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

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Background Orthopaedic injuries of National Football League (NFL) players can have a deleterious effect on their health, with minimal to no high-level evidence on the management of these injuries. Purpose To summarize all data published between January 1980 and March 2018 on orthopaedic injuries experienced by NFL candidates and professional players in the NFL. Study Design Systematic review; Level of evidence, 4. Methods A literature search of studies examining orthopaedic injuries in the NFL was performed through the PubMed, Embase, and CINAHL databases. The review included studies of orthopaedic injuries in college football recruits attending the NFL Combine as well as professional NFL players. Excluded were studies of nonorthopaedic injuries, such as concussions, traumatic brain injury, facial injuries, and vascular injuries, as well as case reports. Results A total of 147 articles met the inclusion criteria and were divided into 11 topics based on anatomic site: general (16%), spine (13%), shoulder (13%), elbow (3%), hand and wrist (3%), trunk (0.7%), hip and pelvis (7%), thigh (3%), knee (24%), ankle (5%), and foot (12%). Of these studies, 74% were of level 4 evidence. Most studies obtained data from the NFL Combine database (26%), by searching the internet (24%), and via the NFL Injury Surveillance System (22%). Studies using internet search methods to identify injuries consistently found fewer participants than studies using the NFL Injury Surveillance System. Conclusion This systematic review provides National Collegiate Athletic Association and NFL team physicians with a single source of the most current literature regarding orthopaedic injuries in NFL players. Most research was published on knee, spine, shoulder, and foot injuries and consisted of level 4 evidence. A substantial portion of the published literature was based on data obtained from internet searches and may not accurately represent the NFL population.
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Review
A Systematic Review of the Orthopaedic
Literature Involving National Football
League Players
Melissa A. Kluczynski,* MS, William H. Kelly,* MS, William M. Lashomb,* BS,
and Leslie J. Bisson,*
MD
Investigation performed at the University at Buffalo, The State University of New York at Buffalo,
Buffalo, New York, USA
Background: Orthopaedic injuries of National Football League (NFL) players can have a deleterious effect on their health, with
minimal to no high-level evidence on the management of these injuries.
Purpose: To summarize all data published between January 1980 and March 2018 on orthopaedic injuries experienced by NFL
candidates and professional players in the NFL.
Study Design: Systematic review; Level of evidence, 4.
Methods: A literature search of studies examining orthopaedic injuries in the NFL was performed through the PubMed, Embase,
and CINAHL databases. The review included studies of orthopaedic injuries in college football recruits attending the NFL Combine
as well as professional NFL players. Excluded were studies of nonorthopaedic injuries, such as concussions, traumatic brain injury,
facial injuries, and vascular injuries, as well as case reports.
Results: A total of 147 articles met the inclusion criteria and were divided into 11 topics based on anatomic site: general (16%),
spine (13%), shoulder (13%), elbow (3%), hand and wrist (3%), trunk (0.7%), hip and pelvis (7%), thigh (3%), knee (24%), ankle
(5%), and foot (12%). Of these studies, 74% were of level 4 evidence. Most studies obtained data from the NFL Combine database
(26%), by searching the internet (24%), and via the NFL Injury Surveillance System (22%). Studies using internet search methods to
identify injuries consistently found fewer participants than studies using the NFL Injury Surveillance System.
Conclusion: This systematic review provides National Collegiate Athletic Association and NFL team physicians with a single
source of the most current literature regarding orthopaedic injuries in NFL players. Most research was published on knee, spine,
shoulder, and foot injuries and consisted of level 4 evidence. A substantial portion of the published literature was based on data
obtained from internet searches and may not accurately represent the NFL population.
Keywords: orthopaedic; musculoskeletal; injury; football; Combine; National Football League
American football enjoys broad participation, and injuries
commonly occur.
1,4,101
Football is also associated with the
most catastrophic injuries and fatalities among sportsin the
United States.
1
The National Football League (NFL) and
fantasy football are extremely popular, and information
about player’s injuries can often be found in the public
domain. This makes it possible to create databases from
publicly available information and publish studies using
these databases. Additionally, the anecdotal observations
of NFL team physicians suggest that the injuries experi-
enced by NFL players experience are unique in comparison
with those of the general US population. One goal of medi-
cine should be to base treatment on the highest levels of
evidence. Injuries can have a deleterious effect on a football
player’s health and career, and there is no high-level evi-
dence to guide the management of injuries sustained by
NFL players.
88
The primary objective of this systematic
review was to summarize all data published on orthopae-
dic injuries among college-level NFL recruits and profes-
sional players in the NFL. The secondary objective was to
characterize the literature based on anatomic site, level of
evidence, and source of data from which the study was
based. Finally, when possible, we sought to compare the
Address correspondence to Leslie J. Bisson, MD, UBMD Ortho-
paedics and Sports Medicine, Erie County Medical Center, 462 Grider St,
Buffalo, NY 14215, USA (email: ljbisson@buffalo.edu).
*Department of Orthopaedics, Jacobs School of Medicine and
Biomedical Science, University at Buffalo, Buffalo, New York, USA.
One or more of the authors has declared the following potential con-
flict of interest or source of funding: This study was funded by the Ralph C.
Wilson, Jr, Foundation. L.J.B. has received funding for education from
Arthrex, royalties from Zimmer Biomet, and hospitality payments from
Prodigy Surgical Distribution.
The Orthopaedic Journal of Sports Medicine, 7(8), 2325967119864356
DOI: 10.1177/2325967119864356
ªThe Author(s) 2019
1
This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (http://creativecommons.org/
licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are
credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For article reuse guidelines, please visit SAGE’s website at
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results among the different sources of data, including the
NFL Injury Surveillance System (NFLISS), team and
medical records, and internet-based sources.
METHODS
PubMed, Embase, and CINAHL were searched from Janu-
ary 1, 1980, to March 31, 2018, to identify all studies of
orthopaedic injuries in professional football players. Search
terms were “National Football League” in combination with
“combine” or “football.” We included studies of orthopaedic
injuries in college football recruits attending the NFL Com-
bine as well as those to professional NFL players. Excluded
were case reports and studies of nonorthopaedic injuries,
including concussions, traumatic brain injury, facial inju-
ries, and vascular injuries. Two authors (W.H.K., W.M.L.)
independently conducted the literature search and com-
pared their findings. The articles were divided into 11 cate-
gories corresponding with the anatomic site of injury:
general, spine, shoulder, elbow, hand and wrist, trunk, hip
and pelvis, thigh, knee, ankle, and foot. Level of evidence,
source of data, and type of injury were extracted from each
article. Finally, when possible, we compared studies on over-
lapping topics that used various data sources, including the
NFLISS, team or surgeon medical records, and the internet.
RESULTS
The PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) flowchart of the searchstrategy
is presented in Figure 1. We identified 855 articles through
our literature search,of which 147 articlespublished between
1980 and 2018 met the inclusion criteria. Figure 2 illustrates
the number of included articles by type of orthopaedic injury.
Most articles examined knee (24%), spine (13%), shoulder
(13%), and foot (12%) injuries. Of the studies reviewed, 74%
were of level 4 evidence (Figure 3). No level 1 studies met the
inclusion criteria. As shown in Table 1, most studies obtained
data from the NFL Combine database (26%), the internet
(24%), and the NFLISS (22%). The results of the included
articles are summarized and grouped according to anatomic
location.
General Information
Several studies investigated the football field and environ-
mental conditions and their effect on injury. The studies
consistently found higher rates of lower extremity injury
on artificial surfaces in comparison with natural
turf,
46,107,108
although 1 study from 1989 to 1998 found lower
rates of anterior cruciate ligament (ACL) tears on AstroTurf
in cold weather.
102
Lawrence et al
71
found that game-day
temperature below 50was a risk factor for concussions and
ankle injuries.
Medical grading systems can predict future availability
and performance in NFL Scouting Combine players and
should incorporate the player’s position and history of
injury, with shoulder instability, meniscal injury, ACL
tear, and other lower extremity injuries having well-
documented decreased performance and availability
effects.
4,10,11,15,79,111
The most common site of injury was the knee, followed by
hamstring strains and contusions.
35,72
Injuries were more
common in the first 2 weeks of training camp and during
games
35
and occurred most commonly in defensive players,
particularly defensive backs, although other positions had
unique injury patterns. These included acromioclavicular
Records idenfied through database
searching
(PubMed, n = 521
Embase, n = 730
CINAHL, n = 28
Total, n = 1,279)
Records idenfied by
searching reference lists
(n = 41)
Records screened aer duplicates removed
(n = 855)
Full-text arcles assessed
for eligibility
(n = 214)
Full-text arcles included
(n = 147)
Records excluded based
on tle and abstract
(n = 641)
Full-text arcles excluded (n = 67)
Case reports (n = 12)
Nonmusculoskeletal (n = 55)
Figure 1. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) flowchart.
2Kluczynski et al The Orthopaedic Journal of Sports Medicine
(AC) joint separations in quarterbacks, forearm fractures in
defensive backs, and lower extremity strains in kick-
ers.
17,49,61,72
Corticosteroid injections for muscle strains
as well as certain ligament sprains, such as the AC joint
or ankle syndesmosis, have been shown to be safe as well as
effective in allowing earlier return to play (RTP).
29,30,75,85
Finally, several studies documented increased arthritis and
whole-person impairment in former NFL players, with the
cervical and lumbar spine being highly affected.
27,42,97
Spinal Injuries
Spine injuries accounted for 7%of NFL injuries, were about
10 times more common in games than in practices, were
most common in the cervical spine, and most commonly
occurred in offensive linemen or defensive players who
were blocking or tackling.
43,82
Cervical Spine. The space available for the spinal cord on
cervical magnetic resonance imaging (MRI) was decreased
in heavy-contact NFL positions and was associated with
chronic stingers when the space available for the spinal cord
was <5mm.
109,110
Cervical pathology negatively affected the
number of games played in the NFL but did not affect player
performance.
50,122
Players with cervical disc herniation may
safely RTP, but RTP decreased to approximately 70%in
those requiring anterior cervical discectomy and fusion
(ACDF).
80,93
Adjacent segment degeneration occurred in
10%of players undergoing ACDF, while those treated with
foraminotomy had an RTP rate of 92%and returned earlier
than those with ACDF but had a 50%reoperation rate.
80
Lumbar Spine. Hyperconcavity of the lumbar spine was
commonly found on radiographs but had no evident conse-
quences.
106
The lumbar spine was the most common site of
Figure 2. Percentage of articles by type of orthopaedic injury. Injury categories are not mutually exclusive.
Figure 3. Number of articles by level of evidence and type
of orthopaedic injury. No level 1 or 2 articles were found.
The Orthopaedic Journal of Sports Medicine Orthopaedic Injuries in NFL Players 3
disc herniation, especially L5/S1, and lumbar herniations
were most common in offensive linemen.
44
Lumber condi-
tions, including disc herniation or spondylolisthesis, com-
monly led to team physicians’ downgrading draft prospects;
but there were conflicting data regarding player longevity
and no evident effect on performance in those players
drafted into the NFL.
78,121,123,127
Treatment of lumbar disc
herniations with epidural injections allowed RTP in 90%of
NFL players with few practices or games missed, but it was
less successful in the setting of weakness on examination or
disc sequestration on MRI.
68
When surgery was indicated
for lumbar disc herniation, NFL data and internet-based
studies showed that RTP was approximately 75%to 80%
but with 15%of players requiring revision decompres-
sion.
51,52,118,141
Performance was preserved in those
returning to play. Lumbar transverse process fractures
occurred, rarely involved viscera, and typically took 3 to
4 weeks before RTP.
138
Trunk Injuries
Chondral rib fractures were common and typically diag-
nosed by computed tomography and/or MRI. Sixty percent
of team physicians used an anesthetic block for pain man-
agement acutely, and 40%used a block to allow for RTP.
Shoulder Injuries
A history of shoulder injury, particularly AC separation
and instability, was found in 50%of NFL prospects, and
the most common shoulder surgery was for anterior insta-
bility.
39,58
Compared with players without shoulder inju-
ries, those with a history of shoulder injury were more
likely to go undrafted, and they played and started in
fewer games.
39
AC Joint. Most AC injuries occurred in games rather
than practices, were low grade, and rarely required sur-
gery, with quarterbacks missing more time than other
players (17 vs 10 days).
61,77
Rotator Cuff. Preexisting rotator cuff tears were rare in
NFL prospects but, when present, they decreased the ath-
letes’ likelihood of being drafted and were associated with
lower availability and performance in those who were
drafted.
41
Rotator cuff injuries included contusions and
tears, and contusions led to minimal time lost and were
treated with rehabilitation and occasionally with injec-
tion.
25
Of players with rotator cuff injuries, 11%ultimately
required surgery. Rotator cuff tears occurred most com-
monlyinoffensivelinemenandlinebackers,with90%
being treated with surgery and 90%of those surgically
treated returning to play at a mean of 5 months.
38
Residual
shoulder pain after rotator cuff repair was common.
Fractures. Clavicle fractures were successfully treated
nonoperatively and operatively, with both methods allow-
ing RTP in 95%of players; however, surgical treatment led
to earlier healing and RTP.
55,94
Some athletes had
decreased availability and/or performance after a clavicle
fracture, including offensive skill players (quarterbacks,
wide receivers [WRs], and running backs [RBs]).
55,56
Shoulder Instability. Shoulder instability decreased the
likelihood of NFL Combine prospects being drafted as well
as reduced career longevity.
14
Nonoperative treatment of
instability had recurrence rates from 40%to 55%but
allowed players to RTP in 1 week for subluxation and 3
weeks for dislocation, while players undergoing surgery
had 80%to 90%RTP rates but took nearly 9 months before
RTP, with a recurrence rate that ranged from 13%to
26%.
74,100,145
Latarjet surgery history was rare in NFL
Combine players but, when present, decreased the likeli-
hood of being drafted and was commonly associated with
hardware complications and glenohumeral osteoarthritis,
TABLE 1
Number of Articles by Source of Data and Type of Injury
a
Source of Data
Type of
Injury
NFL
Combine
Database
NFL Injury
Surveillance
System
Internet-Based
Search of Publicly
Available Data
Data From
a Single
Team
Medical
Records of
Players
Survey of Team
Physicians or Athletic
Trainers or Players
Med Sports
Systems Limited
Database
Data Collected
by Athletic
Trainers
Trunk 0 0 0 0 1 1 0 0
Elbow 0 4 0 0 0 0 0 0
Hand/Wrist 0 2 1 1 0 1 0 0
Hip/Pelvis 3 3 2 0 2 0 0 0
Thigh 1 2 0 2 0 0 0 0
Ankle 1 2 0 3 1 2 0 0
Foot 6 0 10 4 1 2 0 0
General
Injuries
54 3 52 4 0 2
Shoulder 6 5 3 2 5 1 0 0
Spine 7 3 6 2 1 1 1 0
Knee 9 8 11 5 1 6 0 0
Total 38 33 36 24 14 18 1 2
a
Data are not mutually exclusive. NFL, National Football League.
4Kluczynski et al The Orthopaedic Journal of Sports Medicine
with 1 of 2 studies showing a negative effect of Latarjet
surgery on NFL participation.
66,73
Other. SLAP (superior labral anterior-posterior) tears
were rare in NFL Combine participants (3%)but,when
present, decreased future player availability. When NFL
Combine participants underwent labral repair, 32%had
recurrent tearing and/or degenerative joint disease on MRI,
but this did not affect availability in their first NFL sea-
son.
65
In NFL players, SLAP tears were most common in
offensive linemen and were typically treated nonopera-
tively (60%).
23
Nonoperative treatment led to RTP after a
mean of 21 days versus 4 to 5 months with surgery. Pector-
alis major injuries were rare in NFL players (1 injury per
season for the entire league) and occurred most often in
games (90%) and during tackling (50%) rather than with
weight lifting, with RTP after surgery taking 4 months on
average.
136
Elbow and Forearm Injuries
Most NFL elbow injuries were sprains (77%)ordisloca-
tions (18%) and included hyperextension (56%)ormedial
collateral ligament (MCL) injuries (20%).
63
They most
commonly occurred in offensive and defensive linemen.
21
Elbow MCL sprains were usually treated nonoperatively,
andplayersmissedupto1game.Tricepstearsoften
occurred in linemen, with one-third having prodromal
symptoms and 25%having a prior steroid injection. Nearly
half of partial triceps tears eventually required surgery,
and athletes commonly returned to play following repair of
partial and complete tears, although they may miss the
remainder of the season and possibly the season after sur-
gery.
37,81
Forearm injuries were most commonly fractures
and involved defensive backs.
21
Hand and Wrist Injuries
Mall et al
83
reported that the overall incidence of hand
injuries in NFL players over 10 years (1996-2005) was
10.6 per 1000 athletic exposures, with 50%of injuries
involving the fingers, 30%hand, and 20%first ray. Also
according to Mall et al,
83
metacarpal fractures (17%)and
peripheral interphalangeal dislocations (17%), especially
of the ulnar 2 digits, were the most common types of inju-
ries, with the most common activity being tackling and the
most common positions being linemen (hand) and WRs
and defensive secondary (fingers). Thumb ligament inju-
ries have been a topic of study, and researchers have found
that ulnar collateral ligament injuries are often treated
surgically, with RTP in 4 to 5 weeks and no decline in
performance; 25%of ulnar collateral ligament injuries
also involve the radial collateral ligament and should be
treated surgically (which can safely be delayed until the
end of the season).
133,143
Lunate or perilunate dislocations were described in
10 NFL players, with hyperextension being the most fre-
quent mechanism of injury.
112
Closed or open reduction
with percutaneous pinning allowed for successful RTP after
a minimum of 4 weeks.
Hip and Pelvis Injuries
Feeley et al
36
found that 3%of all NFL injuries involved the
hip and were primarily muscle strains (36.3%). Defensive
backs and WRs had the most hip injuries, and offensive
linemen missed the most time (mean, 18.3 days). Blocking
was the most common mechanism of hip injury, and contu-
sions were due to contact while strains were usually non-
contact injuries. Proximal rectus femoris avulsion was
successfully treated nonoperatively, but time to RTP varied
from 3 to 10 weeks.
40
Adductor longus ruptures were usu-
ally treated nonoperatively, with RTP at a mean of 6 weeks,
but surgery was indicated in approximately 25%of cases
and RTP took 12 weeks.
120
In NFL Combine attendees, a history of core muscle sur-
gery did not significantly affect an athlete’s draft status or
future NFL performance.
64
In NFL players, an internet-
based study found that 95%of players undergoing surgery
for a core muscle injury were able to RTP, with no decrease
in statistical performance but a slightly shorter career
(approximately 6 months shorter on average) and 2 fewer
games played per season in comparison with controls.
53
Imaging studies of NFL Combine attendees and retired
NFL players noted a high incidence of impingement find-
ings, including labral tears (89%), chondral lesions (98%),
and ligamentum teres tears (81%) in athletes with symp-
toms.
28,95
An increased alpha angle seemed to be the best
imaging study predictor of pain.
70
Persistent symptoms of
adductor and rectus strain that did not resolve despite
therapy were described as the “sports hip triad” and
should raise suspicion of a labral tear.
36
Finally, when hip
surgery was indicated, impingement surgery and labral
repair both showed an RTP rate of approximately 85%
to 90%,
100,108
although the odds of RTP were about 6 times
less in lineman compared to other positions.
92,98
Thigh Injuries
A case-control study found that isokinetic parameters mea-
sured at the NFL Combine were not associated with ham-
string injuries that occurred within the player’s first
season.
147
Hamstring injuries primarily occurred 4 times
as often during the preseason as in the regular season,
happened primarily during practices (53%), were noncon-
tact (82%), and resulted in a mean 13 days lost among NFL
players.
32
Forty-one percent of hamstring injuries were minor
(<7dayslost),41%moderate (1-3 weeks lost), and 18%major
(>21 days lost), and most hamstring injuries occurred in
defensive backs (23%), WRs (21%), and special teams players
(13%). Corticosteroid injection for hamstring straincan safely
speed RTP without leading to recurrence, while platelet-rich
plasma has not been effec tive.
75,114
Finally,repair of proximal
hamstring avulsions can restore strength, but only 5 of 10
NFL players who underwent early repair were able to play
in more than 1 NFL game after surgery.
86
Knee Injuries
General. Among NFL Combine attendees, approxi-
mately 50%had a history of knee injury, most commonly
The Orthopaedic Journal of Sports Medicine Orthopaedic Injuries in NFL Players 5
MCL (40.8%), meniscal (26.3%), or ACL (19%).
8
Linemen
and tight ends had the highest incidence of knee injury
(57%-68%), and knee surgery was most common in RBs and
linebackers (35%).
Anterior Cruciate Ligament. Two percent of all injuries
reported to the NFLISS between 1994 and 1998 involved the
ACL.
9
Most noncontact ACL tears from 1989 to 1993
occurred during games (47.5%), on natural grass (65.6%),
and on a dry surface (93.4%).
125
A video analysis found that
the majority of ACL tears (72%) in NFL athletes involved a
noncontact mechanism, with the lower extremity exhibiting
significant valgus of the knee, particularly during lateral
movement.
57
The incidence of ACL injuries was the highest
for speed players (6.3%-10%), including WRs, tight ends,
linebackers, fullbacks, and halfbacks, and players experienc-
ing reinjury were more likely to injure the same knee versus
the contralateral knee (12.3%vs 7.3%,P<.05).
26
A study of NFL Combine participants found that a 30
reduction of hip internal rotation was associated with
increased odds of ACL tears in the ipsilateral (odds ratio,
4.06) and contralateral (odds ratio, 5.29) sides.
5
In a sepa-
rate imaging study of combine athletes, ACL reconstruc-
tions with more posterior tibial tunnels and grafts with
less sagittal obliquity had increased translation on Lach-
man examination.
84
Finally, Keller et al
60
studied players
at the 2010 through 2014 NFL Combines and found no
differences in measures of speed, jumping, agility, and
quickness in players with a history of ACL reconstruction
versus controls; in addition, they found that isolated ACL
reconstruction in combine participants did not shorten
their future NFL career.
13
Survey studies of NFL team physicians regarding man-
agement of ACL injuries found that 80%to 90%preferred
patellar tendon autograft via a single-bundle technique,
most recommended at least 6 months until RTP, and most
did not routinely recommend a brace.
9,33,88
RTP after ACL reconstruction ranged from 60%to 90%,
varied by position, and was highest in quarterbacks, but
longevity was found to be diminished.
24,31,34,113,128,146
RTP
was lower in less experienced and/or less highly skilled
players, had a significant negative financial impact on
future earnings, and was also associated with diminished
performance following RTP in all positions except
quarterbacks.
20,31,34,126,128
Okoroha et al
99
found that if the ACL graft failed, 79%of
24 NFL players who underwent revision ACL reconstruc-
tion returned to play at a mean of 12.6 months, with expe-
rience and skill associated with successful RTP and no
effect on career longevity.
Collateral Ligaments. Two studies documented success-
ful nonoperative treatment of isolated collateral ligament
injuries up to grade 3, reporting faster RTP with lower-
grade injuries and injuries managed nonoperatively.
19,129
MRI was helpful in predicting time lost following injury.
129
Articular Cartilage. Full-thickness cartilage lesions
were common in NFL prospects, being found in 40%to
60%of players at the NFL Combine who underwent knee
MRI.
47,96
Most isolated cartilage lesions were in the patel-
lofemoral compartment, and full-thickness cartilage lesions
were more common in a compartment of the knee that
underwent prior arthroscopic partial meniscectomy (APM),
particularly laterally. In NFL Combine players with knee
osteoarthritis based on plain radiographs or MRI, 27%had
a history of APM, 24%ACL reconstruction, and 11%menis-
cal repair.
132
History of knee surgery and body mass index
30 kg/m
2
were associated with knee osteoarthritis. When
players experienced articular cartilage injuries in the NFL,
roughly 50%occurred during games, 50%involved linemen,
50%involved the medial femoral condyle, and 50%required
eventual surgery.
16
RTP was longer for operative versus
nonoperative management (124 vs 36 days). Finally,
according to a survey of team physicians regarding the
management of chondral lesions, microfracture was
favored the most (43%), followed by debridement (31%) and
nonoperative treatment (13%).
16
Several studies focused on treatment of articular carti-
lage injuries in NFL players, with chondroplasty with or
without microfracture rates of 70%to 75%and with predic-
tors of return rates being absence of microfracture and
more presurgical games per season played.
119,124,134
Finally, Tabacco et al
135
studied 31 NFL players with knee
osteoarthritis treated with autologous stem cell therapy
and found that all players were satisfied with their treat-
ment and that RTP occurred at a mean of 2.4 months.
Meniscus. Lateral meniscectomy resulted in 60%RTP in
NFL players by 8 to 9 months after surgery, with more
skilled and experienced players successfully returning and
speed players less likely to return.
2
Isolated APM resulted
in fewer games played and a shortened career.
13
Concomitant Injuries. One study of multiligament knee
injuries identified through the NFLISS database (2000-
2016) found RTP rates of 70%after combined ACL-MCL
injuries, 55%RTP after ACL and posterior cruciate liga-
ment and/or lateral collateral ligament injuries, and 50%
RTP after frank knee dislocations.
3
Other. Tejwani et al
137
identified 24 players from a sin-
gle NFL team (1993-2006) with Morel-Lavallee lesions, of
which only 2 players missed 1 game each and all players
were treated successfully with compression/cryotherapy/
physical therapy (52%) or aspiration (48%). However, 20%
of players required repeated aspirations, and 10%needed
doxycycline sclerodesis when 3 aspirations failed to resolve
the fluid collections. Quadriceps injuries most commonly
occurred in defensive linemen and had only a 50%RTP
rate, with return more successful in more talented players.
7
In contrast, patellar tendon ruptures had an approximately
80%RTP rate, with return again favoring more talented
players.
6
Finally, a radiographic study of patellofemoral
congruence in 132 athletes at the 2011 NFL Combine found
incongruence in 10%, with an association of higher body
mass index with patellofemoral incongruence but no asso-
ciation with quadriceps-to-hamstring strength ratios.
18
Ankle Injuries
A history of ankle (and foot) injuries, particularly lateral
sprains, was very common in NFL Combine participants
(>70%), particularly in special teams players, WRs, and
offensive linemen.
59
Syndesmotic injuries were a topic of
several studies in the NFL; they often occurred in special
6Kluczynski et al The Orthopaedic Journal of Sports Medicine
teams players and offensive linemen, with the mean num-
ber of days missed being just over 2 weeks when all grades
were combined.
59,103
Steroid injection of stable syndesmosis
sprains led to early RTP by approximately 10 days, while
higher-grade injuries with positive squeeze test were asso-
ciated with longer RTP times.
85,130
In a survey of NFL trai-
ners in 1997, most used ice, electrical muscle stimulation, a
cast and/or brace, and nonsteroidal anti-inflammatory
drugs during the acute phase of the injury; proprioceptive
training, ultrasound, and taping were the most common
follow-up modalities. Recovery time was thought to be
reduced by immobilization, corticosteroid injection, ice, and
exercise.
29
Isolated fibular fractures were found to require surgery in
50%of cases and allowed for faster RTP when isolated, but
when treated with surgery, even isolated fractures required
a mean of 10 weeks to RTP.
144
In NFL athletes requiring
ankle fracture fixation, superficial deltoid complex avulsion
was a distinct injury that should be recognized, and these
players might benefit from primary open repair.
48
Finally, calf injuries have been studied in NFL players,
and 75%were isolated to the gastrocnemius, 15%to the
soleus, and 10%to both muscles.
142
The mean time to RTP
for calf injuries was 17 days, and 3 players required sur-
gery. Larger fascial defects and the presence of fluid collec-
tion on MRI were associated with longer RTP.
Foot Injuries
Lisfranc Injuries. Kent et al
62
reviewed 16 videos of tar-
sometatarsal injuries and found that these injuries typi-
cally occurred when a player was engaged with another
player and when a combination of axial loading of a
plantarflexed foot, external rotation, and pronation or supi-
nation occurred. Lisfranc sprains in NFL Combine partici-
pants were shown to negatively affect draft position and
player availability, particularly when >2-mm residual dis-
placement is present, while internet data of Lisfranc
sprains in NFL players showed >90%RTP at a median of
11 months with no effect on performance or career
length.
90,91
Type 1 and 2 injuries were treated nonopera-
tively, with RTP within 1 week for grade 1 and at 5 weeks
for grade 2, while grade 3 injuries required surgery but
allowed eventual RTP.
104
Achilles Tendon Ruptures. Several studies investigated
Achilles tendon ruptures in NFL athletes, including data
from the NFLISS, the internet, and individual surgeon
studies. There were similar results based on all these data
sets, with RTP occurring in 66%to 72%of players and var-
ious performance metrics being decreased for 2 to 3 years
following repair.
45,54,67,89,105,139
Fractures. Multiple studies investigated fifth metatarsal
fracturesin NFL Combine participants and NFL players. The
incidence of this injury was approximately 2%in NFL Com-
bine participants and was higher in athletes with long,
straight, narrow fifth metatarsals and an adducted forefoot;
7%to 12%had nonunions after surgery versus 20%without
surgery.
22,69,76,116,140
There was a nonsignificant association
with player availability in 1 study
22
and no association in
another,
140
as well as a negative effect on performance.
131
Successful completion of at least 1 college season after sur-
gery for fifth metatarsal fracture decreased the likelihood of
reinjury.
117
Operative treatment was successful at maximiz-
ing RTP when it employed (1) a protocol of fixation with a
Jones-specific intramedullary screw and iliac crest bone mar-
row aspirate with demineralized bone matrix injected at the
fracture site, (2) noninvasive bone stimulators, (3) use of cus-
tomized orthoses, and (4) an aggressive patient-specific reha-
bilitation protocol; however, 12%developed nonunion and
required revision surgery when returning during the same
season (at a mean of 9 weeks).
69
Other. One study found that age, playing on artificial
surface, and decreased ankle dorsiflexion were risk factors
for turf toe in NFL players,
115
while another study found
that players with a history of turf toe had decreased first
metatarsophalangeal dorsiflexion and higher peak hallucal
pressures but no difference in peak first metatarsophalan-
geal pressures.
12
Comparison of Overlapping Findings
From the NFLISS vs Medical Records
vs Internet-Based Studies
Cervical Disc Herniation. Hsu
50
sought to describe out-
comes of cervical disc herniation in NFL athletes and, using
the internet, was able to identify 99 players with cervical
disc herniations over 30 seasons (1979-2008), or 3.3 cases
per year. In contrast, Gray et al
44
used NFLISS data and
found 61 cervical herniations over 12 seasons (2000-2012),
or 5.1 cases per year. No studies of cervical disc herniation
utilized team medical record data. Although many remote
cases were likely missed by Hsu using an internet search
and despite the fact that the number of teams in the NFL
has increased since 1979, the disparity between the
2 sources of data suggests that the medical information
on NFL players available via the internet is likely
incomplete.
Lumbar Disc Herniation. Two studies contained over-
lapping data regarding lumbar disc herniation.
44,141
Weis-
troffer and Hsu
141
used internet search methods to identify
lumbar disc herniations in NFL linemen and found 66 cases
from 1982 to 2009 (approximately 2.4 cases per year). In
contrast, Gray et al
44
used NFLISS data to identify lumbar
disc herniations and found 83 cases in linemen from 2000 to
2012 (6.9 cases per year).
44
This suggests that a large num-
ber of cases are missed with information from the public
domain and introduces bias into the internet-based study.
No studies of lumbar disc herniation utilized team medical
record data.
Achilles Tendon Repair. Five studies collected internet-
based data and found 31 to 172 ruptures in NFL players;
however, there was much variation in the period for data
extraction (2-58 years).
45,54,67,105,1 39
Two of these studies
reported RTP rate, which ranged from 66%to 72%and was
similar to a study by McCullough et al,
89
who found that 78%
returned to play after mini-open repair according to medical
record data from a single surgeon’s practice.
54,105
No studies
on Achilles tendon ruptures utilized data from the NFLISS.
The Orthopaedic Journal of Sports Medicine Orthopaedic Injuries in NFL Players 7
ACL Injuries. Multiple studies used the internet or
NFLISS to identify ACL tears in certain NFL populations,
affording an opportunity to determine the ability of an inter-
net search to capture a given player population.
9,20,24,26,3 1,57
Three studies provided data regarding the number of RBs
and WRs experiencing ACL tears over a defined period.
9,20,26
Using the NFLISS, Bradley et al
9
searched the years 1994 to
1998 (5 seasons) and found 39 ACL tears among RBs and
WRs, while Dodson et al
26
found 57 ACL tears in RBs and
WRs from 2010 to 2013 (4 seasons). In contrast, Cary et al
20
found 33 ACL tears in these positions using the internet for
the 5 seasons from 1998 to 2002.
In another set of studies focusing on a different position,
Cinque et al
24
used the internet to identify ACL tears in
linemen and, over the 6 seasons from 2010 to 2015, found 38
ACL tears. In comparison, Bradley et al
9
found 57 ACL
tears in these positions in their study using the NFLISS
over 5 seasons, and Dodson et al
26
found 56 tears over 4
seasons, also using the NFLISS. Finally, in 2 studies using
the internet to identify all NFL ACL tears over the same
period, Eisenstein et al
31
found 92 cases in the 2013 and
2014 seasons, while Johnston et al
57
found 108 ACL tears
during those same 2 seasons.
Taken together, these findings imply that (1) an internet
search is likely to miss eligible participants; (2) higher-
profile players, such as RBs and WRs, may be more easily
identified via an internet search; (3) internet searches to
identify ACL tears at lower-profile positions, such as line-
men, may miss a significant number of cases with a risk of
spurious findings; and (4) differences in internet search
methods may lead to many eligible cases being missed.
No studies on ACL injuries extracted data from medical
records.
DISCUSSION
This systematic review provides a comprehensive summary
of the orthopaedic literature involving NFL players. Most
studies examined knee, spine, and shoulder injuries in NFL
players, and the majority of articles were level 4 evidence.
The most common sources of data were the NFL Combine
database, internet, and NFLISS.
Orthopaedic injuries in NFL players occurred more often
during games than practices and led to decreased perfor-
mance.
4,35
Injuries to the trunk were rare, with only 1 chon-
dral rib fracture reported per year.
87
Spine injuries
accounted for 7%of all injuries in NFL players.
82
Preexisting
cervical spine conditions resulted in fewer games played but
were not associated with diminished performance.
122
Cervi-
cal pathology failing nonoperative management was often
treated with ACDF or foraminotomy, depending on the
pathoanatomy and symptom complex. About 70%of players
returned to play after ACDF; however, later adjacent seg-
ment degeneration occurred in 10%of players.
93
The RTP
rate after foraminotomy (92%) was higher than that after
ACDF, although 50%of players required another opera-
tion.
80
Players with a history of lumbar spine conditions
were less likely to be drafted, but when they were drafted,
their career longevity and performance were not affected.
123
Shoulder injuries were fairly common in football players,
with about 50%of recruits at the NFL Combine reporting a
history of shoulder injury. Shoulder injuries occurred most
often during passing plays and as a result of direct
trauma.
58
AC separation and anterior instability were the
most common types of shoulder injuries, and the rate of
RTP was as high as 90%after shoulder surgery (rotator cuff
repair and surgery for clavicle fractures and shoulder insta-
bility).
38,55,61,145
Most hand injuries were fractures and dis-
locations; elbow and wrist injuries were primarily
ligamentous; and forearm injuries were fractures.
21,83
Hip injuries accounted for only 3%of all injuries in NFL
players and were mainly muscle strains.
36
Most NFL
players returned to play within 1 to 2 weeks of treatment
for thigh injuries, but only 50%returned following complete
proximal hamstring avulsion and quadriceps inju-
ries.
7,32,75,86
About 50%of players at the NFL Combine
reported a history of knee injury, primarily MCL, meniscal,
and ACL injuries.
8
Team physicians preferred patellar ten-
don autograft for ACL reconstruction.
9,33,88
About 60%of
players returned to play after ACL reconstruction, and per-
formance seemed to diminish after surgery.
60,128
About
40%to 60%of players at the NFL Combine had full-
thickness cartilage lesions on MRI, and 46%of NFL players
with articular cartilage injuries required surgery and took
longer to RTP than those treated nonoperatively.
16,96
About 70%of players at the NFL Combine had a history
of ankle injuries, with lateral and syndesmotic sprains,
metatarsophalangeal dislocations, and fibular fractures
being the most common.
59
Sixty eight percent of players
returned to play following Achilles tendon rupture.
105
Type
1 (undisplaced) and type 2 (2 mm or less of widening vs the
opposite side on weightbearing bilateral radiographs) Lis-
franc injuries were treated nonoperatively, with RTP
within 1 week for grade 1 and at 5 weeks for grade 2, while
grade 3 (3 mm of widening) required surgery (open reduc-
tion internal fixation without fusion, with optional removal
of hardware at approximately 4-6 months) but allowed for
eventual RTP.
104
Care must also be taken to recognize
proximal Lisfranc variants with any degree of widening
between the medial and middle cuneiform, and these were
commonly treated with internal fixation.
One strength of this study is that it is the first systematic
review, to our knowledge, that has examined the range of
orthopaedic injuries in NFL players. This systematic review
provides National Collegiate Athletic Association (NCAA)
and NFL team physicians with the most up-to-date infor-
mation regarding the frequency and outcomes of orthopae-
dic injuries in professional football players. There are
several limitations of this systematic review. Very few stud-
ies have been published for certain types of orthopaedic
injuries in NFL players, such as trunk injuries. This may
be due to the rarity of these types of injuries. The majority of
studies provided lower-quality evidence (level 3 or 4); how-
ever, this seems appropriate, as all of the included studies
examined descriptive data pertaining to injuries in NFL
players. Multiple studies in this review collected their data
by performing an internet-based search of publicly available
data (eg, injury reports, player profiles, press releases).
Data collected in this fashion were not standardized and
8Kluczynski et al The Orthopaedic Journal of Sports Medicine
may produce unreliable estimates. Also, publically available
data are very limited and do not provide access to detailed
medical records and demographics of the players. We found
that 17%of studies collected data from a single team only;
therefore, the results of these studies may not be generaliz-
able to all NFL players. We also found that 10%of studies
conducted a survey of team physicians and/or athletic trai-
ners. Survey data are subject to recall bias (ie, information
is misremembered) and nonresponse (ie, all questions are
not completed or all respondents do not complete the
survey).
In conclusion, this systematic review provides the NCAA
and NFL team physicians with a single source of the most
current literature regarding orthopedic injuries in NFL
players.
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... In the National Football League (NFL), knee injuries have been shown to represent approximately 20% to 30% of all injuries, 6,20 and 24% of literature on orthopaedic injuries in NFL athletes focuses on the knee. 19 While NFL athletes are subject to numerous types of knee injuries, there has been much interest in the evaluation of players after anterior cruciate ligament (ACL) tears. ACL tears represent 2% of injuries in the NFL. ...
... In the 2020 NFL season, the preseason was canceled in its entirety due to the coronavirus disease 2019 (COVID- 19) pandemic, making training challenging due to distancing guidelines, limited training camp roster sizes down to 80 players from the typical 90, 26 and less formalized training. The offseason programming differed from typical years with not only preseason game cancellations but also substantial practice schedule changes, including more strength and conditioning sessions, more walk throughs, and delayed live contact and padded practices. ...
... This may limit conclusions relative to data that may derive from league-derived electronic health systems; similar inconsistencies in the literature based on data sources have been found in both professional football and basketball. 3,19 The number of tears identified through this methodology was fewer than that identified using the NFL electronic health record, which includes all players. 28 Moreover, developing an accurate assessment of AEs is challenging. ...
Article
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Background The impact of fatigue and preseason preparation on anterior cruciate ligament (ACL) tears in the National Football League (NFL) are not well described. The 2020 NFL season did not include the standard preseason in response to changes secondary to the coronavirus disease-2019 (COVID-19) pandemic. Purpose To evaluate the association of game play on ACL tears in NFL athletes and to determine if differences in ACL tear epidemiology were present based on season of play from 2013 to 2020. Study Design Descriptive epidemiology study. Methods ACL tears in NFL athletes were identified using publicly available data. Games played and snap counts at the time of injury were recorded for each athlete sustaining game-related injuries. Tear rates were determined, and injuries were also calculated per 1000 athlete-exposures. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated. Results Overall, 379 ACL tears were identified, including 256 (67.6%) during game play and 118 (31.1%) during practice. Practice-based injuries were significantly higher in the preseason versus the remainder of the season. Games and snaps at the time of injury did not differ by year. The incidence rate of preseason injuries was significantly greater relative to in-season injuries (IRR = 2.68; 95% CI, 2.18-3.29; P < .00001). There was an elevated incidence rate of in-season injuries in 2020 relative to 2014-2019 combined (IRR = 1.49; 95% CI, 0.98-2.19; P = .048). In 2013 to 2019, the most frequent month of injury was the first month of the preseason in August (119/334 tears; 35.6%), whereas in 2020, the most frequent month was September (13/41 tears, 31.7%). The proportion of tears in September 2020 was not different from the proportion of tears in August 2013 to 2019. Conclusion There was an increased proportion of in-season ACL tears in the 2020 NFL season relative to 2014 to 2019; this is attributable to a frameshift in the consistent trend of injuries in the 1st month to return of competitive play, with 2020 being in the regular season in September as opposed to the preseason in August.
... The standard of care for ACL injuries in the athletic population is ACLR, 17,23 with about 120,000 to 200,000 ACLRs being performed each year in the United States. 30 Survey studies of NFL team physicians have found that 80% to 90% preferred single-bundle patellar tendon autograft. ...
Article
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Background Considerable variability exists in return-to-play rates after anterior cruciate ligament (ACL) injury and reconstruction (ACLR) among National Football League (NFL) players of different positions. Purpose/Hypothesis The purpose of this study was to compare return-to-play and performance levels by position in NFL players after ACLR. It was hypothesized that (1) ACL injuries have significant effects on the careers of NFL players, including return to play and performance, and (2) players of certain positions that involve relatively less pivoting and cutting perform better after ACLR. Study Design Descriptive epidemiology study. Methods All NFL players who underwent ACLR between 2013 and 2018 were identified using the FantasyData injury database. Player characteristics, snap count, games played, games started, and performance metrics were collected for 3 years before and after injury using the Pro Football Reference database. Performance was measured using an approximate value (AV) algorithm to compare performance across positions and over time. Nonparametric tests were used to compare the pre- and postinjury data and the percentage change in performance between different positions. Results Overall, 312 NFL players were included in this study, and 174 (55.8%) returned to play. Of the eligible players, only 28.5% (n = 59/207) remained in the league 3 years postinjury. Within the first 3 years postinjury, players played in fewer games (8.7 vs 13.7; P < .0001), started in fewer games (3.0 vs 8.3; P < .0001), had lower AVs (1.5 vs 4.3; P < .0001), and had decreased snap counts (259.0 vs 619.0; P < .0001) compared with preinjury. Quarterbacks were most likely to return to play (92.9% vs 53.7%; P = .0040) and to return to performance (2% vs 50% decrease in AV; P = .0165) compared with the other positions. Running backs had the largest decrease in AV (90.5%), followed by defensive linemen (76.2%) and linebackers (62.5%). Conclusion The study findings indicated that NFL players are severely affected by ACL injury, with only 28.5% still active in the league 3 years after the injury. Running backs, defensive linemen, and linebackers performed the worst after injury. Quarterbacks were most likely to return to play and had superior postinjury performance compared with the other positions.
... 7 Knee injuries are the most common injury in the NFL (24%), most often being ligamentous in nature (anterior cruciate or medial cruciate ligament). 12 The prominence of lower extremity injuries in the NFL make them a crucial area of investigation for player safety. Establishing clear risk factors for acute noncontact lower extremity injuries after concussive events can help team physicians treat athletes with new preventative guidelines to promote athlete well-being. ...
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Background Impaired neuromuscular function after concussion has recently been linked to increased risk of lower extremity injuries in athletes. Purpose To determine if National Football League (NFL) athletes have an increased risk of sustaining an acute, noncontact lower extremity injury in the 90-day period after return to play (RTP) and whether on-field performance differs pre- and postconcussion. Study Design Cohort study, Level of evidence, 3. Methods NFL concussions in offensive players from the 2012-2013 to the 2016-2017 seasons were studied. Age, position, injury location/type, RTP, and athlete factors were noted. A 90-day RTP postconcussive period was analyzed for lower extremity injuries. Concussion and injury data were obtained from publicly available sources. Nonconcussed, offensive skill position NFL athletes from the same period were used as a control cohort, with the 2014 season as the reference season. Power rating performance metrics were calculated for ±1, ±2, and ±3 seasons pre- and postconcussion. Conditional logistic regression was used to determine associations between concussion and lower extremity injury as well as the relationship of concussions to on-field performance. Results In total, 116 concussions were recorded in 108 NFL athletes during the study period. There was no statistically significant difference in the incidence of an acute, noncontact lower extremity injury between concussed and control athletes (8.5% vs 12.8%; P = .143), which correlates with an odds ratio of 0.573 (95% CI, 0.270-1.217). Days (66.4 ± 81.9 days vs 45.1 ± 69.2 days; P = .423) and games missed (3.67 ± 3.0 vs 2.9 ± 2.7 games; P = .470) were similar in concussed athletes and control athletes after a lower extremity injury. No significant changes in power ratings were noted in concussed athletes in the acute period (±1 season to injury) when comparing pre- and postconcussion. Conclusion Concussed, NFL offensive athletes did not demonstrate increased odds of acute, noncontact, lower extremity injury in a 90-day RTP period when compared with nonconcussed controls. Immediate on-field performance of skill position players did not appear to be affected by concussion.
Article
Background: American football players are at increased risk for many forms of spinal injury. Intervertebral disk herniations are particularly concerning as they are the leading cause of days lost to injury and can have long-term effects on player careers. Disk herniation management plays a major role in the likelihood and success of return-to-play (RTP). Objective: To assess the incidence, demographic variables, treatment approaches, outcomes, and RTP rates of disk herniations in American football players. Methods: A systematic review of the literature investigating disk herniations in American football players using PubMed, Cochrane Library, and Embase was performed. RTP estimates were calculated by pooling study-specific data using a random-effects model. Results: Four hundred twenty-two studies were identified, with 18 meeting inclusion criteria. Offensive and defensive linemen were the 2 most commonly injured positions. Players undergoing operations were on average younger, with higher body mass indexes, fewer seasons played, and longer post-treatment careers than nonsurgical counterparts. Postsurgical recovery periods lasted an average 106 d, with a mean RTP duration of 33 games over 2.7 yr and an 8.45% reoperation rate. Operative treatment offered a nonsignificant increase in the likelihood of return-to-play compared with nonoperative treatment (odds ratio = 2.81, 95% CI 0.83-9.51). Conclusion: Disk herniations are a common injury, with surgery potentially improving post-treatment outcomes. The literature suffers from heterogeneous definitions of RTP and varying performance metrics, making it difficult to draw clear conclusions. To better understand the impact of disk herniation and treatment on player health and performance, more studies should be performed prospectively and with standardized metrics.
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Purpose To use fantasy football points as a simple measure alongside on-field statistics to compare performance in National Football League (NFL) offensive skill position players before and after anterior cruciate ligament (ACL) reconstruction. Methods A retrospective review of all NFL quarterbacks (QB), running backs (RB), wide receivers (WR), and tight ends (TE) who sustained an isolated, unilateral ACL injury from 1988 to 2017 was conducted. Data were collected from public data sources, team releases, NFL injury reports, press releases, and other Internet resources. For each player, a matched control with similar demographics was identified. Their in-game performance post-ACL reconstruction was analyzed using fantasy football points as an outcome measure. Results A total of 13 QBs, 30 RBs, and 29 WRs who underwent ACL reconstruction from 1988 to 2017 and who met inclusion criteria were retrospectively identified and reviewed. Of the 13 quarterbacks included in the study, there was no statistically significant difference in fantasy football points between the pre- and post-ACL reconstruction groups, as well as post-ACL and matched control groups. There was a statistically significant decrease in career fantasy football performance of running backs post-ACL reconstruction compared with matched control groups (129.6 vs 553.6; P < .0001). There was also a statistically significant decrease in per game fantasy football points post-ACL reconstruction (4.4 vs 11.2; P < .0001). Lastly, WRs also demonstrated a decrease in career fantasy football performance post-ACL reconstruction compared with matched controls (145.3 vs 460.9; P = .002). In addition, they also had a decrease in per game fantasy football performance (5.0 vs 7.7; P = .042). Conclusion Quarterbacks did not have a statistically significant decrease in performance following ACL reconstruction based on fantasy football performance. Conversely, both running backs and wide receivers had decreased per game and career performance post-ACL reconstruction based on their fantasy football statistics. Furthermore, RBs had the largest decline in production each season over a 3-year period following ACLR compared to QBs and WRs, respectively.
Article
BACKGROUND: American Football (AF) players are assigned to positions by specific abilities and responsible for different tasks on the field what may result in wide differentiation in experienced injuries. The aim of this study was to analyze the causes of injuries and their differentiation depending on the position on the pitch. METHODS: Original questionnaire was used to investigate 150 Polish amateur AF players who had suffered from 189 injuries. The questionnaire detailed the following positions: offensive line (OL), defensive line (DL), quarterback (QB), running back (RB), wide receiver (WR), linebacker (LB), defensive backs (DB). The results were statistically analyzed by SofaStas v. 1.4.5 and then had been interpreted. RESULTS: Over 90% of all investigated AF players had self-reported injury history with the injury rate 1.27 injury per player. No statistically significant relationship was stated between position on the pitch and the occurrence rate, type and location of the injury. Significant relationship (p=0.030) was stated between the injury circumstances and position on the pitch - QB were mostly injured in collision with opponent, OL in direct sport fight while WR and RB due to a falls. CONCLUSIONS: Occurrence and type of injuries in AF players does not depend on position on the pitch in AF. Relationship between the injury location or injury circumstances and position on the pitch requires further studies. The most common location of injury is the knee joint and the most common type of injury is sprain while the most common causes of injury were collision with opponent and direct sport fight.
Article
Objectives The National Football League (NFL) altered the 2020 season due to the COVID-19 pandemic, which resulted in cancelled preseason games and a dynamic regular season schedule to accommodate for cancelled games. The purpose of this study was to evaluate if the disrupted training and preseason schedule lead to increased injury rates as seen in other professional sports. We hypothesized that the overall injury rate would be higher in the 2020 season compared to the 2018-2019 seasons, and that this increase will affect all body regions equally. Methods : Publicly released NFL weekly injury reports were queried to identify players listed as out or placed on the injured reserve for at least one game in the 2018-2020 seasons. Injuries were categorized into upper extremity, lower extremity, spine/core, head, illness, not injury related and undisclosed injuries. Incidence per 1000 athlete exposures was calculated for the prior two seasons (2018-2019) and for the 2020 season separately. Percentage of injuries occurring in each position were calculated separately for the pre-COVID-19 (2018 and 2019) and post-COVID-19 (2020) cohorts. Incidence rate ratios (IRR) and confidence intervals were used to compare injury rates in 2018-2019 versus 2020. The z-test for proportions was used to determine significant differences between injury incidences Results : The overall incidence rate per 1000 athlete exposures in 2020 was not significantly different compared to pre-COVID-19 seasons (21.6 versus 23.1, IRR 0.94, 95% CI: 0.9-1.0 p>0.999). The proportion of injuries by position did not change before and after COVID-19 either (p>0.999). Out listings due to illness were significantly increased during the 2020 season (0.8 versus 0.3, IRR 2.8, 95% CI: 1.4-5.2, p=0.004). Conclusion The incidence of NFL injuries did not significantly change in 2020. The distribution of injuries did not change with respect to position.
Article
Objectives Hip and core injuries are common in National Football League (NFL) athletes; however, the impact following injury remains unclear. The goal of this manuscript is to determine the impact of nonoperative hip and core injuries on return to play and performance. Methods NFL athletes who sustained a hip or core injury treated non-operatively between 2010-2016 were identified. Offensive and defensive power ratings were calculated for each player’s injury season and 2 seasons before and after to assess longitudinal impact. A matched control group without an identified hip and/or core injury were assembled for comparison. Results A total of 41 offensive and 71 defensive players with nonoperative hip or core injury were analyzed. All athletes returned to play; offensive and defensive players missed 4.0 ± 5.2 and 3.1 ± 2.6 games after injury, respectively. Offensive players played fewer cumulative career games returning from core injury versus hip (23.5 ± 20.6 vs 41.0 ± 26.4). Defensive players played fewer games (58.1 ± 41.1 versus 37.4 ± 27.1, p<0.05) with lower defensive power rating (133.9 ± 128.5 versus 219.8 ± 212.2, p<0.05) cumulatively after hip or core injury. Additionally, two years following injury, defensive players played fewer games compared to controls (9.5 ± 7.0 versus 10.9 ± 6.8, p<0.05). Following hip injury specifically, NFL defenders played fewer games (39.8 ± 27.9 vs 61.9 ± 38.8; p<0.05) and had a lower defensive power rating (145.9 ± 131.7 vs 239.0 ± 205.9; p<0.05) compared to before injury. Conclusion Overall, NFL players return to play following nonoperative hip and core injuries. Defensive players played in fewer games following hip or core injury compared to controls; offensive players were unaffected. Hip injuries have a greater impact on performance compared to core injuries in defensive athletes; offensive players played fewer games upon return from core injury.
Article
Objectives COVID-19 altered National Football League (NFL) player and team training during the 2020 offseason. All preseason games were cancelled resulting in absence of game play before the first week of the regular season. Thus concerns exist regarding injury susceptibility of players during regular season games. The purpose of this study was to evaluate and compare injury rates during the 2020 NFL season versus injury rates from the unaffected 2017-2019 seasons. We hypothesized there would be an increased injury rate and an increased rate of season ending injuries during the modified 2020 season. Methods The NFL’s public injury database was queried to identify players placed on the injury lists throughout the 2017-2020 seasons. All players listed as “out” and on the injured reserve due to physical injury were included in the data set. For further stratification, injury incidence was separated based on position. Time missed due to COVID-19 illness was not included. Injury rates were expressed as injuries per 1000 athlete exposures (AE). Results Overall, 893 individual players missed games due to injury during the 2020 NFL regular season compared to an average of 743 over the 2017-2019 seasons. Defensive players at all positions had a statistically significant increase in injury incidence from an average of 7.54 to 10.20 injuries per 1000 AE. Defensive backs were most affected with a 46% increase in players injured. There was no statistically significant difference in season ending injuries for any position. Conclusions The COVID-19 stricken 2020 NFL regular season saw an increased rate and incidence of injuries. Specifically, defensive players had a higher incidence of injury overall with defensive backs experiencing the greatest increase in injury rates.
Article
Background Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players. Purpose To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies. Study Design Systematic review; Level of evidence, 4. Methods A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams’ medical staff to the NFL Injury Surveillance System database linked to the League’s electronic health record. An ACL “capture rate” for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest. Results A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams’ medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play. Conclusion The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.
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Background: Previous studies have reported that hip abnormalities may account for 10% of injuries in professional football players. The effect of femoroacetabular impingement (FAI) and arthroscopic FAI surgery in National Football League (NFL) athletes has not been well studied. Purpose: To investigate the effect of arthroscopic FAI surgery on return to play (RTP) and RTP performance in NFL players. Study design: Cohort study; Level of evidence, 3. Methods: NFL athletes undergoing arthroscopic FAI surgery at a single institution between 2006 and 2014 were identified. Medical records were reviewed for demographic, clinical, and operative variables. RTP and RTP performance were assessed based on a review of publicly available NFL player statistics. RTP and RTP performance data included time to RTP; games played before and after the injury; yearly total yards and touchdowns for offensive players; and yearly total tackles, sacks, and interceptions for defensive players. The offensive power rating (OPR = [total yards/10] + [total touchdowns × 6]) and defensive power rating (DPR = total tackles + [total sacks × 2] + [total interceptions × 2]) were calculated. Paired t tests comparing preinjury and postinjury seasons were performed. A matched cohort of NFL players was created to compare trends for OPR, DPR, and career longevity. Results: Forty-eight hips in 40 NFL players (mean age, 25.6 years) with symptomatic FAI were included; 8 players underwent staged bilateral hip arthroscopic procedures. The majority of players were offensive (n = 24; 60.0%), with offensive lineman (n = 11; 27.5%) being the most common of all positions. Of the 48 included hips, all had labral tears, and 41 (85.4%) underwent labral repair. Forty-two of the 48 hips (87.5%) underwent cam decompression, and 10 (20.8%) underwent rim decompression. Of the 40 included players, 37 (92.5%) achieved RTP to professional competition after their hip arthroscopic surgery at a mean of 6.0 months. Before the injury, included patients played in a mean of 11.0 games compared with 9.5 games in their postoperative season ( P = .26). The mean OPR and DPR demonstrated a nonsignificant decline in the postoperative season (preinjury OPR, 40.2; postinjury OPR, 32.3; P = .34) (preinjury DPR, 49.6; postinjury DPR, 36.4; P = .10). A similar decline in the OPR and DPR across seasons was observed in the control group. NFL athletes played, on average, 3.3 ± 1.5 seasons after undergoing hip arthroscopic surgery; this was not significantly different from the controls (2.5 ± 1.5 seasons; P = .47). There was no significant difference in mean annual salaries based on contracts negotiated before the injury and the first negotiated contract after surgery ($3.3 million vs $3.6 million, respectively; P = .58). Conclusion: There was a very high rate of RTP in the NFL after arthroscopic FAI surgery; this rate is higher than what has been previously reported for other orthopaedic procedures in NFL athletes. Additionally, these NFL athletes achieved RTP at a faster time frame (6 months) than previously reported for other procedures. These findings have important implications for counseling elite football players about the expected outcome of arthroscopic FAI surgery.
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Background Anterior cruciate ligament (ACL) injuries pose a significant risk to the careers of players in the National Football League (NFL). The relationships between draft round and position on return to play (RTP) among NFL players are not well understood, and the ability to return to preinjury performance levels remains unknown for most positions. Purpose To test for differences in RTP rates and changes in performance after an ACL injury by position and draft round. We hypothesized that skilled positions would return at a lower rate compared to unskilled positions. We further hypothesized that early draft-round status would relate to a greater rate of RTP and that skilled positions and a lower draft round would correlate with decreased performance for players who return to sport. Study Design Case-control study; Level of evidence, 3. Methods Utilizing a previously established database of publicly available information regarding ACL tears among NFL players, athletes with ACL tears occurring between the 2010 and 2013 seasons were identified. Generalized linear models and Kaplan-Meier time-to-event models were used to test the study hypotheses. Results The overall RTP rate was 61.7%, with skilled players and unskilled players returning at rates of 64.1% and 60.4%, respectively (P = .74). Early draft-round players and unskilled late draft-round players had greater rates of RTP compared to skilled late draft-round players and both unskilled and skilled undrafted free agents (UDFAs). Skilled early draft-round players constituted the only cohort that played significantly fewer games after an injury. Unskilled UDFAs constituted the only cohort to show a significant increase in the number of games started and ratio of games started to games played, starting more games in which they played, after an injury. Conclusion Early draft-round and unskilled players were more likely to return compared to their later draft-round and skilled peers. Skilled early draft-round players, who displayed relatively high rates of RTP, constituted the only cohort to show a decline in performance. Unskilled UDFAs, who exhibited relatively low rates of RTP, constituted the only cohort to show an increase in performance. The significant effect of draft round and position type on RTP may be caused by a combination of differences in talent levels and in opportunities given to returning to play.
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Category Sports Introduction/Purpose Non-insertional Achilles tendon ruptures are a devastating injury in the National Football League (NFL) athlete. Depending on timing, these often are season ending injuries. There are mixed reports in the literature regarding impact of Achilles injuries in elite athletes. Additionally, there have been advancements in techniques including a mini-open repair that has proven successful. The purpose of this study was to critically analyze a large, single surgeon series of non-insertional Achilles ruptures in NFL athletes treated with a mini-open technique. Our primary focus was to determine return to play and evaluate possible contributing factors that affect this. Additionally, we sought to compare pre and post injury performance for those who successfully returned to the NFL. Methods NFL athletes treated for non-insertional Achilles ruptures since 2012 were included. Demographic and performance data were obtained from the NFL.com player database and included position, age, years in the league, return to sport and relevant performance metrics listed below. Pre injury frequency of play (games played per total games in season) for athletes were recorded. The impact of injury on performance after return to sport was assessed by comparing data from two years prior and two years post injury, normalized to a “per game” basis. For defensive players, specific metrics included tackles, pass deflection, interceptions and sacks. For offensive players, rushing and receiving statistics for running backs and wide receivers/tight ends were recorded, respectively. Average yards per run/catch, attempts per game, number of 20+ yard plays and touchdowns were recorded. Data was analyzed with Welch’s method 2-Sample t test in Minitab. Results Thirty-five ruptures were identified in predominantly defensive players (25/35). Ruptures occurred, on average, at age 27.7 years with 4.1 years of NFL experience. There was no significant difference in offensive (70%) and defensive (76%) player’s ability to return to the NFL (p=1.0). The frequency of play in the two seasons prior to injury differed significantly for players who did not return (21%) compared to those who did (95%) (p=.0013). Due to limited skill-position offensive players, further sub- analysis was limited. Defensive players who returned demonstrated significant differences in performance pre-injury compared to players who failed to return. In the two years following injury, returning defensive players performed at near baseline compared to pre injury statistics (figure 1). Conclusion Achilles injuries occurred predominately in defensive players. Typically occurring past the average NFL career length, it represents a mid to late career injury. The comeback rate of 74% is excellent and is higher than previously reported. Those who failed to return were utilized less frequently pre-injury and had poorer performance statistics (defensive), indicating less talented players were impacted to a greater extent. Lastly, given limited or no differences found in productivity for those who returned, we conclude that while an Achilles injury is most often season ending, most skilled players are able to return with little impact on performance.
Article
Background: Acute ruptures of the ulnar collateral ligament (UCL) of the thumb are common injuries in sports. Surgical repair of complete tears has yielded excellent results in elite athletes. Methods: National Football League (NFL) players who underwent thumb UCL surgery and matched controls were identified. Demographic and performance data were collected. Performance scores were calculated using a standardized scoring system. Return to sport (RTS) in the NFL was defined as playing in at least 1 NFL game after thumb UCL surgery. Comparisons between case and control groups and preoperative and postoperative time points were made using paired-samples Student t tests. Results: Twenty-three players were identified (mean age: 28.8 ± 3.4 years and mean experience in the NFL: 5.9 ± 3.4 years). Twenty-two players (95.7%) were able to return to sport in the NFL at an average of 132.2 ± 126.1 days. The overall 1-year NFL career survival rate of players undergoing thumb UCL surgery was 87.0%. There was not a statistically significant decrease in games per season and career length for any position following surgery. No positions had a significant difference in postoperative performance when compared with preoperative performance, and there was no significant performance difference postoperatively when compared with matched controls. Conclusions: There is a high rate of RTS in the NFL following thumb UCL surgery. Players who underwent thumb UCL surgery played in a similar number of games per season and had similar career lengths in the NFL as controls. No position group had any significant postoperative performance score differences when compared with postindex matched controls.
Article
Background: Anterior cruciate ligament (ACL) injuries are prevalent in contact sports that feature cutting and pivoting, such as American football. These injuries typically require surgical treatment, can result in significant missed time from competition, and may have deleterious long-term effects on an athlete's playing career and health. While the majority of ACL tears in other sports have been shown to occur from a noncontact mechanism, it stands to reason that a significant number of ACL tears in American football would occur after contact, given the nature of the sport. Hypothesis/Purpose: The purpose was to describe the mechanism, playing situation, and lower extremity limb position associated with ACL injuries in professional American football players through video analysis to test the hypothesis that a majority of injuries occur via a contact mechanism. Study design: Case series; Level of evidence, 4. Methods: A retrospective cohort of National Football League (NFL) players with ACL injuries from 3 consecutive seasons (2013-2016) was populated by searching publicly available online databases and other traditional media sources. Of 156 ACL injuries identified, 77 occurred during the regular season and playoffs, with video analysis available for 69 injuries. The video of each injury was independently viewed by 2 reviewers to determine the nature of the injury (ie, whether it occurred via a noncontact mechanism), the position of the lower extremity, and the football activity at the time of injury. Playing surface, player position, and time that the injury occurred were also recorded. Results: Contrary to our hypothesis, the majority of ACL injuries occurred via a noncontact mechanism (50 of 69, 72.5%), with the exception of injury to offensive linemen, who had a noncontact mechanism in only 20% of injuries. For noncontact injuries, the most common football activity at the time of injury was pivoting/cutting, and the most common position of the injured extremity included hip abduction/flexion, early knee flexion/abduction, and foot abduction/external rotation. There was no association between injury mechanism and time of injury or playing surface in this cohort. Conclusion: In this study of players in the NFL, the majority of ACL tears involved a noncontact mechanism, with the lower extremity exhibiting a dynamic valgus moment at the knee. These findings suggest that ACL injury prevention programs may reduce the risk of noncontact ACL tears in American football players.
Article
Background: Elite American football athletes are at high risk for Jones fractures. Fixation is recommended to minimize nonunion and allow early return to play. The purpose of this investigation was to evaluate the prevalence of Jones fracture repair in athletes invited to the National Football League (NFL) Combine and the impact of fracture repair on short-term NFL participation compared to athletes with no history of repair. Methods: A total of 1311 athletes participating in the Combine from 2012 to 2015 were evaluated. Athletes with history of Jones fracture repair were identified. Athlete demographic information was collected while physical examination findings were recorded. Radiographs were evaluated to determine fixation type and the presence of nonunion. Future participation in the NFL was evaluated based on draft status, games played, and games started in the athlete's first season following the Combine. Results: Fixation was performed for 41 Jones fractures in 40 athletes (3.1%). The highest prevalence was in defensive linemen (n = 10 athletes), with the greatest rate in tight ends (5.1%, n = 4 of 79 athletes). Intramedullary screw fixation was used for all fractures. Incomplete bony union was present in 3 (8%) fractures. Athletes with a history of repair were not at significant risk for going undrafted ( P = .61), playing ( P = .23), or starting ( P = .76) fewer NFL games compared to athletes with no history of repair during athletes' first NFL season. Conclusion: Athletes with a history of Jones fracture repair were not at significant risk of going undrafted or for diminished participation during their first season in the NFL. Level of evidence: Level IV, case series.
Article
We conducted a study to identify and contrast patterns in the treatment of common injuries that occur in National Football League (NFL) players and National Collegiate Athletic Association (NCAA) Division I football players. Orthopedic team physicians for all 32 NFL and 119 NCAA Division I football teams were asked to complete a survey regarding demographics and preferred treatment of a variety of injuries encountered in football players. Responses were received from 31 (97%) of the 32 NFL and 111 (93%) of the 119 NCAA team physicians. Although patellar tendon autograft was the preferred graft choice for both groups of team physicians, the percentage of NCAA physicians who allowed return to football 6 months or less after anterior cruciate ligament reconstruction was significantly (P = .03) higher than that of NFL physicians. Prophylactic knee bracing, which may prevent medial collateral ligament injuries, was used at a significantly (P < .0001) higher rate by NCAA teams (89%) than by NFL teams (28%). Ketorolac injections were given by a significantly (P < .01) higher percentage of NFL teams (93%) than of NCAA teams (62%). Understanding the current trends in the management of these injuries is beneficial in designing studies that may help improve the treatment and prevention of injuries in football players.
Article
Purpose: To investigate the prevalence of shoulder labral repair and utility of magnetic resonance imaging (MRI) in determining the risks of recurrent labral tearing and impact on future participation in the National Football League (NFL). Methods: Athletes invited to the NFL Combine between 2012 and 2015 were retrospectively reviewed. Athletes with a history of labral repair and MRI of the operative shoulder at the Combine were included in the study for further analysis, excluding athletes without a history of labral repair, labral repair without MRI at the Combine, additional procedure to the operative shoulder, or athletes still undergoing rehabilitation at the time of the Combine after labral repair. All MRIs were reviewed to determine initial labral repair location, the presence of recurrent tearing, and any concomitant shoulder pathology. Prospective information on future NFL participation in regard to draft status, games played, and games started in the athlete's first NFL season after the Combine was compared between athletes with a history of labral repair with and without recurrent tearing versus all other athletes participating in the Combine. Results: A total of 132 (10.1%) athletes underwent 146 shoulder labral repair procedures before the NFL Combine, of whom 32% (n = 39 athletes, n = 46 shoulders) had recurrent labral tears on MRI. Athletes with recurrent tears were more likely to have undergone bilateral labral repairs (P = .048) and possess concomitant shoulder pathology (P < .001). Recurrent labral tearing was significantly more common in the posterior labrum in athletes with a history of posterior labral repairs (P = .032). Prospective participation in the NFL in terms of games played (P = .38) or started (P = .98) was not significantly reduced in athletes with a history of labral repair compared with those without repair. Participation was not diminished in athletes with recurrent labral tears compared with those with intact repairs or those with evidence of degenerative joint disease. Conclusions: Athletes invited to the NFL Scouting Combine with a history of bilateral repair, posterior labral repair, and concomitant shoulder pathology are at high risk of recurrent labral tearing on MRI. No significant reduction in NFL participation the year after the Combine was seen in athletes with a history of labral repair, recurrent labral tearing, or degenerative joint disease who were successfully drafted into the NFL. In athletes with a history of labral repair, assessment of labral integrity on MRI alone is not predictive of future short-term participation. Level of evidence: Level IV, prognostic study-case series.
Article
Hypothesis: We hypothesized that National Football League (NFL) players sustaining a shoulder destabilizing injury could return to play (RTP) successfully at a high rate regardless of treatment type. Methods: We identified and evaluated 83 NFL players who sustained an in-season shoulder instability event while playing in the NFL. NFL RTP, incidence of surgery, time to RTP, recurrent instability events, seasons/games played after the injury, and demographic data were collected. Overall RTP was determined, and players who did and did not undergo operative repair were compared. Results: Ninety-two percent of NFL players returned to NFL regular season play at a median of 0.0 weeks in those sustaining a shoulder subluxation and 3.0 weeks in those sustaining a dislocation who did not undergo surgical repair (P = .029). Players who underwent operative repair returned to play at a median of 39.3 weeks. Forty-seven percent of players had a recurrent instability event. For players who were able to RTP, those who underwent surgical repair (31%) had a lower recurrence rate (26% vs. 55%, P = .021) and longer interval between a recurrent instability event after RTP (14.7 vs. 2.5 weeks, P = .050). Conclusion: There is a high rate of RTP after shoulder instability events in NFL players. Players who sustain shoulder subluxations RTP faster but are more likely to experience recurrent instability than those with shoulder dislocations. Surgical stabilization of the shoulder after an instability event decreases the chances of a second instability event and affords a player a greater interval between the initial injury and a recurrent event.
Article
Background: Professional athletes are predisposed to fractures of the foot due to large stresses placed on the lower extremity. These players are concerned with efficiently returning to play at a high level. Return-to-play rates after operative treatment have been previously reported, yet performance outcomes after such treatment are generally unknown in this population. Hypothesis: Overall, professional athletes sustaining a foot fracture would return to play at high rates with little impact on post-operative performance or league participation. However, National Football League (NFL) athletes would have a significantly greater decline in performance, due to the high impact nature of the sport. Study design: Case series. Level of evidence: Level 4. Methods: Athletes in the National Basketball League (NBA), NFL, Major League Baseball (MLB), and National Hockey League (NHL) undergoing operative fixation of a foot fracture were identified through a well-established protocol confirmed by multiple sources of the public record. Return-to-play rate and time to return were collected for each sport. League participation and game performance data were collected before and after surgery. Statistical analysis was performed, with significance accepted as P ≤ 0.05. Results: A total of 77 players undergoing 84 procedures met the inclusion criteria. Overall, 98.7% (76/77) of players were able to return to play, with a median time to return across all sports of 137 days. Players returned to preoperative performance levels within 1 season of surgery. Six players (7.8%) sustained refracture requiring reoperation, all of whom were in the NBA. Percentage of games started during the season after primary operative treatment was a predictive factor for reinjury (99% vs 40%, P = 0.001). Conclusion: Athletes returned to play at a high rate after foot fracture fixation, with excellent postoperative performance levels, regardless of sport and fracture location. NBA athletes sustaining fifth metatarsal and navicular fractures are at greater risk of reinjury compared with other athletes. Returning to high levels of athletic participation soon after surgery may predispose athletes to refracture and subsequent reoperation. Clinical relevance: Players, coaches, and team physicians should be aware of the impact of foot fractures on career performance and longevity to best guide therapy.