78% RTP rate, with a mean RTP time of 5 months. Injured players played less and demonstrated inferior performance during the season of injury. With the exception of midfielders, players displayed no significant differences in play time or performance during any of the 4 postinjury seasons.
Article
Background Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR. Methods Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated. Results All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength. Conclusion The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort. Level of Evidence Level II, prospective cohort case series study.
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Background The average professional soccer team experiences 1 to 2 traumatic leg fractures per season, with unknown effects on player performance. Purpose To (1) determine the rate and time to return to play (RTP) following leg fracture, (2) investigate the rate of reinjury following RTP, and (3) investigate long-term effects that lower extremity (LE) fracture may have on elite soccer player performance. Study Design Cohort study; Level of evidence, 3. Methods Using publicly available records, we identified athletes sustaining a traumatic leg fracture across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Athletes with leg fracture (femur, tibia, and/or fibula) were matched 1:2 to controls by demographic characteristics and performance metrics 1 season before the index timepoint. Investigations included the RTP rate, reinjury rate, player characteristics associated with RTP within 2 seasons, long-term player retention, performance metrics during the 4 following seasons, and subgroup analysis by player position. Results A total of 112 players with LE fracture and 224 controls were identified. Players with LE fractures were absent for a mean of 157 days (range, 24-601 days) and 21 games (range, 2-68 games). The rate of RTP within 1 season was 80%, with 4% experiencing subsequent refracture. Injured players remained active in the league at a higher rate than their uninjured counterparts. As compared with controls, injured athletes played 309 fewer total minutes ( P < .05), scored 0.09 more assists per game ( P < .01) 1 season after injury, and scored 0.12 more points per game 4 seasons after injury ( P < .01). Defenders were most affected by an LE fracture, playing 5.24 fewer games ( P < .05), 603 fewer total minutes ( P < .01), and recording 0.19 more assists per 90 minutes of play as compared with controls 1 season after injury ( P < .001). Attackers and midfielders demonstrated no significant difference in metrics after RTP when compared with controls. Conclusion Most players sustaining an LE fracture returned to elite soccer at the same level after a significant loss of playing time, with a 4% rate of refracture. Player retention was higher for those sustaining an LE fracture versus uninjured controls. Overall, injured players did not experience a decline in performance after recovery from an LE fracture.
Article
Background Deficits in sporting performance after Achilles tendon repair may be due to changes in musculotendinous unit structure, including tendon elongation and muscle fascicle shortening. Purpose/Hypothesis The purpose was to discern whether Achilles tendon rupture reduces triceps surae muscle force generation, alters functional ankle range of motion, or both during sports-related tasks. We hypothesized that individuals who have undergone Achilles tendon repair lack the functional ankle range of motion needed to complete sports-related tasks. Study Design Descriptive laboratory study. Methods The study included individuals 1 to 3 years after treatment of Achilles tendon rupture with open repair. Participants (n = 11) completed a heel-rise task and 3 jumping tasks. Lower extremity biomechanics were analyzed using motion capture. Between-limb differences were tested using paired t test. Results Pelvic vertical displacement was reduced during the heel-rise (mean difference, −12.8%; P = .026) but not during the jumping task ( P > .1). In the concentric phase of all tasks, peak ankle plantarflexion angle (range of mean difference, −19.2% to −48.8%; P < .05) and total plantar flexor work (defined as the area under the plantar flexor torque – ankle angle curve) (range of mean difference, −9.5% to −25.7%; P < .05) were lower on the repaired side relative to the uninjured side. No significant differences were seen in peak Achilles tendon load or impulse with any of the tasks. There were no differences in plantar flexor work or Achilles tendon load parameters during eccentric phases. Conclusion Impaired task performance or increased demands on proximal joints were observed on the repaired side in tasks isolating ankle function. Tasks that did not isolate ankle function appeared to be well recovered, although functional ankle range of motion was reduced with rupture. Reduced plantar flexor muscle-tendon unit work supports previous reports that an elongated tendon and shorter muscle fascicles caused by Achilles tendon rupture constrain functional capacity. Achilles tendon peak load and impulse were not decreased, suggesting that reduced and shifted functional ankle range of motion (favoring dorsiflexion) underlies performance deficits. Clinical Relevance These findings point to the need to reduce tendon elongation and restore muscle length of the triceps surae after Achilles tendon rupture in order to address musculature that is short but not necessarily weak for improved performance with sports-related activities.
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Background Surgical treatment of insertional Achilles tendinopathy with Haglund deformity in highly competitive professional athletes has not been previously investigated. Purpose To assess clinical outcomes, including return to play (RTP), after surgical treatment of insertional Achilles tendinopathy in professional athletes. Study Design Case-control study; Level of evidence, 3. Methods This retrospective study included 20 professional athletes who were surgically treated for insertional Achilles tendinopathy and had at least 2 years of follow-up. An open longitudinal lateral approach was used for the operation, without violation of the Achilles tendon. Outcome evaluation included American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, subjective patient satisfaction, mean time of return to competition (RTC), and rate of RTP. We defined RTC as return to an official match for at least 1 minute and RTP rate as the percentage of patients who were able to participate in at least 2 full seasons. A subgroup analysis was performed to compare the RTP and no-RTP groups. Results The AOFAS score improved significantly from preoperatively to the final follow-up (from 65.1 to 88.4; P < .001), and 75% of the patients reported good to excellent satisfaction. The mean time of RTC was 7.45 months (range, 4-18 months), and the rate of RTP was 60%. The RTP group had a significantly lower mean body mass index than did the no-RTP group (22.03 vs 23.86, respectively; P = .005) and faster mean RTC (5.0 vs 11.1 months, respectively; P < .001). Conclusion Open calcaneoplasty for surgical treatment of insertional Achilles tendinopathy with Haglund deformity in highly competitive professional athletes should be approached cautiously. Our patients had a 7.5-month recovery period before return to their first official match, and only 60% of the patients returned to their sports activity and participated in at least 2 full seasons. Lower body mass index and a faster RTC after surgery were related to longer functional maintenance.
Article
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Background Anterior cruciate ligament (ACL) rupture is one of the most common injuries afflicting soccer players and requires a lengthy recovery processes after reconstructive surgery. The impact of ACL reconstruction (ACLR) on return to play (RTP) time and player performance in professional soccer players remains poorly studied. Purpose/Hypothesis To determine player performance and RTP rate and time after ACLR in elite professional soccer players with a retrospective matched-cohort analysis. We expected that the RTP time and rate will be similar to those of other professional-level athletes. Study Design Cohort study; Level of evidence, 3. Methods Included were 51 players from 1 of the 5 elite Union of European Football Associations (UEFA) soccer leagues who suffered a complete ACL rupture between 1999 and 2019. These athletes were matched by position, age, season of injury, seasons played, and height and compared to uninjured control players. Change in performance metrics for the 4 years after the season of injury were compared with metrics 1 season before injury. Univariate 2-group comparisons were performed using independent 2-group t tests; Wilcoxon rank-sum tests were used when normality of distributions was violated. Results Overall, 41 players (80%) returned to play after ACL rupture, with 6 (12%) experiencing a subsequent ipsilateral or contralateral ACL tear. The mean (±SD) RTP time for soccer players after ACLR was 216 ± 109 days (26 ± 18 games). Injured athletes played significantly fewer games and minutes per season and recorded inferior performances for 2 seasons after their injury ( P < .001). However, the game performance of injured players equaled or exceeded that of their matched controls by season 3 after injury, with the exception of attackers, who demonstrated a continued decline in performance ( P < .001). Conclusion Results indicated that the mean RTP time for soccer players after ACLR is short in comparison with other major sports leagues (216 days). However, RTP rates were high, and rerupture rates were comparable with those of other sports. With the exception of attackers, player performance largely equaled or exceeded that of matched controls by the third postinjury season.
Article
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Foot and ankle sports injuries encompass a wide spectrum of conditions from simple contusions or sprains that resolve within days to more severe injuries that change the trajectory of an athlete’s sporting career. If missed, severe injuries could lead to prolonged absence from the sport and therefore a catastrophic impact on future performance. In this article, we discuss the presentation of the commonest foot and ankle sports injuries and share recent evidence to support an accurate diagnosis and best management practice.
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Background Studies on subsequent anterior cruciate ligament (ACL) ruptures and career length in male professional football players after ACL reconstruction (ACLR) are scarce. Aim To investigate the second ACL injury rate, potential predictors of second ACL injury and the career length after ACLR. Study design Prospective cohort study. Setting Men’s professional football. Methods 118 players with index ACL injury were tracked longitudinally for subsequent ACL injury and career length over 16.9 years. Multivariable Cox regression analysis with HR was carried out to study potential predictors for subsequent ACL injury. Results Median follow-up was 4.3 (IQR 4.6) years after ACLR. The second ACL injury rate after return to training (RTT) was 17.8% (n=21), with 9.3% (n=11) to the ipsilateral and 8.5% (n=10) to the contralateral knee. Significant predictors for second ACL injury were a non-contact index ACL injury (HR 7.16, 95% CI 1.63 to 31.22) and an isolated index ACL injury (HR 2.73, 95% CI 1.06 to 7.07). In total, 11 of 26 players (42%) with a non-contact isolated index ACL injury suffered a second ACL injury. RTT time was not an independent predictor of second ACL injury, even though there was a tendency for a risk reduction with longer time to RTT. Median career length after ACLR was 4.1 (IQR 4.0) years and 60% of players were still playing at preinjury level 5 years after ACLR. Conclusions Almost one out of five top-level professional male football players sustained a second ACL injury following ACLR and return to football, with a considerably increased risk for players with a non-contact or isolated index injury.
Article
Objective: To evaluate the epidemiology, incidence rate, incidence proportion, and prevalence of Achilles tendon ruptures (ATRs) in professional footballers and their performance after the injury. Data sources: Professional male footballers participating in Serie A in 11 consecutive seasons (2008/2009-2018/2019) were screened to identify ATRs through the online football archive transfermarkt.com. Exposure in matches and training was calculated. The number of matches played in the 5 seasons before and after ATRs was obtained, when possible, together with transfers to a different team or participation in lower Divisions. Main results: Eleven ATRs were found in 11 footballers with a mean age of 29.8 ± 4.4 years; 72% of ATR involved the nondominant leg; 58% occurred during matches and 42% during training, with no peculiar distribution along the playing season. The overall incidence proportion was 0.17% (0.11% during matches and 0.06% during training). The overall incidence rate was 0.007 injuries per 1000 hours of play (0.051 during matches and 0.003during training; P < 0.0001). All players returned to play soccer after a mean of 170 ± 35 days after ATRs and participated in an official match after a mean of 274 ± 98 days. However, 2 seasons after ATRs, 3 footballers were playing in a lower Division; 1 played less than 10 matches (compared with >25 matches in the 5 seasons before an ATR) and 1 had retired. Conclusions: An overall ATR rate of 0.007 per 1000 hours of soccer play and an incidence proportion of 0.17% were reported. All footballers return to play; however, up to 40% players decreased the level of play by reducing the number of games or participating in a lower Division 2 seasons after an ATR.
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Acute Achilles tendon ruptures are common injuries with increasing incidence. Management of acute ruptures is controversial. Early evidence suggested that nonoperative treatment led to a significantly higher rerupture rate; however, operative modalities have also been shown to have a higher risk of wound complications. Advances in therapeutic protocols have normalized the rerupture rate between operative and nonoperative modalities, and many have recommended nonoperative treatment becuase of the mitigated complication profile. The purpose of this review is to report contemporary management of Achilles tendon ruptures and provide our preferred technique of management. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Article
Purpose To evaluate the clinical and sports-related outcomes of arthroscopic MFx for OLT in elite athletes. Methods The athletes who had undergone arthroscopic MFx for OLTs at our institution between January 2011 and September 2015 with minimum two-years of follow-up were reviewed. The Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog pain (VAS) score, time and rate of “return-to-competition” (RTC, return to an official match for at least one minute after treatment), and rate of “return-to-play” (RTP, participation in at least two entire seasons after treatment) were used to evaluate the outcomes. We compared athletes who were able to RTP with those who were not. Results Total 41 patients (mean age 19.34 ± 3.76 years) were included. The mean follow-up was 54.9 ± 13.72 months. 36 patients were with medial lesions, and 5 patients were with lateral lesions. All subscales of preoperative FAOS were significantly improved at the final follow-up. The mean preoperative AOFAS score of 74.46 ± 8.10 improved to 91.62 ± 2.99 (P < 0.001) at the final follow-up. The mean preoperative VAS score of 5.44 ± 1.57 improved to 2.66 ± 1.04 (P < 0.001). All patients achieved RTC (100%) at mean time of 5.45 ± 3.18 months, and 74.4% of patients were able to RTP. The RTP-group showed significantly smaller lesions compared to the No-RTP group (71.52 ± 43.29 vs. 107.00 ± 45.28 mm², P = 0.009). The cut-off OLT size for predicting RTP was 84.0 mm², with a sensitivity of 90.0% and specificity of 75.9%. Conclusions All athletes were able to RTC at average of 5.45 months after MFx for OLTs with minimal subchondral involvement, and 74.4% were able to RTP. The only prognostic variable for RTP was lesion size, and its predictive cut-off was 84.0 mm².
Article
Studies have demonstrated successful return to sport rates following Achilles tendon rupture and repair. The purpose of this study is to understand the subjective intrinsic and extrinsic motivational factors influencing an athlete's return to pre-injury level of sport following Achilles tendon repair. Qualitative, semi-structured interviews of 23 athletes who had undergone Achilles tendon repair were conducted and analyzed to derive codes, categories, and themes. Three major themes affecting return to sport were elucidated from the interviews: personal motivation, shift in focus, and confidence in healthcare team. These findings can direct healthcare teams on how to better guide patients post-operatively.
Article
»: Surgical decision-making should consider factors to help optimize return to play for athletes with foot and ankle injuries, including injuries to the syndesmosis, the Achilles tendon, the fifth metatarsal, and the Lisfranc complex. Understanding influential factors on return to play may help orthopaedic surgeons counsel athletes and coaches on expectations for a timeline to return to play and performance metrics. »: Outcomes after rigid and flexible fixation for syndesmotic injuries are generally favorable. Some data support an earlier return to sport and higher functional scores with flexible fixation, in addition to lower rates of reoperation and a decreased incidence of malreduction, particularly with deltoid repair, if indicated. »: Minimally invasive techniques for Achilles tendon repair have been shown to have a decreased risk of wound complications. Athletes undergoing Achilles repair should expect to miss a full season of play to recover. »: Athletes with fifth metatarsal fractures have better return-to-play outcomes with surgical management and can expect a high return-to-play rate within approximately 3 months of surgery. »: Percutaneous treatment of Lisfranc injuries may expedite return to play relative to open procedures.
Article
Objectives To compare re-rupture rate, functional and quality-of-life outcomes, return to sports and work, complications, and resource use in patients treated non-surgically with different rehabilitation regimens for Achilles tendon rupture. Study design Systematic review and meta-analysis. Methods We performed a systematic literature search in PubMed, Embase, Scopus and the Cochrane Library through May 2020 to identify randomized controlled trials (RCTs) that included patients treated non-surgically for Achilles tendon rupture. All analyses were stratified according to rehabilitation protocols. Results Eight RCTs with a total of 978 patients were included. There was no significant difference about re-rupture rate (P = 0.38), return to sports (P = 0.85) and work (P = 0.33), functional outcome (P = 0.34), quality of life (P = 0.50), and complication rate (P = 0.29) between early weight bearing with functional ankle motion and traditional ankle immobilisation with non-weight bearing. Similarly, no significant difference in re-rupture rate (P = 0.88), return to sports (P = 0.45) and work (P = 0.20), functional outcome (P = 0.26), and complication rate (P = 0.49) was seen between ankle immobilisation with non-weight bearing and early weight bearing without functional ankle motion. Conclusion Traditional ankle immobilisation with non-weight bearing was not found to be superior to early weight bearing with or without functional ankle motion for patients treated non-surgically for Achilles tendon rupture. Clinicians may consider early weight bearing in functional brace as a safe and cost-effective alternative to non-weight bearing with plaster casting.
Article
Background The purpose of this systematic review is to examine the literature on Achilles tendon (AT) injuries in professional athletes to determine their rate of return to play (RTP), performance, and career outcome after AT rupture. Methods A literature search of MEDLINE, Google Scholar, CINAHL, and Cochrane Library databases was performed. Included studies reported outcomes related to RTP (time and rate), durability and player participation, and player performance following AT rupture in professional athletes of the National Football League (NFL), National Basketball Association (NBA), Major League Baseball (MLB), and professional soccer leagues. Results Fifteen studies met inclusion criteria for analysis. Athletes were able to return to professional sport participation 76% of the time, with mean time to RTP of 11 months following AT injury. Athletes experienced a decline in player efficiency ratings, power ratings, and sport- and position-specific statistics in the NFL, NBA, and professional soccer leagues compared to noninjured controls. RTP rate was significantly lower following AT rupture in comparison to athletes sustaining other common orthopaedic injuries such as anterior cruciate ligament injuries, meniscal tears, and ankle fractures in both NFL and NBA athletes. Conclusions AT rupture prohibits nearly 25% of professional athletes from returning to their respective sport. Of those able to return to compete at a professional level, the mean time to RTP is 11 months—nearly double the estimated 6-month recovery for RTP in the general population. Furthermore, player performance and durability were curtailed following AT rupture. This review of the literature should be used to set evidence-based goals and establish realistic expectations for RTP for elite athletes following AT injuries. Level of Evidence Level III, systematic review.
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Basketball is a springing, jumping, and sprinting sport with players repetitively jumping to play shots and to make and receive passes or work sudden sprints together with the start–stop nature of the game. In the United States, sporting activity was responsible for 68% tendon ruptures, of which basketball was the most commonly involved sport, accounting for 48% of sports-related ruptures. There has been considerable debate as to whether operative or nonoperative treatment leads to the best outcome. Operative treatment may reduce the resultant calf muscle weakness, tendon elongation, predictability of outcome, and re-rupture rate compared with nonoperative treatment. Patients undergoing minimally invasive surgery are significantly more likely to report a satisfactory subjective outcome compared with open surgery. The overall rate of return to play (RTP) in all sports following Achilles tendon rupture has been estimated to 80%. However, for players in the National Basketball Association (NBA) who sustained an Achilles tendon rupture, more than a third (36.8%) either did not return to play or started in fewer than 10 games for the remainder of their career. Twenty-one percent of ruptures led to retirement. The mean time to return to play was 10.5 months, and the rate of return to play was lower in the NBA, 61–71%, compared with that of the National Football League players, 64–71%. Achilles tendon rupture in elite basketball players continues to be a serious, potentially career ending, injury.
Article
Background Rupture of the Achilles tendon is a common injury and the ability to return to the same level of sporting activity after treatment is an important outcome for patients. The objective of the current study was to examine the relationship between ankle strength and the ability to return to previous level of play following operative repair of an Achilles tendon rupture. Methods Patients aged 18 to 50 years at a minimum 1 year postoperation from surgical repair of an Achilles tendon returned for a study visit. Patients reported both preinjury and current activity level using the 10-point Tegner Activity Level Scale. Isokinetic strength testing was performed and the Isokinetic Strength Score (ISS) was calculated. Logistic regression analysis was used to determine the relationship between ISS and return to play by Tegner level. A total of 36 patients (mean 35 years old, 72% male) completed the study protocol at a mean 1.8 years postoperatively. Results Logistic regression revealed no association between ISS and return to play in the complete cohort. Subgroup analysis revealed that for 20 high-level athletes (preinjury Tegner ≥ 7), for every 16-point increase in ISS, the odds ratio (OR) for return to same level of play was 8.3 ( P = .055) and the OR for return to within 1 Tegner level of play was 6.3 ( P = .043). There was no association between ISS and return to previous activity in the 16 patients with lower preinjury levels of activity. Conclusion Improved ankle strength was associated with return to previous level of activity in patients participating in high-level athletic activity, suggesting that these patients were more dependent on recovery of ankle strength in the postoperative time period in order to return to their previous high level of play. In contrast, regaining strength may be less important for returning to normal activities for less active patients. Level of Evidence Level III, comparative series.
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Background: Arthroscopic hip surgery has been shown to be effective in returning professional athletes back to play at a high level of performance in different sports. Limited information exists regarding professional soccer players and their return to play. Purpose: To determine the rate and time to return to sport for professional soccer players after hip arthroscopic surgery for the treatment of femoroacetabular impingement (FAI) and to identify possible risk factors associated with a delay in returning to play. Study design: Case series; Level of evidence, 4. Methods: Professional soccer players who underwent hip arthroscopic surgery for FAI by a single surgeon between 2005 and 2015 were evaluated. Data retrieved from www.mlssoccer.com , www.fifa.com , www.transfermarkt.co.uk , and www.wikipedia.org included information on each player's professional career, participation on the national team, length of professional career before surgery, number of appearances (games) before surgery, time between surgery and first appearance in a professional game, and number of appearances after surgery. Other data were obtained from the patient's medical records. Results: Twenty-four professional soccer players (26 hips) were included. The mean age at surgery was 25.0 ± 4.0 years (range, 19-32 years). A total of 96% of patients were able to return to play at the professional level. The mean time between surgery and the first professional game played was 9.2 months (range, 1.9-24.0 months). On average, players played in 70 games after surgery (range, 0-224). National team players were able to return to play significantly earlier than the rest of the players (median, 5.7 months vs 11.6 months, respectively; P = .018). Severe chondral damage and microfracture did not interfere with return to play. Conclusion: The arthroscopic management of FAI in symptomatic professional soccer players allowed 96% of them to return to play. Players with national team experience were able to return to play earlier than those without it. Severe chondral damage and microfracture did not interfere with return to play.
Article
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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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Deciding when to return to sport after injury is complex and multifactorial-an exercise in risk management. Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated. 4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups-each group focused on 1 section of the consensus statement. Participants in each group discussed and summarised the key issues for their section before the 17-member group met again for discussion to reach consensus on the content of the 4 sections. Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. Biopsychosocial models may help the clinician make sense of individual factors that may influence the athlete's return to sport, and the Strategic Assessment of Risk and Risk Tolerance framework may help decision-makers synthesise information to make an optimal return to sport decision. Research evidence to support return to sport decisions in clinical practice is scarce. Future research should focus on a standardised approach to defining, measuring and reporting return to sport outcomes, and identifying valuable prognostic factors for returning to sport.
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There are no long-term prospective controlled trials comparing postoperative regimens after Achilles tendon rupture repair. To compare ≥10-year outcomes of 2 postoperative regimens after Achilles tendon rupture repair: early weightbearing with early mobilization versus early weightbearing with early immobilization in tension. Randomized controlled trial; Level of evidence, 1. A total of 50 patients with acute Achilles tendon ruptures were randomized postoperatively to receive either early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks (group 1) or Achilles tendon immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks (group 2). Patients were assessed at 3, 6, and 14 months and 11 years postoperatively. There were 37 patients (74%) evaluated at a mean (±SD) of 11.0 ± 0.9 years. The mean Leppilahti score was 92.9 ± 5.6 in group 1 and 93.6 ± 7.2 in group 2 (P = .68). The mean isokinetic plantar flexion peak torque deficits or average work deficits in plantar flexion showed no differences between the groups with any angular velocity. Isokinetic strength changed minimally between 1 and 11 years compared with the unaffected ankle, but a mean deficit of 5% in peak torque and mean deficit of 8% in average work were still present after 11 years. On the contrary, isometric plantar flexion strength recovered significantly, with only a 2.4% difference at 11-year follow-up. After the 11-year follow-up, early mobilization and immobilization in tension after Achilles rupture repair resulted in similar clinical outcomes and isokinetic strengths. Regardless of patient satisfaction with the operative treatment, calf muscle strength did not recover normally even at 11-year follow-up. © 2015 The Author(s).
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We investigated the epidemiology of total Achilles tendon ruptures and complication rates after operative and nonoperative treatments over a 33-year period in Oulu, Finland. Patients with Achilles tendon ruptures from 1979 to 2011 in Oulu were identified from hospital patient records. Demographic data, treatment method, and complications were collected retrospectively from medical records. Overall and sex- and age-specific incidence rates were calculated with 95% confidence intervals (CIs). The overall incidence per 100 000 person-years increased from 2.1 (95% CI 0.3-7.7) in 1979 to 21.5 (95% CI 14.6-30.6) in 2011. The incidence increased in all age groups. The mean annual increase in incidence was 2.4% (95% CI 1.3-4.7) higher for non-sports-related ruptures than for sports-related ruptures (P = 0.036). The incidence of sports-related ruptures increased during the second 11-year period whereas the incidence of non-sports-related ruptures increased steadily over the entire study period. Infection was four times more common after operative treatment compared with nonoperative treatment, re-rupture rates were similar. The incidence of Achilles tendon ruptures increased in all age groups over a 33-year period. Increases were mainly due to sports-related injuries in the second 11-year period and non-sports-related injuries in the last 11-year period.
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Background There is limited information about Achilles tendon disorders in professional football. Aims To investigate the incidence, injury circumstances, lay-off times and reinjury rates of Achilles tendon disorders in male professional football. Methods A total of 27 clubs from 10 countries and 1743 players have been followed prospectively during 11 seasons between 2001 and 2012. The team medical staff recorded individual player exposure and time-loss injuries. Results A total of 203 (2.5% of all injuries) Achilles tendon disorders were registered. A majority (96%) of the disorders were tendinopathies, and nine were partial or total ruptures. A higher injury rate was found during the preseason compared with the competitive season, 0.25 vs 0.18/1000 h (rate ratio (RR) 1.4, 95% CI 1.1 to 2.0; p=0.027). The mean lay-off time for Achilles tendinopathies was 23±37 (median=10, Q1=4 and Q3=24) days, while a rupture of the Achilles tendon, on average, caused 161±65 (median=169, Q1=110 and Q3=189) days of absence. Players with Achilles tendon disorders were significantly older than the rest of the cohort, with a mean age of 27.2±4 years vs 25.6±4.6 years (p<0.001). 27% of all Achilles tendinopathies were reinjuries. A higher reinjury risk was found after short recovery periods (31%) compared with longer recovery periods (13%) (RR 2.4, 95% CI 2.1 to 2.8; p<0.001). Conclusions Achilles tendon disorders account for 3.8% of the total lay-off time and are more common in older players. Recurrence is common after Achilles tendinopathies and the reinjury risk is higher after short recovery periods.
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.
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There is a dearth of literature on the performance enhancement in the recovering athlete in the terminal phases of rehabilitation. There are established training methods that target strength, power, speed, endurance, and metabolic capacity that all lead to performance enhancement. A PubMed search from 1980 to 2010 was undertaken for articles in English. Additional references were accrued from reference lists of research articles. Multiple options are available to improve strength, power, speed, endurance, and metabolic capacity during rehabilitation. Sports clinicians have several components to address in the rehabilitation of a recovering athlete in addition to performance enhancement. Sports clinicians should focus their efforts on increasing power, a product of maximum force and speed of performance.
Article
Objective To describe the criteria used to clear athletes to return to sport (RTS) following primary ACL reconstruction. Design Scoping review. Data sources MEDLINE, Embase, CINAHL and SPORTDiscus electronic databases were searched using keywords related to ACL and RTS. Eligibility criteria Prospective or retrospective studies reporting at least one RTS criterion for athletes who had primary ACL reconstruction with an autograft. Results In total, 209 studies fulfilled the inclusion criteria. RTS criteria were categorised into six domains: time, strength, hop testing, clinical examination, patient-report and performance-based criteria. From the 209 included studies, time was used in 178 studies (85%), and in 88 studies (42%) was the sole RTS criterion. Strength tests were reported in 86 studies (41%). Sixteen different hop tests were used in 31 studies (15%). Clinical examination was used in 54 studies (26%), patient report in 26 studies (12%) and performance-based criteria in 41 studies (20%). Summary Time and impairment-based measures dominated RTS criteria, despite sport being a complex physical and biopsychosocial activity with demands across all aspects of function. Time was included as a criterion in 85% of studies, and over 80% of studies allowed RTS before 9 months. Whether RTS tests are valid—do they predict successful RTS?—is largely unknown.
Article
Background: There is no consensus on the optimal technique for repairing an acute Achilles tendon rupture. The purpose of this meta-analysis was to compare the complications, subjective outcomes, and functional results between minimally invasive surgery and open repair of an Achilles tendon rupture. Methods: A systematic literature search of MEDLINE/PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EBSCOhost, and ClinicalTrials.gov was performed. Eligible studies were randomized controlled trials (RCTs) comparing minimally invasive surgery and open repair of acute Achilles tendon ruptures. A meta-analysis was performed, while bias and the quality of the evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. The meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. Results: Eight studies, with 182 patients treated with minimally invasive surgery and 176 treated with open repair, were included. The meta-analysis showed a significantly decreased risk ratio (RR) of 0.21 (95% confidence interval [CI] = 0.10 to 0.40, p = 0.00001) for overall complications and 0.15 (95% CI = 0.05 to 0.46, p = 0.0009) for wound infection after minimally invasive surgery. Patients treated with minimally invasive surgery were more likely to report good or excellent subjective results (RR = 1.18, 95% CI = 1.04 to 1.33, p = 0.009). No differences between groups were found with respect to reruptures, sural nerve injury, return to preinjury activity level, time to return to work, or ankle range of motion. The overall quality of evidence was generally low because of a substantial risk of bias, heterogeneity, indirectness of outcome reporting, and evaluation of a limited number of patients. Conclusions: There was a significantly decreased risk of postoperative complications, especially wound infection, when acute Achilles tendon rupture was treated with minimally invasive surgery compared with open surgery. Patients treated with minimally invasive surgery were significantly more likely to report a good or excellent subjective outcome. Current evidence is associated with high heterogeneity and a considerable risk of bias. Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Article
Objectives: A media-based collection and further analysis of relative return to play (RTP) rates and the corresponding quality of play after anterior cruciate ligament (ACL) rupture in top level football was the aim of our study. Methods: In the 5-year case-control study, male players from the first two leagues of the five European countries top leagues, who sustained a total ACL rupture during the season 2010/11 and/or 2011/12, were included. For them and a matched control sample (ratio 1:2), data were retrieved from the publicly available and validated media-based platforms (transfermarkt.de & whoscored.com) until the end of season 2016/17. Injury and return to play-specific data were calculated as rate ratios (RR) to compare the injured and matched control athletes rates and as a survival analysis (log-rank-test; career duration). Results: Overall, 132 ACL-injuries in 125 players occurred. The RTP rate was 98.2%, the RTP to same level was 59.4%. Five years post RTP, 69.9% of the ACL group were still engaged in football (RR = 87%), 40.9% at the same level (RR = 72%). Survival analysis revealed a systematic group difference in career duration compared to controls (Cox-Mantel's Chi² =5.8; p= .016). Game performance (scoring points, p < .001; rates/number of completed passes, p = .048; and minutes played, p < .001) was lower in the ACL athletes than in the matching group in the RTP and post RTP seasons. Conclusion: Although absolute and relative RTP rates after ACL reconstruction are high in professional football, career duration and performance quality are lower than in the reference group.
Article
Background: Anterior cruciate ligament ruptures (ACLRs) are severe sports-related injuries with significant consequences for affected players and teams. This study aims to identify the epidemiology and injury-related lay-off after ACLR in professional male soccer players from the first-division German Bundesliga. Methods: Exposure times and incidence of anterior cruciate ligament ruptures were collected during 7.5 consecutive seasons using two media-based registers. Results: A total of 72 total ACLRs were registered in 66 different players with an incidence of 0.040 per 1000h of exposure (95% CI 0.009-0.12). On average there were 9.6 ACLRs per season and 0.53 per team and season. The mean age of players affected was 24 (standard deviation±3.6) years. The number of ACLRs recorded per season fluctuated during the period observed. Goalkeepers are significantly (P<0.05) less prone to suffer an ACLR compared to outfield players. Conclusions: Understanding ACLR loading mechanisms, knowing risk factors for the injury and mean off time after ACLR are essential information for the coach, the medical staff, the elite soccer players, the insurance and team managers. Our results are in accordance with reports based on information from medical team staff. Therefore, our analysis of ACLR based on media sources may serve as an alternative for injury reports in elite soccer. The information of this study may be helpful for the medical staff taking care of professional soccer players and for orthopedic surgeons performing ACL reconstructions in this patient population.
Article
Acute Achilles tendon ruptures can be treated with surgical and nonsurgical treatment. However, the optimal intervention for acute Achilles tendon rupture remains controversial. The aim of the present study was to compare the clinical outcomes of surgical treatment versus conservative management for acute Achilles tendon rupture. Eight randomized controlled studies involving 762 patients were included in the meta-analysis. In general, re-rupture occurred in 14 of 381 surgically treated patients (3.7%) and 37 of 377 nonsurgically treated patients (9.8%). Pooled results showed that the total re-rupture rate was significantly lower in surgical group than that in the nonsurgical group (risk ratio 0.38, 95% confidence interval 0.21 to 0.68; p =.001). No significant differences were found between the 2 treatment groups in the incidence of deep venous thrombosis, the number who returned to sport, ankle range of motion (dorsiflexion, plantarflexion), Achilles tendon total rupture score, or physical activity scale. Surgical treatment can effectively reduce the re-rupture rate and might be a better choice for the treatment of acute Achilles tendon rupture. Multicenter, double-blind randomized controlled trials with stratification and long-term follow-up are needed to obtain a higher level of evidence and to guide clinical practice, especially in the comparison and selection of different treatments.
Article
Introduction: Aim of this retrospective cohort study was to identify fracture epidemiology and off times after different types of fractures in German male elite soccer players from the first division Bundesliga based on information from the public media. Methods: Exposure and fracture data over 7.5 consecutive seasons (2009/10 -1.Half 2016/17) were collected from two media based register (transfermarkt.de® and kicker.de®). Results: 357 fractures from 290 different players were recorded with an incidences of 0.19/1000 h of exposure (95% 0.14 - 0.24). Most fractures in German elite soccer players involved the lower extremities (35.3%), the head/face (30.3%) and the upper extremities (24.9%). The median off time after a fracture in German elite male professional soccer in 7.5 Season was 51.1 days (range 0-144). The number of fractures per 100 players per season decreased between 2009 and 2016. There was no significant difference in overall fracture incidence when comparing players at different position (p=0.11). Goalkeepers have a significantly (p<0.02) higher likelihood of suffering hand and finger fractures and they are significantly (p<0.03) less prone of suffering foot fractures, cranial and maxillofacial fractures (p<0.04) compared to outfield players. Conclusions: This study can confirm that male professional soccer teams experience 1-2 fractures per season in German elite soccer. The incidence of fractures in elite German soccer players decreased between 2009 and 2016. The most fractures occur in the lower extremities and there is no difference in overall fracture risk for players at different playing positions. The information from our study might be of a great importance to medical practitioners, soccer coaches and soccer manager.
Article
Background: Most Achilles tendon ruptures are sports related. However, few studies have examined and compared the effect of surgical repair for complete ruptures on return to play (RTP), play time, and performance across multiple sports. Purpose: To examine RTP and performance among professional athletes after Achilles tendon repair and compare pre- versus postoperative functional outcomes of professional athletes from different major leagues in the United States. Study design: Cohort study; Level of evidence, 3. Methods: National Basketball Association (NBA), National Football League (NFL), Major League Baseball (MLB), and National Hockey League (NHL) athletes who sustained a primary complete Achilles tendon rupture treated surgically between 1989 and 2013 were identified via public injury reports and press releases. Demographic information and performance-related statistics were recorded for 2 seasons before and after surgery and compared with matched controls. Statistical analyses were used to assess differences in recorded metrics. Results: Of 86 athletes screened, 62 met inclusion criteria including 25 NBA, 32 NFL, and 5 MLB players. Nineteen (30.6%) professional athletes with an isolated Achilles tendon rupture treated surgically were unable to return to play. Among athletes who successfully returned to play, game participation averaged 75.4% ( P < .001) and 81.9% ( P = .002) of the total games played the season before injury at 1 and 2 years postoperatively, respectively. Play time was significantly decreased and athletes performed significantly worse compared with preoperative levels at 1 and 2 years after injury ( P < .001). When players were compared with matched controls, an Achilles tendon rupture resulted in fewer games played ( P < .001), decreased play time ( P = .025), and worse performance statistics ( P < .001) at 1 year but not 2 years postoperatively ( P > .05). When individual sports were compared, NBA players were most significantly affected, experiencing significant decreases in games played, play time, and performance. Conclusion: An Achilles tendon rupture is a devastating injury that prevents RTP for 30.6% of professional players. Athletes who do return play in fewer games, have less play time, and perform at a lower level than their preinjury status. However, these functional deficits are seen only at 1 year after surgery compared with matched controls, such that players who return to play can expect to perform at a level commensurate with uninjured controls 2 years postoperatively.
Article
Objectives: To describe the Return to competition after Achilles Tendon rupture (ATR) in an elite soccer player. Design: Case report. Setting: Return to sport (RTS) of a professional soccer player who suffered an ATR during a match. The RTS phase started 15 weeks after surgery and specific on-field activities were gradually introduced. Criteria used to monitor the transition through the different phases were strength and endurance of the calf muscle and ability to sustain specific on-field training loads (TL) monitored with Global Positioning System and heart-rate system. TLs were weekly compared to pre-injury values to evaluate recovery and to prescribe future sessions. Participant: A 39-year-old (height 178 cm, weight 75 kg) elite soccer defender player, playing in Italian Serie-A league. Results: Days of absence were lower compared to a cohort presented in UEFA study (119 versus 161 ± 65 days, respectively). External-TL and Internal-TL were organized to gradually increase during RTS and resulted in higher values prior to return to competition compared to pre-injury values. Concentric plantar flexion peak torque increased till 9th months after surgery. Conclusions: Monitoring of the field activities allowed comparison with pre-injury values and provided a useful and functional criteria to pass return to team activity and competition.
Article
The purpose of the present study was to investigate the long-term effect of deep infection, sural nerve injury, and repeat rupture in the treatment of acute Achilles tendon rupture. A total of 324 patients had made a claim to the Danish Patient Insurance Association from 1992 to 2010 for a complication after acute Achilles tendon rupture. Of the 324 patients, 119 (77 males and 42 females) returned the Achilles tendon total rupture score and the 36-item short-form survey questionnaires. Patients with deep infection (n = 10), sural nerve injury (n = 10), and repeat rupture (n = 16) participated in a follow-up investigation. The mean follow-up period was 8.9 years (range 3 to 21). The mean Achilles tendon total rupture score was 49 ± 27. The summary scores of the physical component and mental components scales of the 36-item Short Form Survey were 43 ± 11 and 52 ± 11, respectively. No significant differences were found among the subpopulations with deep infection, injury to the sural nerve, or repeat rupture. The physical evaluation investigating tendon length and heel rise work revealed a statistically significant difference between the affected and unaffected limb after repeat rupture (p < .01) but not after injury to the sural nerve (p = NS) or deep infection (p = NS). In conclusion, patients with from a complication after acute Achilles tendon rupture had a remarkable reduction of the Achilles tendon total rupture score and physical component scale score at mean follow-up point of 9 years. Patients with repeat rupture had a significant elongation of the tendon and reduction of strength in the affected limb.
Article
Aims: The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada. Patients and methods: Patients ≥ 18 years of age who presented with an AATR to an emergency department in Ontario, Canada between 1 January 2003 and 31 December 2013 were identified using administrative databases. The overall and annual incidence density rate (IDR) of AATR were calculated for all demographic subgroups. The annual rate of surgical repair was also calculated and compared between demographic subgroups. Results: A total of 27 607 patients (median age, 44 years; interquartile range 26 to 62; 66.5% male) sustained an AATR. The annual IDR increased from 18.0 to 29.3 per 100 000 person-years between 2003 and 2013. The mean IDR was highest among men between the ages of 40 and 49 years (46.0/100 000 person-years). The annual rate of surgical repair dropped from 20.1 in 2003 to 9.2 per 100 AATRs in 2013. There was a noticeable decline after 2009. Conclusion: The incidence of AATR is increasing in Ontario, while the annual rate of surgical repair is decreasing. A sharp decline in the rate of surgical repair was noted after 2009. This coincided with the publication of several high-quality RCTs which showed similar outcomes for the 'functional' non-operative management and surgical repair. Cite this article: Bone Joint J 2017;99-B:78-86.
Article
The study objective was to describe the types, localizations and severity of injuries among first division Bundesliga football players, and to study the effect of playing position on match and training injury incidence and severity, based on information from the public media. Exposure and injuries data from 1 448 players over 6 consecutive seasons were collected from a media-based register. In total, 3 358 injuries were documented. The incidence rate for match and training injuries was 11.5 per 1 000 match-hours (95% confidence interval [CI]: 10.9-12.2), and 61.4 per 100 player-seasons (95% CI: 58.8-64.1), respectively. Strains (30.3%) and sprains (16.7%) were the major injury types, with the latter causing significantly longer lay-off times than the former. Significant differences between the playing positions were found regarding injury incidence and injury burden (lay-off time per incidence-rate), with wing-defenders sustaining significantly lower incidence-rates of groin injuries compared to forwards (rate ratio: 0.43, 95% CI: 0.17-0.96). Wing-midfielders had the highest incidence-rate and injury burden from match injuries, whereas central-defenders sustained the highest incidence-rate and injury burden from training injuries. There were also significant differences in match availability due to an injury across the playing positions, with midfielders sustaining the highest unavailability rates from a match and training injury. Injury-risk and patterns seem to vary substantially between different playing positions. Identifying positional differences in injury-risk may be of major importance to medical practitioners when considering preventive measures. © Georg Thieme Verlag KG Stuttgart · New York.
Article
Aim This systematic review and meta-analysis sought to identify return to play (RTP) rates following Achilles tendon rupture and evaluate what measures are used to determine RTP. Design A systematic review and meta-analysis were performed. Studies were assessed for risk of bias and grouped based on repeatability of their measure of RTP determination. Data sources PubMed, CINAHL, Web of Science and Scopus databases were searched to identify potentially relevant articles. Eligibility criteria for selecting studies Studies reporting RTP/sport/sport activity in acute, closed Achilles tendon rupture were included. Results 108 studies encompassing 6506 patients were included for review. 85 studies included a measure for determining RTP. The rate of RTP in all studies was 80% (95% CI 75% to 85%). Studies with measures describing determination of RTP reported lower rates than studies without metrics described, with rates being significantly different between groups (p<0.001). Conclusions 80 per cent of patients returned to play following Achilles tendon rupture; however, the RTP rates are dependent on the quality of the method used to measure RTP. To further understand RTP after Achilles tendon rupture, a standardised, reliable and valid method is required.
Article
Background Studies investigating the development of ACL injuries over time in football are scarce and more data on what happens before and after return to play (RTP) are needed. Aim To investigate (1) time trends in ACL injury rates, (2) complication rates before return to match play following ACL reconstruction, and (3) the influence of ACL injury on the subsequent playing career in male professional football players. Methods 78 clubs were followed between 2001 and 2015. Time trend in ACL injury rate was analysed using linear regression. ACL-injured players were monitored until RTP and tracked for 3 years after RTP. Results We recorded 157 ACL injuries, 140 total and 17 partial ruptures, with a non-significant average annual increase in the ACL injury rate by 6% (R2=0.13, b=0.059, 95% CI −0.04 to 0.15, p=0.20). The match ACL injury rate was 20-fold higher than the training injury rate (0.340 vs 0.017 per 1000 h). 138 players (98.6%) with a total rupture underwent ACL reconstruction; all 134 players with RTP data (4 players still under rehabilitation) were able to return to training, but 9 of them (6.7%) suffered complications before their first match appearance (5 reruptures and 4 other knee surgeries). The median layoff after ACL reconstruction was 6.6 months to training and 7.4 months to match play. We report 3-year follow-up data for 106 players in total; 91 players (85.8%) were still playing football and 60 of 93 players (65%) with ACL reconstruction for a total rupture played at the same level. Conclusions The ACL injury rate has not declined during the 2000s and the rerupture rate before return to match play was 4%. The RTP rate within a year after ACL reconstruction was very high, but only two-thirds competed at the highest level 3 years later.
Article
Objective: The purpose of this study was to present the functional outcomes of percutaneous tenorrhaphy of the Achilles tendon with a minimum follow-up of 10 years. Methods: The medical records of patients who underwent percutaneous surgery for acute unilateral Achilles tendon rupture between 2000 and 2004 were retrospectively reviewed. Results: A total of 11 male patients met the inclusion criteria and were followed for a mean of 12.6 years (range: 10-13 years). The average age at the time of surgery was 39.3 years (range: 29-53 years). Patients returned to work at an average of 2.7 months (range: 1-4 months) after surgery and to normal daily activities (NDA) at an average of 4.1 months (range: 3-6 months) postoperatively. The mean strength ratio between the injured and normal sides was 90%. Compared with the contralateral normal side, the thickness of the operated tendon increased by a mean of 0.7 cm, while the circumference of the affected calf diminished by a mean of 1.1 cm. No difference in active and passive range of motion (ROM) was recorded between the affected and the contralateral normal ankle joints. Isometric plantar flexion was 87% of normal. Sensory impairment in the territory of the sural nerve was identified in 1 patient immediately after surgery. The sensory defect had completely resolved by 6 months postoperatively. Conclusion: Long-term outcomes of our series support the effectiveness of percutaneous tenorrhaphy in Achilles function rehabilitation of patients with acute ruptures.
Article
“When will I be able to play again?” is usually the reflex thought when an athlete suffers an injury. When making return to play decisions, clinicians (including physiotherapists, athletic trainers and physicians) and athletes might engage in a risk–benefit analysis of sorts, consciously or unconsciously weighing up the risks associated with participation and the extent to which those risks can be tolerated.1 ,2 There are a number of questions to contemplate: How does the clinician determine when the athlete is ready to return to play? Is physical recovery alone enough for return to play? What is successful return to play? What are the sports medicine clinician's responsibilities within the team, and to the athlete? Should athletes even return to play? But what evidence can be used to answer these questions? We highlight some of the complexities in making the return to play decision, and key areas that need to be addressed. ### How does the clinician determine when the athlete is ready to return to play? In the traditional evidence-based practice model,3 the clinician integrates the best available evidence from research with individual clinical experience and the patient's preferences when making decisions. In the search for the best evidence, considering an ankle sprain, the clinician might consult a textbook, where the evidence says that the athlete should have no pain or swelling, full strength and range of motion, and a healed ligament before returning to full competition.4 The time taken for pain and swelling to subside and full range of motion to return might vary from a couple of weeks to a couple of months; it may take a year for ligament healing.5 But in real life the athlete may return to play within 1 or 2 weeks of …
Article
Whether Achilles tendon rupture benefits from surgery or conservative treatment remains controversial. Moreover, the outcome can be influenced by the rehabilitation protocol. The goal of the present meta-analysis was to compare the rerupture rate after surgical repair of the Achilles tendon followed by weightbearing within 4 weeks versus conservative treatment with weightbearing within 4 weeks. In addition, a secondary analysis was performed to compare the rerupture rates in patients who started weightbearing after 4 weeks. Seven randomized controlled trials published from 2001 to 2012, with 576 adult patients, were included. The primary outcome measure was the rerupture rate. The secondary outcomes were minor and major complications other than rerupture. In the early weightbearing group, 7 of 182 operatively treated patients (4%) experienced rerupture versus 21 of 176 of the conservatively treated patients (12%). A secondary analysis of the patients treated with late weightbearing showed a rerupture rate of 6% (7 of 108) for operatively treated patients versus 10% (11 of 110) for conservatively treated patients. The differences concerning the rerupture rate in both groups were not statistically significant. No differences were found in the occurrence of minor or major complications after early weightbearing in both patient groups. In conclusion, we found no difference in the rerupture rate between the surgically and nonsurgically treated patients followed by early weightbearing. Weightbearing after 4 weeks also resulted in no differences in the rupture rate in the surgical versus conservatively treated patients. However, surgical treatment was associated with a twofold greater complication rate than conservative treatment.
Article
Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate. A literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed with use of the Egger and Begg tests. Heterogeneity was assessed with use of the I2 test, and fixed or random-effect models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean differences, as appropriate. Meta-regression was employed to identify causes of heterogeneity. Subgroup analysis was performed to assess the effect of early range of motion. Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226). The results of the meta-analysis demonstrate that conservative treatment should be considered at centers using functional rehabilitation. This resulted in rerupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the rerupture risk in such patients. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Article
The purpose of this study was to determine the long-term impact of surgical repair and subsequent 6-week immobilization of an Achilles tendon rupture on muscle strength, muscle strength endurance and muscle activity. 63 patients participated in this study on average 10.8 ± 3.4 years after surgically repaired Achilles tendon rupture and short-term immobilization. Clinical function was assessed and muscle strength, strength endurance and muscle activity were measured using a dynamometer and electromyography. Ankle ROM, heel height during heel-raise tests and calf circumference were smaller on the injured than on the contralateral side. Ankle torques during the concentric dorsiflexion tasks at 60 °/sec and 180 °/sec and ankle torques during the eccentric plantarflexion task and during the concentric plantarflexion task at 60 °/sec for the injured leg were significantly lower than those for the contralateral leg. The total work during a plantarflexion exercise at 180 °/sec was 14.9% lower in the injured compared to the contralateral leg (p < 0.001). Muscle activity for the gastrocnemius muscle during dorsiflexion tasks was significantly higher in the injured than in the contralateral limb. Limited ankle joint ROM and increased muscle activity in the injured leg suggest compensatory mechanisms to account for differences in muscle morphology and physiology caused by the injury.