Rehabilitation and Return to Play Protocols After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review.

BACKGROUND: Rehabilitation after anterior cruciate ligament ACL reconstruction (ACLR) is crucial for safe return to play (RTP) and reducing the chances of a reinjury. Yet, there is no consensus on the ideal functional tests to assess rehabilitation progress in soccer players after ACLR. PURPOSE: The primary objective was to highlight the existing gap in the literature concerning the most effective standardized rehabilitation protocols and testing for facilitating successful RTP among soccer players. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review using PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. Inclusion criteria encompassed original studies (level of evidence 1-4) that examined rehabilitation protocols, metrics of knee rehabilitation, and clinical outcomes after ACLR in soccer players. RESULTS: This review incorporated 23 studies, predominantly retrospective case series, with a total number of 874 soccer players who underwent ACLR and rehabiliation. 5 (21.7%) studies utilized an accelerated rehabilitation protocol, while 7 (30.4%) of studies utilized a criterion-based rehabilitation. A wide heterogeneity of data was extracted including functional tests of rehabilitation and RTP such as strength test batteries, hop test batteries, and movement quality assessments. Of the 23 selected studies, 2 (8.7%) used all 3 test batteries, 8 (34.8%) used 2 test batteries, 12 (52.2%) used 1 test battery, and 1 (4.3%) used 0 of the test batteries. The mean time between surgery and RTP ranged from 3 to 8 months with only 2 (8.7%) studies reporting complications after ACLR. Lastly, out of the total studies examined, 9 (39.1%) assessed patient-reported outcome measures (PROMs), all of which demonstrated significant improvement from the initial assessment to the final follow up. CONCLUSION: Soccer-specific rehabilitation after ACLR lacks standardization. Even though many studies have assessed protocols for optimal RTP and reduced secondary ACL injuries, there is a gap in the literature regarding the most effective protocols and RTP testing. The methodology reported by Kyritsis et al could serve as a foundation for future prospective randomized multicenter studies to establish a standard rehabilitation protocol and enable a successful return to soccer.

Bone bruise vs. non-displaced fracture on MRI: a novel grading system for predicting return-to-play.

OBJECTIVE: To devise an MRI grading scheme for osseous contusion patterns in elite hockey players for predicting return-to-play (RTP). METHODS: A retrospective review was performed to identify traumatic lower extremity osseous injuries in professional hockey players. A total of 28 injuries (17 players) were identified over a 10-year period. All had MRIs acquired at ≥ 1.5 T within a mean interval of 2 days from initial injury. MRIs were retrospectively reviewed by 3 musculoskeletal radiologists for osseous contusion pattern, classified as grade 1 (mild), 2 (moderate), or 3 (severe). Grade 3 contusions were further subdivided by the presence or absence of fracture, defined as discrete cortical disruption on MRI or follow-up CT. RTP was calculated from date of injury to next game played based on game log data. Statistical analysis was performed using ANOVA and post hoc unpaired t test. RESULTS: Mean RTP for grade 1, 2, and 3 injuries was 2.8, 4.5, and 20.3 days, respectively. Grade 3 injuries without and with cortical fractures had mean RTP of 18.3 and 21.4 days, respectively. ANOVA analysis between groups achieved statistical significance (p < 0.001). Post hoc t test demonstrated statistically significant differences between grade 3 and grades 1 (p < 0.001) and 2 (p < 0.001) injuries. There was no statistical difference in RTP between grade 3 subgroups without and with fracture (p = 0.327). CONCLUSION: We propose a novel MRI grading system for assessing severity of osseous contusions and predicting RTP. Clinically, there was no statistically significant difference in RTP between severe osseous contusions and nondisplaced fractures in elite hockey players.

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.

Osteochondral Autograft Transplantation for Proximal Lunate Articular Defects.

BACKGROUND: No consensus treatment option for focal osteochondral defects of the proximal lunate exist in the literature. Surgical management has thus far been limited to salvage procedures such as proximal row carpectomy and partial arthrodesis. CASE DESCRIPTION: We report our experience using the osteochondral autograft transplantation surgery (OATS) procedure in two young, active patients with focal osteochondral defects of the proximal lunate. At mean follow-up of 6 years, sustained improvements in pain, motion, and function were observed. Both patients reported high levels of satisfaction and neither experienced any complications. LITERATURE REVIEW: To our knowledge, this is the first report describing the use of OATS to treat proximal lunate defects. CLINICAL RELEVANCE: OATS is a valuable surgical option for treating focal chondral defects of the proximal lunate, with positive outcomes at greater than 5 years postoperatively. This may be an especially useful technique for younger, active patients, and those wishing to maintain maximum functionality.

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/m(2), 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.

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

UNLABELLED: 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.

Pectoralis major ruptures in professional American football players.

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.

Clinical measurement of patellar tendon: accuracy and relationship to surgical tendon dimensions.

Patellar tendon width and length are commonly used for preoperative planning for anterior cruciate ligament reconstruction (ACLR). In the study reported here, we assessed the accuracy of preoperative measurements made by palpation through the skin, and correlated these measurements with the actual dimensions of the tendons at surgery. Before making incisions in 53 patients undergoing ACLR with patellar tendon autograft, we measured patellar tendon length with the knee in full extension and in 90° of flexion, and tendon width with the knee in 90° of flexion. The tendon was then exposed, and its width was measured with the knee in 90° of flexion. The length of the central third of the tendon was measured after the graft was prepared. Mean patellar tendon length and width with the knee in 90° of flexion were 39 mm and 32 mm, respectively. No clinical difference was found between the estimated pre-incision and surgical widths. However, the estimated pre-incision length with the knee in full extension and in 90° of flexion was significantly shorter than the surgical length. Skin measurements can be used to accurately determine patellar tendon width before surgery, but measurements of length are not as reliable.

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.

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.

Cervical spine injuries in American football.

American football is a high-energy contact sport that places players at risk for cervical spine injuries with potential neurological deficits. Advances in tackling and blocking techniques, rules of the game and medical care of the athlete have been made throughout the past few decades to minimize the risk of cervical injury and improve the management of injuries that do occur. Nonetheless, cervical spine injuries remain a serious concern in the game of American football. Injuries have a wide spectrum of severity. The relatively common 'stinger' is a neuropraxia of a cervical nerve root(s) or brachial plexus and represents a reversible peripheral nerve injury. Less common and more serious an injury, cervical cord neuropraxia is the clinical manifestation of neuropraxia of the cervical spinal cord due to hyperextension, hyperflexion or axial loading. Recent data on American football suggest that approximately 0.2 per 100,000 participants at the high school level and 2 per 100,000 participants at the collegiate level are diagnosed with cervical cord neuropraxia. Characterized by temporary pain, paraesthesias and/or motor weakness in more than one extremity, there is a rapid and complete resolution of symptoms and a normal physical examination within 10 minutes to 48 hours after the initial injury. Stenosis of the spinal canal, whether congenital or acquired, is thought to predispose the athlete to cervical cord neuropraxia. Although quite rare, catastrophic neurological injury is a devastating entity referring to permanent neurological injury or death. The mechanism is most often a forced hyperflexion injury, as occurs when 'spear tackling'. The mean incidence of catastrophic neurological injury over the past 30 years has been approximately 0.5 per 100,000 participants at high school level and 1.5 per 100,000 at the collegiate level. This incidence has decreased significantly when compared with the incidence in the early 1970s. This decrease in the incidence of catastrophic injury is felt to be the result of changes in the rules in the mid-1970s that prohibited the use of the head as the initial contact point when blocking and tackling. Evaluation of patients with suspected cervical spine injury includes a complete neurological examination while on the field or the sidelines. Immobilization on a hard board may also be necessary. The decision to obtain radiographs can be made on the basis of the history and physical examination. Treatment depends on severity of diagnosed injury and can range from an individualized cervical spine rehabilitation programme for a 'stinger' to cervical spine decompression and fusion for more serious bony or ligamentous injury. Still under constant debate is the decision to return to play for the athlete.

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.