Symptomatic Focal Knee Chondral Injuries in National Football League Combine Players Are Associated With Poorer Performance and Less Volume of Play.

PURPOSE: To (1) describe the magnetic resonance imaging (MRI) characteristics of knee chondral injuries identified at the National Football League (NFL) Combine and (2) assess in-game performance of prospective NFL players with previously untreated knee chondral injuries and compare it with matched controls. METHODS: All players with knee chondral injuries identified at the NFL Combine (2009-2015) were retrospectively reviewed. Players with prior knee surgery were excluded. A knee MRI for each player was reviewed; location, modified International Cartilage Repair Society (ICRS) grade (I-IV), and associated compartment subchondral edema were documented. Position, respective NFL Draft pick selection number, games started, played, snap percentage, and position-specific performance metrics during the first 2 NFL seasons were recorded for the injury and injury-free control group composed of players with (1) no prior knee injury, (2) no significant missed time prior to the NFL (≤2 total missed games in college), (3) no history of knee surgery, and (4) drafted in the respective NFL Draft following the NFL Combine. RESULTS: Of the 2,285 players reviewed, 101 (4.4%) had an injury without prior knee surgery. The patella (63.4%) and trochlea (34%) were most commonly affected. Defensive linemen were at highest risk for unrecognized injuries (odds ratio 1.8, P = .015). Players with previously untreated injuries, compared with controls, were picked later (mean pick: 125.8) and played (mean: 23) and started (mean: 10.4) fewer games during the initial 2 NFL seasons (P < .001 for all). Particularly, subchondral bone edema and full-thickness cartilage injuries were associated with fewer games played (P = .003). CONCLUSIONS: The patellofemoral joint was most commonly affected in NFL Combine participants. Previously untreated knee articular injuries in players at the NFL Combine are associated with poorer early NFL performance in comparison to uninjured players. Subchondral bone edema and full-thickness cartilage injury on MRI were associated with fewer games played during the initial NFL career. LEVEL OF EVIDENCE: Level III, case-control study.

Posterior Cruciate Ligament Injuries of the Knee at the National Football League Combine: An Imaging and Epidemiology Study.

PURPOSE: To determine the epidemiology by player position, examination, imaging findings, and associated injuries of posterior cruciate ligament (PCL) injuries in players participating in the National Football League (NFL) Combine. METHODS: All PCL injuries identified at the NFL Combine (2009-2015) were reviewed. Data were obtained from the database organized by the NFL medical personnel for the compilation of the medical and physical performance examination results of NFL Draftees participating in the NFL Combine from 2009 to 2015. Inclusion criteria were any player with clinical findings or a previous surgery consistent with a PCL injury who participated in the NFL Combine. RESULTS: Of the 2,285 players who participated in the NFL Combine between 2009 and 2015, 69 (3%) had evidence of a PCL injury, of which 11 players (15.9%) were managed surgically. On physical examination, 35 players (52%) had a grade II or III posterior drawer. Concomitant injuries were present frequently and included medial collateral ligament (MCL; 42%), anterior cruciate ligament (ACL; 11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. CONCLUSIONS: Three percent of the players at the NFL Combine presented with a PCL injury, with a significant amount being either running backs (14/69, 20.2%) or offensive linemen (14/69, 20.2%). Approximately half of the players with a PCL tear had a residual grade II or III posterior drawer after sustaining a PCL injury. Concomitant injuries were present frequently and included MCL (42%), ACL (11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. For those players with clinical concern for PCL ligamentous laxity, there should be a complete comprehensive workup that includes plain and PCL stress view radiographs, and magnetic resonance imaging. LEVEL OF EVIDENCE: Level IV, case series.

Comprehensive identification of PIP3-regulated PH domains from C. elegans to H. sapiens by model prediction and live imaging.

Phosphoinositide 3-kinase (PI3K) and its product phosphatidylinositol(3,4,5)-trisphosphate (PIP3) control cell growth, migration, and other processes by recruiting proteins with pleckstrin homology (PH) domains and possibly other domains to the plasma membrane (PM). However, previous experimental and structural work with PH domains left conflicting evidence about which ones are PIP3 regulated. Here we used live-cell confocal imaging of 130 YFP-conjugated mouse PH domains and found that 20% translocated to the PM in response to receptor-generated PIP3 production. We developed a recursive-learning algorithm to predict PIP3 regulation of 1200 PH domains from different eukaryotes and validated that it accurately predicts PIP3 regulation. Strikingly, this algorithm showed that PIP3 regulation is specified by amino acids across the PH domain, not just the PIP3-binding pocket, and must have evolved several times independently from PIP3-insensitive ancestral PH domains. Finally, our algorithm and live-cell experiments provide a functional survey of PH domains in different species, showing that PI3K regulation increased from approximately two C. elegans and four Drosophila to 40 vertebrate proteins.

Coaching, Mentorship, and Leadership Lessons Learned from Professional Football.

Coaching, mentorship, and leadership are all paramount for the creation of a championship-winning football team. Looking back and studying the great coaches of professional football provides valuable insight into the qualities and the characteristics they possessed and how that impacted their leadership. Many of the great coaches from this game have instilled team standards and a culture that led to unprecedented success and sprouted into many other great coaches and leaders. Leadership at all levels of an organization is essential to consistently achieve a championship-caliber team.

Core Muscle Injury: Evaluation and Treatment in the Athlete.

BACKGROUND: Pain in the groin region, where the abdominal musculature attaches to the pubis, is referred to as a "sports hernia,""athletic pubalgia," or "core muscle injury" and has become a topic of increased interest due to its challenging diagnosis. Identifying the cause of chronic groin pain is complicated because significant symptom overlap exists between disorders of the proximal thigh musculature, intra-articular hip pathology, and disorders of the abdominal musculature. PURPOSE: To present a comprehensive review of the pathoanatomic features, history and physical examination, and imaging modalities used to make the diagnosis of core muscle injury. STUDY DESIGN: Narrative and literature review; Level of evidence, 4. METHODS: A comprehensive literature search was performed. Studies involving the diagnosis, treatment, and rehabilitation of athletes with core muscle injury were identified. In addition, the senior author's extensive experience with the care of professional, collegiate, and elite athletes was analyzed and compared with established treatment algorithms. RESULTS: The differential diagnosis of groin pain in the athlete should include core muscle injury with or without adductor longus tendinopathy. Current scientific evidence is lacking in this field; however, consensus regarding terms and treatment algorithms was facilitated with the publication of the Doha agreement in 2015. Pain localized proximal to the inguinal ligament, especially in conjunction with tenderness at the rectus abdominis insertion, is highly suggestive of core muscle injury. Concomitant adductor longus tendinopathy is not uncommon in these athletes and should be investigated. The diagnosis of core muscle injury is a clinical one, although dynamic ultrasonography is becoming increasingly used as a diagnostic modality. Magnetic resonance imaging is not always diagnostic and may underestimate the true extent of a core muscle injury. Functional rehabilitation programs can often return athletes to the same level of play. If an athlete has been diagnosed with athletic pubalgia and has persistent symptoms despite 12 weeks of nonoperative treatment, a surgical repair using mesh and a relaxing myotomy of the conjoined tendon should be considered. The most common intraoperative finding is a deficient posterior wall of the inguinal canal with injury to the distal rectus abdominis. Return to play after surgery for an isolated sports hernia is typically allowed at 4 weeks; however, if an adductor release is performed as well, return to play occurs at 12 weeks. CONCLUSION: Core muscle injury is a diagnosis that requires a high level of clinical suspicion and should be considered in any athlete with pain in the inguinal region. Concurrent adductor pathology is not uncommon.

Surgical Release of the Adductor Longus With or Without Sports Hernia Repair Is a Useful Treatment for Recalcitrant Groin Strains in the Elite Athlete.

BACKGROUND: Chronic strain and/or tendinopathy of the adductor longus tendon can be a cause of long-standing groin pain in the elite athlete, resulting in significant time lost from competition. Accurate diagnosis and treatment can expedite return to play. PURPOSE/HYPOTHESIS: To evaluate return to sport and performance in National Collegiate Athletic Association (NCAA) Division I football players and National Football League (NFL) players following adductor longus release with or without sports hernia repair. We hypothesized that adductor release will be an effective method of treatment for recalcitrant groin/adductor pain in these athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A cohort study was performed of all NFL players and NCAA Division I college athletes who had undergone an adductor longus tendon release with or without sports hernia repair by 1 of 2 fellowship-trained orthopaedic surgeons between May 1999 and January 2013. All patients reported groin pain below the inguinal ligament and localized to their adductor longus. Symptoms lasted longer than 10 weeks and limited their ability to effectively perform during sport, as assessed by their coach and self-assessment. Questionnaires were given to all 26 patients to assess long-term surgical outcomes. A subgroup analysis was performed for NFL players, in which "performance scores" were calculated according to individual player statistics while playing. Scores obtained before the diagnosis of chronic adductor longus tendinopathy or strain were compared with those after surgery. Patients with prior abdominal or pelvic surgery, radiographic evidence of degenerative joint disease of the hip, labral tears or femoral acetabular impingement, prostatic or urinary tract disease, or nerve entrapment of the ilioinguinal, genitofemoral, or lateral femoral cutaneous nerves were excluded from the study. RESULTS: A total of 32 athletes underwent an adductor longus tenotomy during the study period. Of these patients, 28 were college- or professional-level athletes who underwent an adductor longus tenotomy, with a mean ± SD follow-up time of 6.2 ± 4.2 years (range, 12-178 months). Of the 32 patients, 20 had a concomitant sports hernia repair in addition to an adductor longus tenotomy. Thirty-one patients (97%) were able to return to their previous sport, and 30 (94%) were able to return at their previous level of play. Thirty patients (94%) reported that they were satisfied with their decision to have surgery. No player complained of weakness or a decrease in running speed or power. Mean return to play was 12 weeks from date of surgery. In the subgroup analysis of 16 NFL players, there were no statistically significant differences for the pre- versus postoperative comparisons of the athlete performance scores (P = .74) and the percentage of the games started versus played (P = .46). After separation of players who had a concomitant hernia repair from players who did not, there was no statistically significant difference in performance scores or percentages of games started. CONCLUSION: In this study of elite athletes, adductor longus tenotomy with or without a concomitant sports hernia repair provided overall acceptable and excellent results. Athletes were able to return to their previous level of athletic competition and performance with consistent relief of groin pain. Return to play in an NFL game averaged 12 weeks following surgery.

Diagnosis of penetrating injuries of the pharynx and esophagus in the severely injured patient.

BACKGROUND: Diagnosis of penetrating pharyngeal and esophageal injuries are difficult when the patient has severe facial injuries, is obese or intubated, and hemodynamically unstable. Radiologic aids may be either unsuitable or unreliable. Videoendoscopy, preferably by the trauma surgeon, affords direct visualization at the bedside and is timely and expeditious. METHODS: Patients included in the study had penetrating injuries to the face/neck or torso. Evaluation began with careful assessment of the trajectory, followed by videoendoscopy and a contrast study. Data collected included the accuracy of diagnosis (compared with anatomic findings), time required to perform the studies, and complications resulting from both tests and repair. RESULTS: Thirty-three patients were included in the study. Contrast study detected all esophageal injuries, but failed to detect any hypopharyngeal injuries particularly in the intubated patients. Videoendoscopy detected all injuries, hypopharyngeal and esophageal in intubated and nonintubated patients. CONCLUSIONS: Radiologic studies should not be used for pharyngeal injuries. Although radiologic studies accurately diagnosed penetrating injuries of the esophagus, it is not as expeditious as videoendoscopy performed by the trauma surgeon. Videoendoscopy should be part of the trauma surgeons' armamentarium.

Effect of Anterior Glenoid Labral Tears and Glenoid Bone Loss at the NFL Combine on Future NFL Performance.

BACKGROUND: Anterior glenohumeral instability is a common abnormality in the young, athletic population, especially in those participating in contact or collision sports. PURPOSE: To examine the effect of anterior labral tears, their associated injuries, and their management on future National Football League (NFL) performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of all NFL Combine participants from 2009 to 2015 was performed using medical and imaging reports compiled at the NFL Combine. These notes and images were reviewed and analyzed for involved structures, associated injuries, and evidence of previous surgical interventions. The respective NFL draft position, number of NFL games played, number of NFL games started, and NFL snap percentage for each player's first 2 seasons were collected and compared with a control group and within subgroups. RESULTS: Of the 2285 players at the NFL Combine between 2009 and 2015, there were 206 (9%) anterior labral tears confirmed by magnetic resonance imaging, 20 of which were bilateral, for a total of 226 affected shoulders. There were 908 players who fit the criteria for inclusion in the control group. Overall, there were no significant differences between players with anterior labral tears and the control players in terms of draft position (P = .259), games played in their first 2 NFL seasons (P = .391), games started in their first 2 NFL seasons (P = .486), or snap percentage in their first (P = .268) and second (P = .757) NFL seasons. In general, sustaining a concomitant injury with an anterior labral tear (superior labrum from anterior to posterior [SLAP] tear, glenoid bone loss, Hill-Sachs lesion, rotator cuff tear, humeral avulsion of the glenohumeral ligament, and anterior tear combined with posterior tear) negatively affected a player's NFL draft position when compared with those with an isolated anterior labral tear (P = .003). There was no significant difference between operative and nonoperative management for anterior labral tears in terms of any performance metric. CONCLUSION: A history of anterior labral tears was not significantly associated with future NFL performance. While players with isolated injuries were drafted significantly earlier than those with concomitant injuries, combined injuries did not affect players' games played, games started, or snap percentage in their first 2 NFL seasons. Glenoid bone loss did significantly decrease draft position; however, the severity of bone loss did not affect draft position, and there were no significant associations between glenoid bone loss and games played, games started, or snap percentage.

The Epidemiology of Ankle Injuries Identified at the National Football League Combine, 2009-2015.

BACKGROUND: American football is a leading cause of sports-related injuries, with the knee, ankle, and shoulder most commonly involved. PURPOSE/HYPOTHESIS: The purpose of this study was to describe the epidemiology, characteristics, and imaging findings of ankle injuries in football players at the National Football League (NFL) Combine and determine the relationship to player position. We hypothesized that there would be a high relative incidence of ankle injuries in these players compared with other sports and that there would be a direct correlation between the incidence of ankle injuries and player position. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective chart review of data collected from NFL Combine participants between 2009 and 2015 was performed. Patient demographics, history, physical examination results, and imaging findings were reviewed. RESULTS: Of 2285 players, 1216 (53.2%) had a history of ankle injuries; of these, 987 (81.2%) had unilateral injuries, while 229 (18.8%) had bilateral injuries (total of 1445 ankles injured). This included 1242 ankle sprains (86.0% of ankle injuries): 417 (33.6% of sprains) high and 930 (74.9%) low. The most common soft tissue injuries were to the anterior talofibular ligament (n = 158, 12.7% of sprains) and syndesmosis (n = 137, 11.0%). Of all players at the NFL Combine with radiographs, 131 (10.9%) had evidence of an ankle fracture, all of which had healed. Magnetic resonance imaging (MRI) identified 66 players (28.9% of players at the combine who underwent MRI) with articular cartilage injuries: 62 involving the talus and 16 involving the tibia. Furthermore, 85 players (37.3% of players with MRI) with tendon injuries were identified: 26 Achilles, 55 peroneal, 3 flexor hallucis longus, and 19 posterior tibial. A total of 611 players (50.6% of players with radiographs) had signs of arthrosis on radiography. Running backs (61.9%), offensive linemen (60.3%), and tight ends (59.4%) had the highest rates of ankle injuries by position, while kickers/punters (23.3%) and long snappers (37.5%) had the lowest. CONCLUSION: Prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine. The rate of these ankle injuries varied by player position: offensive linemen, running backs, and tight ends had the highest overall rates, while special teams players had the lowest. Additional prospective work is needed to determine the impact of prior injuries on future playing career.

Medial Collateral Ligament Injuries Identified at the National Football League Scouting Combine: Assessment of Epidemiological Characteristics, Imaging Findings, and Initial Career Performance.

BACKGROUND: The medial collateral ligament (MCL) is one of the most commonly injured structures in the knee, especially in young athletes. The impact of MCL injury on National Football League (NFL) performance in elite collegiate athletes has not yet been described in the literature. PURPOSE: We aim to (1) describe the prevalence and severity of MCL injuries in NFL Combine participants, (2) detail injury management, and (3) analyze the impact of MCL injury on NFL performance in terms of draft position, games played, games started, and snap percentage. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of all NFL Combine participants from 2009 to 2015 was performed by reviewing medical records and imaging reports from the combine to identify all players with MCL injuries. A control group was developed from the players evaluated at the combine without MCL injury. For each affected knee, the MCL injury was classified by location and severity based on results of magnetic resonance imaging (MRI). Each player's respective NFL draft position, number of NFL games played, number of NFL games started, and NFL snap percentage for the first 2 seasons in the league were collected through the use of NFL.com and Pro-Football-Focus, which are web-based, publicly accessible, comprehensive sports statistics databases. RESULTS: A total of 2285 players participated in the NFL Combine between 2009 and 2015. Three hundred one athletes (13.2%) were identified as having MCL injuries; 36 (12%) of the athletes with MCL injury presented with bilateral injuries, for a total of 337 MCL injuries. Additional soft tissue injury was identified on 187 of 337 (55%) MRIs. Players with a history of MCL injury were more likely to play at least 2 years in the NFL compared with those in the control group (P = .003). Players who had isolated MCL injury performed significantly better compared with athletes who had combined injuries with regard to draft position (P = .034), proportion playing at least 2 seasons in the NFL (P = .022), games played (P = .014), and games started (P = .020) in the first 2 years. No significant difference was found between players who underwent operative versus nonoperative management of their MCL injury. CONCLUSION: A relatively high percentage of players at the NFL Combine had evidence of MCL injury (13%). A prior history of MCL tear had no negative impact on an athlete's NFL performance. Players who had isolated MCL injury performed significantly better compared with athletes who had combined injuries with regard to draft position, proportion playing 2 seasons or more in the NFL, and games played and started in the first 2 years.

Effect of Posterior Glenoid Labral Tears at the NFL Combine on Future NFL Performance.

BACKGROUND: Posterior labral injuries have been recognized as a particularly significant clinical problem in collision and contact athletes. PURPOSE: To evaluate the effect that posterior labral tears have on early National Football League (NFL) performance based on position, associated injuries, and operative versus nonoperative management. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of all participants in the NFL Combine from 2009 to 2015 was performed using medical and imaging reports documented at the combine. Magnetic resonance imaging scans were analyzed for tear location, associated injuries, and evidence of previous surgical interventions. Each player's NFL draft position, as well as number of games played, number of games started, and snap percentage in his first 2 NFL seasons were collected for performance analysis and were compared with a control group of uninjured counterparts. RESULTS: Players with posterior labral tears were selected significantly later in the draft than those in the control group (draft position, 171.6 vs 156.1, respectively; P = .017). Although no single individual position was significantly affected by posterior labral tears, linemen (both offensive and defensive) with posterior labral tears were drafted significantly later than those without tears (draft position, 164.0 vs 137.7, respectively; P = .018) and had a significantly lower percentage of snaps in their first NFL season (23.8% vs 27.7%, respectively; P = .014). Players who underwent surgical management before the combine had a significantly higher percentage of snaps in their second NFL season than those who were managed conservatively (31.4% vs 22.3%, respectively; P = .022). None of the concomitant injuries recorded (superior labral anterior-posterior tears, glenoid bone loss, reverse Hill-Sachs lesions, rotator cuff tears, reverse humeral avulsions of the glenohumeral ligament, and posterior labral tears combined with anterior tears) significantly affected the draft position, number of games played, number of games started, or snap percentage for the cohort as a whole or any specific position. CONCLUSION: Posterior labral tears did negatively and significantly affect early NFL outcomes for collegiate football players across several different metrics, especially among linemen. While operative management did not produce significantly superior performance in most outcome measures, it may allow for better longevity of the shoulder and warrants further investigation. Concomitant shoulder injuries did not significantly affect early NFL outcomes in this cohort.

Meniscectomy and Resultant Articular Cartilage Lesions of the Knee Among Prospective National Football League Players: An Imaging and Performance Analysis.

BACKGROUND: The effect of prior meniscectomy and the resulting reduction in meniscal tissue on a potential National Football League (NFL) player's articular cartilage status and performance remain poorly elucidated. Purpose/Hypothesis: (1) To determine the epidemiology, imaging characteristics, and associated articular cartilage pathology of the knee among players with a previous meniscectomy who were participating in the NFL Combine and (2) to evaluate the effect of these injuries on performance as compared with matched controls. The hypothesis was that players with less meniscal tissue would have worse cartilage status and inferior performance metrics in their first 2 NFL seasons. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All athletes with a history of a meniscectomy and magnetic resonance imaging scan of the knee who participated in the NFL Combine (2009-2015) were identified. Medical records and imaging were analyzed, and surgical history, games missed in college, position played, and draft position were documented. The conditions of the meniscus and cartilage were graded with modified ISAKOS scores (International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine) and ICRS scores (International Cartilage Repair Society), respectively. Players with a previous meniscectomy of at least 10% of total medial or lateral meniscal volume excised (ISAKOS meniscus grade ≤8) and matched controls without a significant pre-Combine injury were similarly evaluated and compared by position of play through analysis of draft position, number of games played and started, and how many eligible plays they participated in (snap percentage) within the first 2 NFL seasons. RESULTS: Of the 2285 players who participated in the NFL Combine (2009-2015), 287 players (322 knees) had a prior meniscectomy (206 lateral, 81 medial). Among these players, 247 (85%) had a total of 249 chondral lesions, most commonly on the lateral femoral condyle (111 lesions, 45%). There was a significant inverse correlation found between the ISAKOS medial and lateral meniscus grade and the corresponding compartment chondral lesion grade ( P = .001). A poorer meniscus score was also associated with worse chondral pathology, especially in the lateral compartment. After controlling for position of play, the injury-free control group had a significantly greater number of total games played and games started and higher snap percentage versus those with a prior meniscectomy of at least 10% volume (ISAKOS meniscus grade ≤8). Players with severe chondral lesions (ICRS grade 4) in the medial and lateral compartments had significantly worse performance metrics when compared with matched controls. CONCLUSION: Previous meniscectomy of at least 10% of total medial or lateral meniscus volume in prospective NFL players was significantly correlated with larger and more severe chondral lesions. Chondral and meniscal defects of the knee were found to result in a significant decrease in objective performance measures during a player's initial NFL career versus matched controls. Given these findings, players with a prior meniscectomy with evidence of chondral damage should be evaluated carefully for their overall functional levels; however, additional work is needed to fully clarify the effect of prior knee meniscal surgery on overall NFL performance.

Jones Fractures Identified at the National Football League Scouting Combine: Assessment of Prognostic Factors, Computed Tomography Findings, and Initial Career Performance.

BACKGROUND: Jones fractures result in subsequent dysfunction and remain an issue for athletes. PURPOSE: To (1) describe the epidemiology, treatment, and impact of Jones fractures identified at the National Football League (NFL) Scouting Combine on players' early careers and (2) establish the value of computed tomography (CT) to determine bony healing after a fracture in prospective players. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All players who attended the combine between 2009 and 2015 were retrospectively reviewed to identify their history of Jones fractures. The playing position, treatment method, and number of missed collegiate games were recorded. The mean overall draft pick number, number of games started and played, snap percentage, and position-specific performance scores (fantasy score) over the first 2 years in the NFL were compared between players with fractures and controls. An imaging classification system was applied based on grading of each quadrant of the fifth metatarsal (plantar, dorsal, medial, lateral), with a score of 0 for not healed or 1 for healed. RESULTS: Overall, the number of Jones fractures identified was 72 in 2285 athletes (3.2%), with all treated via intramedullary screw fixation. The mean overall draft pick number for players with fractures was 111.2 ± 67.9 compared with 99.0 ± 65.9 for controls (P = .12). Performance scores for players with fractures were lower than those for controls across all positions, with a significant difference in running backs (2.6 vs 4.0, respectively; P < .001) and defensive linemen (1.4 vs 2.3, respectively; P = .02). The mean CT score was 2.5 ± 1.3. Of the 32 athletes who underwent imaging, 16 Jones fractures (50.0%) were healed or nearly healed, 12 (37.5%) were partially healed, and 4 (12.5%) showed little or no healing. The plantar cortex demonstrated the least healing (18/32; 56.3%), followed by the lateral cortex (15/32; 46.9%). Players with a mean score <1 were found to have fewer games started (2.7 ± 2.5) than those with 1 to 3 cortices healed (17.4 ± 10.4) or all cortices healed (8.7 ± 11.2). CONCLUSION: Based on CT, 50% of all players with a previous Jones fracture demonstrated incomplete healing. Moreover, position-specific performance scores over the first 2 years of a player's career were lower across all positions for those with fractures compared with controls. Players with CT scores <1 were found to start fewer games and were drafted later than controls.

An age-based approach to dermatologic surgery: Kids are not just little people.

Surgical dermatologic procedures in children pose unique challenges that differ from those in adults. Child and parental anxiety, along with procedural anxiety in adults, necessitate different approaches. Special considerations are reviewed in the application of topical anesthesia and administration of local anesthesia in children as opposed to adults, and the use and safety of general anesthesia in children is highlighted. In addition, management of postprocedural analgesia differs in children, largely due to concern for safety of opioids in children.

Epidemiology of Navicular Injury at the NFL Combine and Their Impact on an Athlete's Prospective NFL Career.

BACKGROUND: Navicular injuries can result in persistent pain, posttraumatic osteoarthritis, and diminished performance and function. PURPOSE: To determine the epidemiology of navicular fracture in players participating in the National Football League (NFL) Scouting Combine and evaluate the impact of a navicular injury on the NFL draft position and NFL game play compared with matched controls. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were collected on players who previously sustained a navicular injury and participated in the NFL Combine between 2009 and 2015. The epidemiology of navicular injury was determined through an evaluation of the number of injuries, surgeries, and collegiate games missed as well as the position played, a physical examination, the surgical technique, and imaging findings. Players with a previous navicular injury (2009-2013) were compared with a set of matched controls. NFL performance outcomes included the draft position, career length ≥2 years, and number of games played and started within the first 2 years. RESULTS: Between 2009 and 2015, 14 of 2285 (0.6%) players were identified as having sustained a navicular injury. A total of 11 of 14 (79%) athletes had sustained an overt navicular fracture, while 3 of 14 (21%) were diagnosed with stress reactions on magnetic resonance imaging. Eight patients who sustained a navicular fracture underwent surgery. There was evidence of ipsilateral talonavicular arthritis in 75% of players with a navicular fracture versus only 60% in the uninjured foot (odds ratio, 1.3; P = .04). Fifty-seven percent of players with navicular injury (72.7% of fractures) were undrafted versus 30.9% in the control group (P = .001). Overall, 28.6% of players with navicular fracture played ≥2 years in the NFL compared with 69.6% in the control group (P = .02). CONCLUSION: A previous navicular fracture results in a greater risk of developing posttraumatic osteoarthritis. Although only a low prevalence of navicular injury in prospective NFL players was noted, players with these injuries had a greater probability of not being drafted and not competing in at least 2 NFL seasons when compared with matched controls without an injury history to the NFL Combine.

Epidemiology and Outcomes of Lisfranc Injuries Identified at the National Football League Scouting Combine.

BACKGROUND: Lisfranc injuries are challenging to treat and may have a detrimental effect on athletic performance. PURPOSE: (1) Determine the epidemiological characteristics of Lisfranc injuries at the annual National Football League (NFL) Scouting Combine, (2) define player positions at risk for these injuries, and (3) evaluate the impact that these injuries and radiographic findings have on NFL draft position and performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All players who sustained a Lisfranc injury prior to Combine evaluation between 2009 and 2015 were evaluated. The epidemiological characteristics, player positions affected, treatment methods, and number of missed collegiate games were recorded. Radiographic outcomes were analyzed via Combine radiograph findings, while NFL performance outcomes were assessed for all Lisfranc injuries (2009-2013) compared with matched controls in the first 2 years of play. RESULTS: A total of 41 of 2162 (1.8%) Combine participants were identified with Lisfranc injuries, of whom 26 of 41 (63.4%) were managed operatively. Players who underwent surgery were more likely to go undrafted compared with players managed nonoperatively (38.5% vs 13.3%, operative vs nonoperative management, respectively; P = .04) and featured a worse NFL draft pick position (155.6 vs 109; P = .03). Lisfranc-injured players when compared with controls were noted to have worse outcomes in terms of NFL draft position (142 vs 111.3, Lisfranc-injured players vs controls, respectively; P = .04), NFL career length 2 years or longer (62.5% vs 69.6%; P = .23), and number of games played (16.9 vs 23.3; P = .001) and started (6.8 vs 10.5; P = .08) within the first 2 years of their NFL career. Radiographs demonstrated that 17 of 41 (41.5%) athletes had residual Lisfranc joint displacement greater than 2 mm compared with the contralateral foot. Lisfranc-injured athletes with greater than 2 mm residual displacement, when compared with matched controls, had worse draft position (156.9 vs 111.2 for Lisfranc-injured players vs controls, respectively; P = .009) and fewer games played (14.4 vs 23.3; P = .001) and started (3.1 vs 10.5; P = .03). Moreover, athletes with greater than 2 mm residual displacement featured worse outcomes across all assessed NFL variables versus athletes with residual displacement of 2 mm or less. CONCLUSION: Lisfranc injuries identified at the NFL Combine have an adverse effect on an NFL athlete's draft status, draft position, and overall play during initial NFL seasons. In particular, residual displacement of the Lisfranc joint has a detrimental effect on the first 2 seasons of NFL play and may lead to long-lasting negative effects on the athlete's career.

The Latarjet Procedure at the National Football League Scouting Combine: An Imaging and Performance Analysis.

BACKGROUND: The Latarjet procedure is commonly performed in the setting of glenoid bone loss for treatment of recurrent anterior shoulder instability; however, little is known regarding the outcomes of this procedure in elite American football players. PURPOSE: (1) Determine the prevalence, clinical features, and imaging findings of elite college football athletes who present to the National Football League (NFL) Combine with a previous Latarjet procedure and (2) describe these athletes' performance in the NFL in terms of draft status and initial playing time. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: After review of all football players who participated in the NFL Combine from 2009 to 2016, any player with a previous Latarjet procedure was included in this study. Medical records, position on the field, and draft position were recorded for each player. In addition, imaging studies were reviewed to determine fixation type, hardware complications, and status of the bone block. For those players who were ultimately drafted, performance was assessed based on games played and started, total snaps, and percentage of eligible snaps in which the player participated during his rookie season. RESULTS: Overall, 13 of 2617 (<1%) players at the combine were identified with a previous Latarjet procedure. Radiographically, 8 of 13 (61%) showed 2-screw fixation, while 5 of 13 (39%) had 1 screw. Of the 13 players, 6 (46%) players demonstrated hardware complications. All players had evidence of degenerative changes on plain radiographs, with 10 (77%) graded as mild, 1 (8%) as moderate, and 2 (15%) as severe according to the Samilson Prieto classification. Six of the 13 (46%) players went undrafted, while the remaining 7 (54%) were drafted; however, no player participated in more than half of the plays for which he was eligible during his rookie season. CONCLUSION: Only a small percentage of players at the NFL Combine (<1%) had undergone a Latarjet procedure. High rates of postoperative complications and radiographically confirmed degenerative change were observed. Athletes who had undergone a Latarjet procedure demonstrated a variable amount of playing time, but none participated in more than half of their eligible plays during their rookie season.

Epidemiology of Injuries Identified at the NFL Scouting Combine and Their Impact on Performance in the National Football League: Evaluation of 2203 Athletes From 2009 to 2015.

BACKGROUND: At the annual National Football League (NFL) Scouting Combine, the medical staff of each NFL franchise performs a comprehensive medical evaluation of all athletes potentially entering the NFL. Currently, little is known regarding the overall epidemiology of injuries identified at the combine and their impact on NFL performance. PURPOSE: To determine the epidemiology of injuries identified at the combine and their impact on initial NFL performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All previous musculoskeletal injuries identified at the NFL Combine from 2009 to 2015 were retrospectively reviewed. Medical records and imaging reports were examined. Game statistics for the first 2 seasons of NFL play were obtained for all players from 2009 to 2013. Analysis of injury prevalence and overall impact on the draft status and position-specific performance metrics of each injury was performed and compared with a position-matched control group with no history of injury or surgery. RESULTS: A total of 2203 athletes over 7 years were evaluated, including 1490 (67.6%) drafted athletes and 1040 (47.2%) who ultimately played at least 2 years in the NFL. The most common sites of injury were the ankle (1160, 52.7%), shoulder (1143, 51.9%), knee (1128, 51.2%), spine (785, 35.6%), and hand (739, 33.5%). Odds ratios (ORs) demonstrated that quarterbacks were most at risk of shoulder injury (OR, 2.78; P = .001), while running backs most commonly sustained ankle (OR, 1.39; P = .040) and shoulder injuries (OR, 1.55; P = .020) when compared with all other players. Ultimately, defensive players demonstrated a greater negative impact due to injury than offensive players, with multiple performance metrics significantly affected for each defensive position analyzed, whereas skilled offensive players (eg, quarterbacks, running backs) demonstrated only 1 metric significantly affected at each position. CONCLUSION: The most common sites of injury identified at the combine were (1) ankle, (2) shoulder, (3) knee, (4) spine, and (5) hand. Overall, performance in the NFL tended to worsen with injury history, with a direct correlation found between injury at a certain anatomic location and position of play. Defensive players tended to perform worse compared with offensive players if injury history was present.