National Football League Injury Surveillance System Research Articles

Elbow Dislocations in the National Football League: Epidemiology and Management.

BackgroundCurrently, it is not known how the combined osseous and ligamentous injury of a traumatic elbow dislocation in a National Football League (NFL) athlete affects management and return to play. In this study, we aimed to describe the epidemiology, management, and return to play for elbow dislocations in NFL athletes.MethodologyThis is a descriptive observational study. A retrospective review of all elbow dislocations between 2000 and 2014 (15 seasons) was performed using the NFL Injury Surveillance System (NFLISS).ResultsOver 15 NFL seasons, 82 elbow dislocations were recorded in the NFLISS. Among players who reported surgery (n = 5), players missed an average of 73.8 days of play. Among those who did not report surgery, players missed an average of 36.1 days. The overall incidence was 0.26 dislocation events per 10,000 athlete exposures. The majority of these injuries occurred during regular-season games, in defensive linebackers and linemen, during tackling contact with another player, and most commonly on a running play.ConclusionsThis study demonstrates that an elbow dislocation is not a career-ending or season-ending injury in an NFL cohort. Information regarding incidence, positions affected, whether surgical management is utilized, and return to play will help players who sustain and physicians who treat these injuries in elite football athletes understand the impact of their injuries.

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

Background: Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players. Purpose: To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams’ medical staff to the NFL Injury Surveillance System database linked to the League’s electronic health record. An ACL “capture rate” for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest. Results: A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams’ medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play. Conclusion: The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.

Lower Extremity Compartment Syndrome in National Football League Athletes.

The purpose of this study was to evaluate the incidence of lower extremity compartment syndrome in National Football League (NFL) athletes and report the mechanisms of injury, methods of treatment, and subsequent days missed. We review the existing literature on lower extremity compartment syndrome in athletic populations. Lower extremity compartment syndrome occurs with a low incidence in NFL athletes, and there is a high return-to-play rate after surgical management of acute compartment syndrome. Case series. Level 4. A retrospective review of recorded cases of lower extremity compartment syndrome from 2000 to 2017 was performed using the NFL Injury Surveillance System and electronic medical record system. Epidemiological data, injury mechanism, rates of surgery, and days missed due to injury were recorded. During the study period, 22 cases of leg compartment syndrome in 21 athletes were recorded. Of these injuries, 50% occurred in games and 73% were the result of a direct impact to the leg. Concomitant tibial fracture was noted in only 2 cases (9.1%) and there was only 1 reported case of chronic exertional compartment syndrome. Surgery was documented in 15 of 22 cases (68.2%). For acute nonfracture cases, the average time missed due to injury was 24.2 days (range, 5-54 days), and all were able to return to full participation within the same season. NFL athletes with acute leg compartment syndrome treated with surgery exhibited a high rate of return to play within the same season. Although compartment syndrome is a relatively rare diagnosis among NFL players, team physicians and athletic trainers must maintain a high index of suspicion to expediently diagnose and treat this potentially limb-threatening condition.

Pectoralis Major Injuries in the National Football League.

Pectoralis major (PM) injuries are rare, primarily occurring in males during athletic activity. In the current literature, these injuries have not been well described in National Football League (NFL) athletes. The incidence of PM injuries will be low in NFL athletes, with athletes missing significantly more time after injuries requiring operative management. Cohort study. Level 4. All documented PM injuries were retrospectively analyzed using the NFL Injury Surveillance System over a 15-season period. The data were analyzed by season, session, position, activity, and contact type at the time of injury. Additionally, the incidence, treatment, and days missed as a result of injury were assessed. Over 15 consecutive seasons, there were a total of 211 PM injuries. Of these injuries, 132 were classified as strains and 79 as ruptures. The incidence of strains was 0.41 per 10,000 athlete-exposures, compared with 0.25 per 10,0000 athlete-exposures for ruptures (P < 0.01). Players with PM ruptures treated operatively missed significantly more days than players treated nonoperatively (146.7 ± 55.0 vs 77.2 ± 72.9; P < 0.01). NFL athletes miss significantly more time after operative compared with nonoperative management of PM ruptures. PM injuries are rare, with the current literature lacking description of these injuries in NFL athletes. The paucity of data limits physicians from providing adequate counseling and expectations for athletes with this injury. This research represents the largest study assessing PM injuries in NFL athletes.

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

Background:Orthopaedic injuries of National Football League (NFL) players can have a deleterious effect on their health, with minimal to no high-level evidence on the management of these injuries.Purpose:To summarize all data published between January 1980 and March 2018 on orthopaedic injuries experienced by NFL candidates and professional players in the NFL.Study Design:Systematic review; Level of evidence, 4.Methods:A literature search of studies examining orthopaedic injuries in the NFL was performed through the PubMed, Embase, and CINAHL databases. The review included studies of orthopaedic injuries in college football recruits attending the NFL Combine as well as professional NFL players. Excluded were studies of nonorthopaedic injuries, such as concussions, traumatic brain injury, facial injuries, and vascular injuries, as well as case reports.Results:A total of 147 articles met the inclusion criteria and were divided into 11 topics based on anatomic site: general (16%), spine (13%), shoulder (13%), elbow (3%), hand and wrist (3%), trunk (0.7%), hip and pelvis (7%), thigh (3%), knee (24%), ankle (5%), and foot (12%). Of these studies, 74% were of level 4 evidence. Most studies obtained data from the NFL Combine database (26%), by searching the internet (24%), and via the NFL Injury Surveillance System (22%). Studies using internet search methods to identify injuries consistently found fewer participants than studies using the NFL Injury Surveillance System.Conclusion:This systematic review provides National Collegiate Athletic Association and NFL team physicians with a single source of the most current literature regarding orthopaedic injuries in NFL players. Most research was published on knee, spine, shoulder, and foot injuries and consisted of level 4 evidence. A substantial portion of the published literature was based on data obtained from internet searches and may not accurately represent the NFL population.

Management of Elbow Dislocations in the National Football League.

Background:Although much literature exists regarding the treatment and management of elbow dislocations in the general population, little information is available regarding management in the athletic population. Furthermore, no literature is available regarding the postinjury treatment and timing of return to play in the contact or professional athlete.Purpose:To review the clinical course of elbow dislocations in professional football players and determine the timing of return to full participation.Study Design:Case series; Level of evidence, 4.Methods:All National Football League (NFL) athletes with elbow dislocations from 2000 through 2011 who returned to play during the season were identified from the NFL Injury Surveillance System (NFL ISS). Roster position, player activity, use of external bracing, and clinical course were reviewed. Mean number of days lost until full return to play was determined for players with elbow dislocations who returned in the same season.Results:From 2000 to 2011, a total of 62 elbow dislocations out of 35,324 injuries were recorded (0.17%); 40 (64.5%) dislocations occurred in defensive players, 12 (19.4%) were in offensive players; and 10 (16.1%) were during special teams play. Over half of the injuries (33/62, 53.2%) were sustained while tackling, and 4 (6.5%) patients required surgery. A total of 47 (75.8%) players who sustained this injury were able to return in the same season. For this group, the mean number of days lost in players treated conservatively (45/47) was 25.1 days (median, 23.0 days; range, 0.0-118 days), while that for players treated operatively (2/47) was 46.5 days (median, 46.5 days; range, 29-64 days). Mean return to play based on player position was 25.8 days for defensive players (n = 28; median, 21.5 days; range, 3.0-118 days), 24.1 days for offensive players (n = 11; median, 19 days; range, 2.0-59 days), and 25.6 days for special teams players (n = 8; median, 25.5 days; range, 0-44 days).Conclusion:Elbow dislocations comprise less than a half of a percent of all injuries sustained in the NFL. Most injuries occur during the act of tackling, with the majority of injured athletes playing a defensive position. Players treated nonoperatively missed a mean of 25.1 days, whereas those managed operatively missed a mean of 46.5 days.

Superior Labrum Anterior-Posterior Tears in the National Football League

Background: Shoulder disorders are common in football players, with up to 50% of National Football League (NFL) recruits reporting a history of shoulder injuries. Superior labrum anterior-posterior (SLAP) tears are an entity with well-described detrimental effects on return to play in overhead-throwing athletes but with minimal data in contact athletes. Purpose: To identify the incidence, predisposing factors, and effect of SLAP tears in NFL athletes and prospects as well as the treatment patterns of NFL team physicians. Study Design: Descriptive epidemiology study. Methods: This study was a comprehensive analysis of SLAP tears in elite football players using a dual approach: (1) SLAP injuries recorded in the NFL Injury Surveillance System from 2000 to 2014 were evaluated by player position, type of play, days/games lost, and surgical intervention; (2) NFL Scouting Combine athletes from 2003 to 2011 with prior SLAP repair were evaluated for draft success, and drafted athletes were compared with matched controls for career length and performance scores. Results: SLAP tears represented a small portion (3.1%) of shoulder injuries in NFL athletes from 2000 to 2014, occurring most commonly in offensive linemen (28%). Surgically treated SLAP tears (42%) resulted in more days missed than did nonoperatively managed tears (140.2 vs 21.5 days; P < .001) and more games missed (8.4 vs 2.6 games; P = .003). SLAP repairs were also rare in NFL Combine athletes (n = 25 of 2965 athletes), with most having been performed in offensive linemen (32%). As compared with control NFL Combine athletes without SLAP tears, those drafted into the NFL with prior SLAP repair played significantly fewer games (33.7 vs 48.3; P = .049) and had fewer game starts (19.6 vs 35.4; P = .036). Conclusion: In this comprehensive analysis of SLAP tears in elite football players, it is clear that these injuries have the potential to cause significant detriment to an athlete’s career.

Triceps Tendon Ruptures Requiring Surgical Repair in National Football League Players.

Background:Complete triceps tendon ruptures are relatively rare in the general population but slightly more prevalent in professional football. One prior study found 11 complete ruptures over a 6-season period.Hypothesis:Triceps ruptures occur more commonly in football linemen due to forced elbow flexion during an eccentric contraction and may occur more commonly with the increasing size and speed of professional players. Surgical repair allows full return to sports, but with a lengthy recovery time.Study Design:Case series; Level of evidence, 4.Methods:A search of the National Football League Injury Surveillance System (NFLISS) found a total of 37 triceps tendon ruptures requiring surgical repair from the years 2000 to 2009. Data were obtained for setting of injury, player position, activity causing injury, play type, time of game when injury occurred, height, weight, body mass index (BMI), and number of days lost from football.Results:There were 37 players requiring surgical repair for triceps tendon ruptures over the 10-season period. The average height, weight, and BMI of the players were 75 inches, 292 pounds, and 36.5 kg/m2, respectively. The majority of players were linemen (86%): 16 defensive, 15 offensive, and 1 tight end. The injury took place while blocking or being blocked in 29 players (78%) and while tackling or being tackled in 5 players (14%). Players missed an average of 165 days (range, 49-318 days) from football as a result of their injury and surgery.Conclusion:Triceps tendon tears requiring surgical repair are more common in professional football players than in the general population and are occurring more commonly than previously reported. Surgical repair allows return to play.Clinical Relevance:Our study identifies the rate of triceps tendon tears requiring repair in the NFL according to position, identifying which players may be most at risk for this injury.

Acromioclavicular Joint Injuries in the National Football League

Background: Previous studies investigating acromioclavicular (AC) joint injuries in professional American football players have only been reported on quarterbacks during the 1980s and 1990s. These injuries have not been evaluated across all position players in the National Football League (NFL). Purpose: The purpose of this study was 4-fold: (1) to determine the incidence of AC joint injuries among all NFL position players; (2) to investigate whether player position, competition setting, type of play, and playing surface put an athlete at an increased risk for this type of injury; (3) to determine the incidence of operative and nonoperative management of these injuries; and (4) to compare the time missed for injuries treated nonoperatively to the time missed for injuries requiring surgical intervention. Study Design: Descriptive epidemiological study. Methods: All documented injuries of the AC joint were retrospectively analyzed using the NFL Injury Surveillance System (NFLISS) over a 12-season period from 2000 through 2011. The data were analyzed by the anatomic location, player position, field conditions, type of play, requirement of surgical management, days missed per injury, and injury incidence. Results: Over 12 NFL seasons, there were a total of 2486 shoulder injuries, with 727 (29.2%) of these injuries involving the AC joint. The overall rate of AC joint injuries in these athletes was 26.1 injuries per 10,000 athlete exposures, with the majority of these injuries occurring during game activity on natural grass surfaces (incidence density ratio, 0.79) and most often during passing plays. These injuries occurred most frequently in defensive backs, wide receivers, and special teams players; however, the incidence of these injuries was greatest in quarterbacks (20.9 injuries per 100 players), followed by special teams players (20.7/100) and wide receivers (16.5/100). Overall, these athletes lost a mean of 9.8 days per injury, with quarterbacks losing the most time to injury (mean, 17.3 days). The majority of these injuries were low-grade AC joint sprains that were treated with nonoperative measures; only 13 (1.7%) required surgical management. Players who underwent surgical management lost a mean of 56.2 days. Conclusion: Shoulder injuries, particularly those of the AC joint, occur frequently in the NFL. These injuries can result in time lost but rarely require operative management. Quarterbacks had the highest incidence of injury; however, this incidence is lower than in previous investigations that evaluated these injuries during the 1980s and 1990s.

Evolving Management of Middle-Third Clavicle Fractures in the National Football League

Background Clavicle fractures have historically been managed nonoperatively. Recent literature suggests a subset of clavicle fractures may be best treated with primary surgical treatment. Purpose To review the National Football League (NFL) experience in the management of middle-third clavicle fractures over a 5-year period. Study Design Case series; Level of evidence, 4. Methods A retrospective review of clavicle fractures that occurred during a 5-season period was obtained from the NFL Injury Surveillance System. A detailed questionnaire was also sent to the medical staff of all 32 NFL teams. Results Nineteen players sustained a middle-third clavicle fracture over the 5-year period. Six fractures were nondisplaced or minimally displaced. All 6 healed at an average time of 7.3 weeks. Thirteen fractures were 100% displaced. Six of the 13 underwent acute surgical fixation that resulted in fracture healing without complication at an average of 8.8 weeks. The remaining 7 players with a completely displaced fracture were initially treated nonoperatively. Three of these 7 healed clinically without sequela at an average of 13.3 weeks after injury; however, 4 players sustained a refracture within 1 year of the initial injury. Conclusion Over the past 5 years, nearly 50% of NFL players with a completely displaced middle-third clavicle fracture were treated successfully with acute surgical fixation without sequela and healed at an average of 8.8 weeks. Three of these players were able to return to play during the same season. In addition, 4 of 7 players initially treated nonoperatively for a completely displaced middle-third clavicle fracture refractured their clavicle within a 1-year period from their initial injury. The 4 players missed an average of 1.5 seasons because of their clavicle injury and subsequent clinical course. Based on this review, it may be reasonable to consider acute surgical treatment of this injury in the NFL player to enable a successful clinical outcome in a predictable time frame.

Treatment of Magnetic Resonance Imaging-Documented Isolated Grade III Lateral Collateral Ligament Injuries in National Football League Athletes

Background Isolated high-grade tears of the lateral collateral ligament (LCL) of the knee are rare, as most injuries are part of a broader pattern of damage to the posterolateral corner. Limited data exist in the literature about the ideal management of isolated LCL injuries, especially in elite-level athletes. Hypothesis Operative and nonoperative treatment of MRI-documented isolated grade III LCL injury can produce equal results in terms of return to play in the National Football League (NFL). Study Design Cohort study; Level of evidence, 3. Methods The NFL Injury Surveillance System was used to identify all players with lateral ligament injuries of the knee from 1994 to 2004. In addition, the medical staffs of all NFL clubs were surveyed about injuries during the same period. Nine players with MRI-documented isolated grade III LCL injuries were identified through this process. The medical staff for each respective player then completed a data questionnaire. Statistics were analyzed using 1-way analysis of variance. Results Four players underwent direct surgical repair of their injuries; they missed an average of 14.5 weeks of play and did not return within the same season. Five players were managed nonoperatively and missed an average of 2.0 weeks (P = .0001). Four of the 5 players in the nonoperative group returned within the same season at an average of 10 days; 1 missed the rest of the season. All 9 players were able to return to play the following season, and played for an average total of 2.8 (operative) and 4.4 (nonoperative) additional seasons (P = .253). Conclusion Nonoperative management of MRI-documented isolated grade III lateral collateral ligament injuries in NFL athletes results in more rapid return to play without subjecting the player to the risks of surgery, while achieving an equal likelihood of return to play at the professional level.

Nonoperative Treatment for Proximal Avulsion of the Rectus Femoris in Professional American Football

Background Avulsion of the rectus femoris origin is a rare injury. The only previous report of this injury in professional American football has been limited to the kicking athlete. Purpose To describe the incidence and treatment of proximal rectus femoris avulsion in the National Football League (NFL). Study Design Case series; Level of evidence, 4. Methods The NFL Injury Surveillance System (NFLISS) was reviewed for any proximal rectus femoris avulsion injuries from 1986 to 2006, including the type and mechanism of injury, player demographics, method of treatment, and time to return to play. The NFL team physicians and trainers were surveyed as to their experience with these injuries as well. Results A total of 11 cases of proximal rectus femoris avulsion were identified starting in 1997. These injuries occurred in athletes in a variety of positions. All of these were treated nonoperatively, and the mean return to play was 69.2 days. Conclusion Rectus femoris avulsions are uncommon injuries in the NFL, occurring about once a year in the entire league (once magnetic resonance imaging facilitated correct diagnosis of these injuries). Conservative treatment of these injuries usually results in return to play after 6 to 12 weeks. Clinical Relevance Proximal avulsions of the rectus femoris can be treated nonoperatively with a high degree of predictability for return to full, unrestricted participation in professional American football.

Hip Injuries and Labral Tears in the National Football League

Background Injuries to the hip account for approximately 10% of all injuries in football, but definitive diagnosis is often challenging. Although these injuries are often uncomplicated contusions or strains, intra-articular lesions are increasingly found to be sources of hip pain. Purpose The objective was to define the incidence and etiologic factors of intra- and extra-articular hip injuries in the National Football League (NFL). Study Design Descriptive epidemiology study. Methods The NFL Injury Surveillance System was used to define all hip-related injuries from 1997 to 2006. Injuries were included if the athlete missed more than 2 days. All hip and groin injuries were included for evaluation. The authors also report on NFL players with intra-articular injuries seen at their institution outside of the NFL Injury Surveillance System. Results There were a total of 23 806 injuries from 1997 to 2006, of which 738 were hip injuries (3.1 %) with an average of 12.3 days lost per injury. Muscle strains were the most common injury. Intra-articular injuries resulted in the most time lost. Contact injuries most likely resulted in a contusion, and noncontact injuries most often resulted in a muscle strain. In the authors’ institutional experience, many of the athletes with labral tears have persistent adductor strains that do not improve despite adequate therapy. Conclusion Hip injuries represent a small but substantial percentage of injuries that occur in the NFL. A majority of these injuries are minor, with a return to play within 2 weeks. Intra-articular injuries are more serious and result in a significant loss of playing time. The “sports hip triad” (labral tear, adductor strain, and rectus strain) is described as a common injury pattern in the elite athlete.

Shoulder Injuries to Quarterbacks in the National Football League

Background Quarterbacks are at risk for shoulder injury secondary to both the throwing motion as well as from contact injury. Objective To delineate the incidence and etiology of shoulder injuries to quarterbacks in the National Football League (NFL). Methods Using the NFL Injury Surveillance System (NFLISS), all reported injuries to quarterbacks between 1980 and 2001 were identified. Results A total of 1534 quarterback injuries were identified with a mean of 18.8 and a median of 6.0 days of playing time lost. The majority of these injuries occurred during a game (83.8%). Passing plays were responsible for 77.4% of all quarterbackrelated injuries. Shoulder injuries were the second most common injury reported (233 or 15.2%), following closely behind head injuries (15.4%). Direct trauma was responsible for 82.3% of the injuries, with acromioclavicular joint sprains being the most common injury overall (40%). Overuse injuries were responsible for 14% of the injuries, the most common being rotator cuff tendinitis (6.1%) followed by biceps tendinitis (3.5%). Conclusion In this review, the vast majority of shoulder injuries in quarterbacks occurred as a result of direct trauma (82.3%), and less than 15% were overuse injuries resulting from the actual throwing motion.

Anterior cruciate ligament injuries in the National Football League: Epidemiology and current treatment trends among team physicians

Purpose: To review the epidemiology of anterior cruciate ligament (ACL) injuries in the National Football League (NFL) and current treatment trends within this population. Type of Study: Descriptive. Methods: Part 1 of this study reviews the data collected in the NFL Injury Surveillance System from 1986 to 1995 with respect to these injuries. Included in this review are the specifics surrounding these injuries such as exposure type (game versus practice), position, mechanism, and playing surface on which the injury occurred. Part 2 of this analysis focuses on present treatment performed on these high-level athletes through a survey that was sent to and completed by all 31 NFL team orthopaedic surgeons. Results: The total number of ACL injuries in this select population has remained constant over the period analyzed. Conclusions: Current preferred treatment technique favors endoscopic patellar tendon autograft reconstruction.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 5 (May-June), 2002: pp 502–509