Peter F. Deluca

Hamstring Injuries in Professional Football Players: Magnetic Resonance Imaging Correlation With Return to Play

Background: Magnetic resonance imaging (MRI) allows for detailed evaluation of hamstring injuries; however, there is no classification that allows prediction of return to play. Purpose: To correlate time for return to play in professional football players with MRI findings after acute hamstring strains and to create an MRI scoring scale predictive of return to sports. Study Design: Descriptive epidemiologic study. Methods: Thirty-eight professional football players (43 cases) sustained acute hamstring strains with MRI evaluation. Records were retrospectively reviewed, and MRIs were evaluated by 2 musculoskeletal radiologists, graded with a traditional radiologic grade, and scored with a new MRI score. Results were correlated with games missed. Results: Players missed 2.6 ± 3.1 games. Based on MRI, the hamstring injury involved the biceps femoris long head in 34 cases and the proximal and distal hamstrings in 25 and 22 cases, respectively. When < 50% of the muscle was involved, the average number of games missed was 1.8; if > 75%, then 3.2. Ten players had retraction, missing 5.5 games. By MRI, grade I injuries yielded an average of 1.1 missed games; grade II, 1.7; and grade III, 6.4. Players who missed 0 or 1 game had an MRI score of 8.2; 2 or 3 games, 11.1; and 4 or more games, 13.9. Conclusions: Rapid return to play (< 1 week) occurred with isolated long head of biceps femoris injures with < 50% of involvement and minimal perimuscular edema, correlating to grade I radiologic strain (MRI score < 10). Prolonged recovery (missing > 2 or 3 games) occurs with multiple muscle injury, injuries distal to musculotendinous junction, short head of biceps injury, > 75% involvement, retraction, circumferential edema, and grade III radiologic strain (MRI score > 15). Clinical Relevance: MRI grade and this new MRI score are useful in determining severity of injury and games missed—and, ideally, predicting time missed from sports.

Ulnar collateral ligament injuries of the elbow in professional football quarterbacks

BACKGROUND Ulnar collateral ligament (UCL) injuries of the elbow can cause significant pain and disability in the overhead thrower. Most studies in the literature have focused on baseball players and demonstrated that surgical reconstruction is the most reliable way to allow these athletes to return to their previous level of performance. Little is known about whether or not surgical reconstruction is necessary for other types of elite throwing athletes. We hypothesize that professional football quarterbacks with UCL injuries of the elbow can return to competitive play after nonoperative management. METHODS The NFL Injury Surveillance System (NFLISS) was reviewed for any UCL injuries of the elbow in quarterbacks from 1994 to 2008, including the type and mechanism of injury, player demographics, method of treatment, and time to return to play. RESULTS A total of 10 cases of UCL injuries in quarterbacks were identified starting in 1994. Nine cases were treated nonoperatively and the mean return to play was 26.4 days. CONCLUSION UCL injuries of the elbow are uncommon injuries in professional quarterbacks. This group of overhead athletes can be successfully treated nonoperatively, in contrast to baseball players, who more commonly need surgical reconstruction to return to competitive play. The difference between the 2 groups of overhead athletes is most likely secondary to biomechanics and demand.

Mean subaxial space available for the cord index as a novel method of measuring cervical spine geometry to predict the chronic stinger syndrome in American football players.

OBJECT The chronic stinger syndrome is a distinct entity from acute stingers and has been shown to have its own pathophysiology that, unlike acute stingers, may reflect long-standing geometrical changes of the subaxial spinal canal and chronic irritation/degeneration of the exiting nerve root complex. There is no method available, however, to accurately predict these symptoms in athletes. The mean subaxial cervical space available for the cord (MSCSAC) is a novel alternative to the Torg ratio for predicting neurological symptoms caused by cervical spondylosis in elite athletes. It is the goal of this study to determine critical values for this measurement index and to retrospectively correlate those values to neurological symptoms. METHODS Magnetic resonance images obtained in 103 male athletes participating in the 2005 and 2006 National Football League Scouting Combine and a control group of 42 age-matched male nonathletes were retrospectively reviewed. The Torg ratio and SAC values were calculated in triplicate at each cervical level from C3-6 by using lateral radiographs and midsagittal T2-weighted MR images of the cervical spine, respectively. These values were then averaged for each individual to produce mean subaxial cervical Torg ratio (MSCTR) and MSCSAC values. Receiver operating characteristic curves were constructed for each measurement technique and were compared based on their respective area under the curves (AUCs). RESULTS The MSCSAC difference between athletes with and without chronic stingers was statistically significant (p < 0.01). The difference between athletes with and without chronic stingers compared with controls was also statistically significant (p < 0.001 and p < 0.001, respectively). The AUC for the MSCSAC was 0.813, which was significantly greater than the AUC for both the MSCTR (p = 0.0475) and the individual Torg ratio (p = 0.0277). The MSCTR had the second largest AUC (0.676) and the conventional method of measuring individual Torg ratio values produced the lowest AUC (0.661). It was found that using the MSCSAC with a critical value of 5.0 mm produced a sensitivity of 80% and a negative likelihood ratio of 0.23 for predicting chronic stingers. Lowering the cutoff value to 4.3 mm for the MSCSAC resulted in a possible confirmatory test with a specificity of 96% and a positive likelihood ratio of 13.25. CONCLUSIONS A critical value of 5.0 mm for the MSCSAC provides the clinician with a screening test for chronic stingers and anything < 4.3 mm adds additional confidence as a confirmatory test. These results are approximately 20% more accurate than the classic Torg ratio based on our AUC analysis. It was found that measuring the spinal geometry throughout the length of the subaxial cervical spine produced a more reliable method by which to predict neurological symptoms than the traditional approach of measuring individual levels. This shows that the underlying pathogenesis of the chronic stinger syndrome is best characterized as a process that involves the entire subaxial region uniformly.

Anterior Cruciate Ligament Injuries in National Football League Athletes From 2010 to 2013: A Descriptive Epidemiology Study.

Background: There is a high incidence of anterior cruciate ligament (ACL) injuries among National Football League (NFL) athletes; however, the incidence of reinjury in this population is unknown. Purpose: This retrospective epidemiological study analyzed all publicly disclosed ACL tears occurring in NFL players between 2010 and 2013 to characterize injury trends and determine the incidence of reinjury. Study Design: Descriptive epidemiological study. Methods: A comprehensive online search identified any NFL player who had suffered an ACL injury from 2010 to 2013. Position, playing surface, activity, and date were recorded. Each player was researched for any history of previous ACL injury. The NFL games database from USA Today was used to determine the incidence of ACL injuries on artificial turf and grass fields. Databases from Pro Football Focus and Pro Football Reference were used to determine the injury rate for each position. Results: NFL players suffered 219 ACL injuries between 2010 and 2013. Forty players (18.3%) had a history of previous ACL injury, with 27 (12.3%) retears and 16 (7.3%) tears contralateral to a previous ACL injury. Five players (2.28%) suffered their third ACL tear. Receivers (wide receivers and tight ends) and backs (linebackers, fullbacks, and halfbacks) had significantly greater injury risk than the rest of the NFL players, while perimeter linemen (defensive ends and offensive tackles) had significantly lower injury risk than the rest of the players. Interior linemen (offensive guards, centers, and defensive tackles) had significantly greater injury risk compared with perimeter linemen. ACL injury rates per team games played were 0.050 for grass and 0.053 for turf fields (P > .05). Conclusion: In this retrospective epidemiological study of ACL tears in NFL players, retears and ACL tears contralateral to a previously torn ACL constituted a substantial portion (18.3%) of total ACL injuries. The significant majority of ACL injuries in players with a history of previous ACL injury were retears. Skilled offensive players and linebackers had the greatest injury risk, and significantly more ACL tears occurred among interior linemen than perimeter linemen. The month of August had the highest incidence of ACL injuries, probably because of expanded roster sizes at that point in the NFL season.

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.

Outcomes of Arthroscopic Repair of Panlabral Tears of the Glenohumeral Joint

Background: Combined lesions of the glenoid labrum involving tears of the anterior, posterior, and superior labrum have been infrequently reported in the literature. Purpose: To evaluate the clinical outcomes of arthroscopic repair of these lesions in a general population using validated scoring instruments, presence of complications, and need for revision surgery. Study Design: Case series; Level of evidence, 4. Methods: Fifty-eight patients who had arthroscopic labral repair of tears involving the anterior, posterior, and superior labrum (defined as a panlabral repair) were identified at our institution by retrospective review. All patients underwent arthroscopic labral repair with suture anchor fixation by a uniform approach and with a standardized postoperative protocol. Forty-four patients had a minimum 16-month postoperative follow-up. Outcomes were assessed postoperatively by the American Shoulder and Elbow Surgeons (ASES) score and the Penn Shoulder score. Complications were also documented, including need for revision surgery. Results: The mean age at the time of surgery was 32 years (range, 15-55 years) in the 44 patients. Presenting shoulder complaints included pain alone (40%), instability alone (14%), or pain and instability (45%). Mean number of anchors per repair was 7.9 (range, 5-12). Mean follow-up was 42 months (range, 16-78 months). Mean ± standard deviation ASES score at final follow-up was 90.1 ± 17.7 (range, 22-100), and mean Penn Shoulder score was 90.2 ± 15.3 (range, 38-100). Three of the 4 patients with outcome scores of 70 or less at final follow-up had undergone prior surgery. Thirteen postoperative complications (30%) occurred, with 3 (7%) requiring a second surgery. Five patients (11%) had an instability event following panlabral repair, but only 1 of these patients (2%) required revision surgery for a recurrent labral tear. Conclusion: Combined tears of the anterior, posterior, and superior glenoid labrum represent a small but significant portion of labral injuries. Arthroscopic repair of these injuries can be performed with good postoperative outcomes and a low rate of recurrent labral injury.

Pneumomediastinum from sports-related trauma: key findings and recommendations.

Pneumomediastinum can result from blunt chest trauma in sports. Diagnosis is made using chest radiography. The natural history of isolated pneumomediastinum is benign; however, it can be associated with more serious injuries, such as disruption of the tracheobronchial tree or a perforated digestive viscus. Patients with isolated pneumomediastinum should be monitored with serial chest radiographs. Patients may return to full activity once their chest radiographs have returned to normal, they exhibit no symptoms, and they have regained their stamina.

Pectoralis Major Ruptures in Professional American Football Players

Abstract Background: Pectoralis major injuries are an infrequent shoulder injury that can result in pain, weakness, and deformity. These injuries may occur during the course of an athletic competition, including football. The purpose of this study was to determine the incidence of pectoralis major ruptures in professional football players and time lost from the sport following injury. We hypothesized that ruptures most frequently occur during bench-press strength training. Methods: The National Football League Injury Surveillance System was reviewed for all pectoralis major injuries in all players from 2000 to 2010. Details regarding injury setting, player demographics, method of treatment, and time lost were recorded. Results: A total of 10 injuries—complete ruptures—were identified during this period. Five of the 10 were sustained in defensive players, generally while tackling. Nine occurred during game situations, and 1 occurred during practice. Specific data pertinent to the practice injury was not available. No rupture occurred during weight lifting. Eight ruptures were treated operatively, and 2 cases did not report the method of definitive treatment. The average days lost was 111 days (range, 42–189). The incidence was 0.004 pectoralis major ruptures during the 11-year study period. Conclusions: Pectoralis major injuries are uncommon while playing football. In the National Football League, these injuries primarily occur not during practice or while bench pressing but rather during games. When pectoralis major ruptures do occur, they are successfully treated operatively. Surgery may allow for return to full sports participation. Level of Evidence: IV, case series.

Results of ACL reconstruction with tibial Retroscrew fixation: Comparison of clinical outcomes and tibial tunnel widening

Abstract Summary. ACL reconstruction with the RetroScrew™ shows superior clinical outcomes compared to historical Achilles allograft studies with antegrade screws. Addition of antegrade screw augmentation to retrograde fixation causes an increase in tibial tunnel widening. Introduction. In traditional antegrade screw fixation of Anterior cruciate ligament (ACL) soft tissue allografts, the screw is secured in the opposite direction of graft tension, potentially altering the appropriate tension on the graft. The RetroScrew (Arthrex) is a bioabsorbable screw placed in a retrograde fashion, potentially improving the tension of the graft by placing the screw in a proximal-to-distal direction. In addition, the RetroScrew theoretically decreases tibial tunnel widening by closing the aperture of the tibial tunnel, which prevents ingress of synovial fluid. Early tunnel expansion has been implicated due to excessive transverse and longitudinal graft motion. The clinical effects of tunnel expansion have yet to be fully understood. The purpose of this study is to assess the clinical results and tunnel width after ACL soft tissue fixation in the tibia with the RetroScrew. Methods. Fifty-nine patients who underwent ACL reconstruction performed by two surgeons using the RetroScrew device returned for postoperative evaluation at an average of 25 months following surgery with a minimum follow-up of 12 months. Clinical evaluation, SF-36, IKDC and KT-1000 scores were recorded, and knee radiographs were used to measure tibial tunnel widening. Thirty-five patients had backup antegrade screw fixation in conjunction with the RetroScrew, and 24 patients had RetroScrew fixation alone. The results were compared to two previously reported studies on ACL reconstruction with Achilles tendon allograft that used antegrade screws. Results. The average IKDC score was 87 (range: 44–100), with mean KT-1000 side-to-side difference of 1.2 mm (range: 0–5 mm). Tibial tunnel widening was 4.93 mm (SD 3.32) on AP radiographs and 4.40 mm (SD 2.72) on lateral radiographs greater than the native tunnel drilling. Patients with additional backup fixation had significantly more tunnel widening than patients without backup fixation (P < 0.05). There was one failure based on KT-1000 measurements. When compared to previous studies using ACL allografts, RetroScrew patients had statistically superior Lachman exams, KT-1000 side-to-side differences and decreased tibial tunnel widening (P < 0.05) when antegrade fixation was excluded. Conclusion. Patients who underwent Achilles allograft ACL reconstruction with the RetroScrew had improved clinical results compared to historical controls using antegrade fixation. Tibial tunnel widening was increased when using additional antegrade screw fixation, suggesting that the amount of bioabsorbable material within the tibial tunnel was related to the degree of tunnel widening.

Venous Thromboembolism Within Professional American Sport Leagues

Background: Numerous reports have described players in professional American sports leagues who have been sidelined with a deep vein thrombosis (DVT) or a pulmonary embolism (PE), but little is known about the clinical implications of these events in professional athletes. Purpose: To conduct a retrospective review of injury reports from the National Hockey League (NHL), Major League Baseball (MLB), the National Basketball Association (NBA), and the National Football League (NFL) to take a closer look at the incidence of DVT/PE, current treatment approaches, and estimated time to return to play in professional athletes. Study Design: Descriptive epidemiology study. Methods: An online search of all team injury and media reports of DVT/PE in NHL, MLB, NBA, and NFL players available for public record was conducted by use of Google, PubMed, and SPORTDiscus. Searches were conducted using the professional team name combined with blood clot, pulmonary embolism, and deep vein thrombosis. Results: A total of 55 venous thromboembolism (VTE) events were identified from 1999 through 2016 (NHL, n = 22; MLB, n = 16; NFL, n = 12; NBA, n = 5). Nineteen athletes were reported to have an upper extremity DVT, 15 had a lower extremity DVT, 15 had a PE, and 6 had DVT with PE. Six athletes sustained more than 1 VTE. The mean age at time of VTE was 29.3 years (range, 19-42 years). Mean (±SD) time lost from play was 6.7 ± 4.9 months (range, 3 days to career end). Seven athletes did not return to play. Players with upper extremity DVT had a faster return to play (mean ± SD, 4.3 ± 2.7 months) than those with lower extremity DVT (5.9 ± 3.8 months), PE (10.8 ± 6.8 months), or DVT with PE (8.2 ± 2.6 months) (F = 5.69, P = .002). No significant difference was found regarding time of return to play between sports. Conclusion: VTE in professional athletes led to an average of 6.7 months lost from play. The majority of athletes were able to return to play after a period of anticoagulation or surgery. Those with an upper extremity DVT returned to play faster than those with other types of VTE. Further study is needed to look into modifiable risk factors for these events and to establish treatment and return-to-play guidelines to ensure the safety of these athletes.