Distal Tibiofibular Syndesmosis Injuries in the National Football League (NFL): A Spectrum of Pathology That Correlates With Time to Return to Full Participation.

BACKGROUND: Studies routinely evaluate high ankle sprains in isolation, but recent data suggest that these injuries are often associated with concomitant pathology, potentially influencing return to full participation. HYPOTHESIS: In National Football League (NFL) players, isolated high ankle sprains are rare and syndesmosis injuries with concomitant pathology will result in increased time to return to full participation. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: Distal tibiofibular syndesmosis injuries sustained by NFL players between 2017 and 2019 were identified through NFL Injury Surveillance Database queries and verified with video analysis. Each injury underwent a comprehensive magnetic resonance imaging (MRI) review. Regression modeling was utilized to explore the influence of numerous imaging findings on time to return to full participation. RESULTS: There were 83 external rotation ankle injuries involving the syndesmosis. Isolated distal tibiofibular syndesmosis injuries were rare (n = 11; 13%) and more often associated with other ligamentous injury (deltoid ligament and lateral ligamentous complex) and/or fractures. Regression modeling resulted in clustering of 3 injury pattern groups for time to return to full participation across numerous imaging findings: syndesmosis injury-fracture combinations (250 days [interquartile range [IQR,] 142-266 days]), syndesmosis injury with complete deep deltoid tear or acute diastasis (175 days [IQR, 20-248 days]), and all other syndesmosis injuries (27 days [IQR, 18-46 days]). CONCLUSION: In NFL athletes with external rotation ankle injuries, isolated distal tibiofibular syndesmosis injuries were rare and more often associated with concomitant pathology. Time to return to full participation was affected by an associated fracture and complete deep deltoid ligament tear or diastasis but no other relevant MRI variables such as lateral ligament complex involvement or the presence of osteochondral lesions or bone contusions.

Epidemiology of Stingers in the National Football League, 2015-2019.

BACKGROUND: Transient traumatic neuropraxia of either the brachial plexus or cervical nerve root(s) is commonly described as a "stinger" or "burner" by the athlete. Stingers in American Football commonly occur acutely as isolated injuries; however, concomitant injuries, including cervical spine pathologies, have also been reported. HYPOTHESIS: Among National Football League (NFL) athletes, the incidence rate of stingers is higher during the regular season than during the preseason and among positions with high velocity impacts such as running backs, linebackers, defensive backs, and receivers. STUDY DESIGN: Retrospective epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: Aggregation of all in-game injuries with a clinical impression of "neck brachial plexus stretch" or "neck brachial plexus compression" entered into the NFL injury surveillance database through the centralized league-wide electronic medical record system over 5 years (2015-2019 seasons). Incidence rates per player-play were calculated and reported. RESULTS: A total of 691 in-game stingers occurred during the study period, with a mean of 138.2 per year. Average single-season injury risk for incident stinger was 3.74% (95% CI, 3.46%-4.05%). The incidence rate was higher during regular season games than during preseason games (12.26 per 100,000 player-plays [11.30-13.31] vs 8.87 [7.31-10.76], P < 0.01, respectively). The highest reported stinger incidence rates were among running backs and linebackers (both >15 per 100,000 player-plays). Among stingers, 76.41% did not miss time. Of those that resulted in time lost from football activities, mean time missed due to injury was 4.79 days (range, 3.17-6.41 days). Concomitant injuries were relatively low (7.09%). CONCLUSION: In-game stinger incidence was stable across the study period and occurred most frequently in running backs and linebackers. Stingers were more common during the regular season, and most players did not miss time. Concomitant injuries were relatively rare. CLINICAL RELEVANCE: An improved understanding of the expected time loss due to stinger and concomitant injuries may provide insight for medical personnel in managing these injuries.

Determining the True Incidence of Glenohumeral Instability Among Players in the National Football League: An Epidemiological Study of Non-Missed Time Shoulder Instability Injuries.

Background: Shoulder instability encompasses a spectrum of glenohumeral pathology ranging from subluxation to dislocation. While dislocation frequently leads to removal from play, athletes are often able to play through subluxation. Previous research on glenohumeral instability among athletes has largely focused on missed-time injuries, which has likely disproportionately excluded subluxation injuries and underestimated the overall incidence of shoulder instability. Purpose: To describe the epidemiology of shoulder instability injuries resulting in no missed time beyond the date of injury (non-missed time injuries) among athletes in the National Football League (NFL). Study Design: Descriptive epidemiology study. Methods: The NFL's electronic medical record was retrospectively reviewed to identify non-missed time shoulder instability injuries during the 2015 through 2019 seasons. For each injury, player age, player position, shoulder laterality, instability type, instability direction, injury timing, injury setting, and injury mechanism were recorded. For injuries that occurred during games, incidence rates were calculated based on time during the season as well as player position. The influence of player position on instability direction was also investigated. Results: Of the 546 shoulder instability injuries documented during the study period, 162 were non-missed time injuries. The majority of non-missed time injuries were subluxations (97.4%), occurred during games (70.7%), and resulted from a contact mechanism (91.2%). The overall incidence rate of game-related instability was 1.6 injuries per 100,000 player-plays and was highest during the postseason (3.5 per 100,000 player-plays). The greatest proportion of non-missed time injuries occurred in defensive secondary players (28.4%) and offensive linemen (19.8%), while kickers/punters and defensive secondary players had the highest game incidence rates (5.5 and 2.1 per 100,000 player-plays, respectively). In terms of direction, 54.3% of instability events were posterior, 31.9% anterior, 8.5% multidirectional, and 5.3% inferior. Instability events were most often anterior among linebackers and wide receivers (50% and 100%, respectively), while posterior instability was most common in defensive linemen (66.7%), defensive secondary players (58.6%), quarterbacks (100.0%), running backs (55.6%), and tight ends (75.0%). Conclusion: The majority of non-missed time shoulder instability injuries (97.4%) were subluxations, which were likely excluded from or underreported in previous shoulder instability studies due to the inherent difficulty of detecting and diagnosing shoulder subluxation.

Lower Extremity Strains in the US National Football League, 2015-2019.

BACKGROUND: Lower extremity (LEX) strains, including hamstring, quadriceps, adductor, and calf strains, are among the most common injuries in sports. These injuries lead to high burden, resulting in significant missed participation time. PURPOSE: To describe the incidence of LEX strains in professional American football. STUDY DESIGN: Descriptive epidemiology study. METHODS: This study included all players who played in ≥1 National Football League (NFL) game or sustained a LEX strain during participation in the 2015-2019 seasons. LEX strain frequency was calculated by setting (game, practice, conditioning), timing in season (offseason, preseason, regular season, postseason), and roster position. Game incidence rates were calculated for season, roster position, and play type. LEX strains were identified in the standardized leaguewide electronic health record (n = 32 teams). RESULTS: Across 5 years, 5780 LEX strains were reported among 2769 players (1-year risk, 26.7%; 95% CI, 26.0%-27.3%); 69% (n = 4015) resulted in time loss. Among all LEX strains, 54.7% were hamstring (n = 3163), 24.1% adductor (n = 1393), 12.6% calf (n = 728), 8.3% quadriceps (n = 477), and 0.3% multiple muscle groups (n = 19). Most were reported during preseason practices (n = 1076; 27%) and regular season games (n = 1060; 26%). The 2-week period of training camp practices comprised 19% of all time-loss strains. Among game injuries, preseason games had the highest rate of LEX strain (2.9/10,000 player-plays; 95% CI, 2.6-3.2). Defensive secondary players accounted for the highest proportion of time-loss LEX strains (27%; n = 1082). In games, punt plays had nearly twice the injury rate of kickoff plays (14.9/1000 plays [95% CI, 13.1-17.0] vs 7.5/1000 plays [95% CI, 6.2-8.9], respectively) and >3 times the rate of pass plays (4.3/1000 plays; 95% CI, 4.0-4.7) and run plays (2.6/1000 plays; 95% CI, 2.3-2.9). In aggregate, LEX strains led to an estimated 16,748 participation days missed each year and a median 12 days missed per injury. CONCLUSION: LEX strains affected 1 in 4 NFL players each year, resulting in a high burden of injury in terms of time lost from practice and competition. Safe return to the NFL season during training camp and reduction of injuries during regular season games are key focuses for future injury reduction.

MRI Findings Associated With Anterior Cruciate Ligament Tears in National Football League Athletes.

Background: Anterior cruciate ligament (ACL) tears are a high-frequency injury requiring a lengthy recovery in professional American football players. Concomitant pathology associated with ACL tears as identified on magnetic resonance imaging (MRI) is not well understood in these athletes. Purpose: To describe the MRI findings of concomitant injuries associated with ACL tears among athletes in the National Football League (NFL). Study Design: Cross-sectional study; Level of evidence, 3. Methods: Of 314 ACL injuries in NFL athletes from 2015 through 2019, 191 complete MRI scans from the time of primary ACL injury were identified and reviewed by 2 fellowship-trained musculoskeletal radiologists. Data were collected on ACL tear type and location, as well as presence and location of bone bruises, meniscal tears, articular cartilage pathology, and concomitant ligament pathology. Mechanism data from video review were linked with imaging data to assess association between injury mechanism (contact vs noncontact) and presence of concomitant pathology. Results: Bone bruises were evident in 94.8% of ACL tears in this cohort, most often in the lateral tibial plateau (81%). Meniscal, additional ligamentous, and/or cartilage injury was present in 89% of these knees. Meniscal tears were present in 70% of knees, lateral (59%) more than medial (41%). Additional ligamentous injury was present in 71% of all MRI scans, more often a grade 1/2 sprain (67%) rather than a grade 3 tear (33%), and most often involving the medial collateral ligament (MCL) (57%) and least often the posterior cruciate ligament (10%). Chondral damage was evident in 49% of all MRI scans, with ≥1 full-thickness defect in 25% of all MRI scans, most often lateral. Most (79%) ACL tears did not involve direct contact to the injured lower extremity. Direct contact injuries (21%) were more likely to have a concomitant MCL tear and/or medial patellofemoral ligament injury and less likely to have a medial meniscal tear. Conclusion: ACL tears were rarely isolated injuries in this cohort of professional American football athletes. Bone bruises were almost always present, and additional meniscal, ligamentous, and chondral injuries were also common. MRI findings varied by injury mechanism.

Return to Full Participation Following Concussion in the National Football League, 2015 Through 2020.

OBJECTIVE: Quantify days missed, games missed, injury burden, and time to return to full participation (RTFP) among National Football League (NFL) players who sustained a concussion. DESIGN: Retrospective cohort study. SETTING: 2015 through 2020 NFL seasons. PARTICIPANTS: National Football League players diagnosed with a concussion from 2015 to 2020. INTERVENTIONS: National Football League-mandated graduated RTFP protocol. MAIN OUTCOME MEASURES: Days missed, games missed, burden, and time to RTFP, overall and by position. RESULTS: An annual average of 3639 player-days of participation and 255 games were missed across NFL because of concussion. Concussed players missed a median of 9 days (mean = 15.0), a relatively stable metric over 6 years, with slight variation by position. Offensive linemen, tight ends, running backs, and linebackers missed the most days per concussion; defensive secondary, offensive linemen, and wide receivers sustained the highest injury burden. Postconcussion, 59% of players missed one or more scheduled games. Among players concussed in a Sunday game, 38% played in a Sunday game one week later. CONCLUSIONS: The 9-day median time missed post-concussion may be related to emphasis on graduated phase-based concussion management. No concussed player returned to competition on the day of injury, and less than 40% participated in games the following week. Further work is needed to better understand characteristics of concussions that take longer to return and movement through stages of return.

Factors Associated With the Mechanism of ACL Tears in the National Football League: A Video-Based Analysis.

BACKGROUND: The factors associated with anterior cruciate ligament (ACL) injury mechanism in professional American football players are not well-understood. HYPOTHESIS: It was hypothesized that football-related and player-specific factors, such as position and body mass index (BMI), are associated with ACL injury mechanism in these athletes. STUDY DESIGN: Descriptive epidemiology study. METHODS: Videos of ACL tears occurring in National Football League (NFL) games over 6 consecutive seasons from 2014 to 2019 were reviewed by 2 orthopaedic surgeons who specialize in sports medicine. For each injury, the role of contact (direct contact [contact to the injured knee/lower extremity], indirect contact [contact not involving the injured knee/lower extremity], or no contact) as well as playing situation and lower extremity position were recorded. Additional player characteristics, timing of injury, and surface information were obtained from NFL game-day and injury database statistics. RESULTS: Of the 140 ACL tears, a minority occurred via direct contact to the injured lower extremity (30%), although this varied by position. Just over two-thirds (70%) of ACL tears in offensive linemen occurred via direct contact to the injured lower extremity, while wide receivers had no direct contact ACL tears. Elevated BMI was associated with a greater likelihood of ACL tears occurring via direct contact (53% in players with BMI ≥35 kg/m2 vs 24% in players with BMI <35 kg/m2; P = <.01). Rookies had the lowest percentage of direct contact ACL tears (18%; P = .22). ACL tears that occurred during the middle 8 weeks of the regular season resulted more often from direct contact (38%; P = .06). ACL tears that occurred in the third quarter were the most likely to occur via direct contact (44%), while those that occurred in the fourth quarter were the least likely to occur via direct contact (13%; P < .01). CONCLUSION: Although most NFL players sustained ACL tears via a noncontact mechanism (ie, through indirect or no contact), players with an elevated BMI, especially on the offensive line, were more likely to injure their ACL through direct contact. Position-dependent variance in injury mechanism may help guide injury prevention efforts in these athletes.

Epidemiology of Shoulder Instability in the National Football League.

BACKGROUND: Shoulder instability is a common and potentially debilitating injury among collision sport athletes that can lead to long-term damage of the glenohumeral joint. Limited data exist regarding instability among elite athletes in the National Football League (NFL). PURPOSE: To describe the epidemiology of shoulder instability in the NFL from 2012 through 2017. STUDY DESIGN: Descriptive epidemiology study. METHODS: The NFL's injury database was reviewed for shoulder instability injuries resulting in missed time during the study inclusion dates. Injuries were classified by type and direction, as well as timing, setting, and mechanism. Median missed time was determined for the different types and directions of instability. Incidence rates for game-related injuries were calculated based on timing during the season and player position. Finally, the relationship between player position and instability direction was assessed. RESULTS: During the 6-year study period, 355 players sustained 403 missed-time shoulder instability injuries. Most injuries occurred during games (65%) via a contact mechanism (85%). The overall incidence rate of game-related instability was 3.6 injuries per 100,000 player-plays and was highest during the preseason (4.9 per 100,000 player-plays). The defensive secondary position accounted for the most injuries, but quarterbacks had the highest incidence rate in games (5.5 per 100,000 player-plays). Excluding unspecified events (n = 128; 32%), 70% (n = 192) of injuries were subluxations and 30% (n = 83) were dislocations; 75% of dislocations were anterior, while subluxations were more evenly distributed between the anterior and posterior directions (45% vs 52%, respectively). Players missed substantially more time after dislocation compared with subluxation (median, 47 days vs 13 days, respectively). When instability direction was known, the majority of instability events among quarterbacks and offensive linemen were posterior (73% and 53%, respectively), while anterior instability was most common for all other positions. CONCLUSION: Shoulder instability is a common injury in the NFL and can result in considerable missed time. Dislocations occur less frequently than subluxations but lead to greater time lost. While most dislocations are anterior, more than half of subluxations are posterior, which is likely the result of repetitive microtrauma to the posterior capsulolabral complex sustained during sport-specific motions such as blocking. The risk of instability varies by player position, and position may also influence instability direction.

Fluoroquinolone Antibiotics and Tendon Injury in Adolescents.

OBJECTIVES: To estimate the association between fluoroquinolone use and tendon injury in adolescents. METHODS: We conducted an active-comparator, new-user cohort study using population-based claims data from 2000 to 2018. We included adolescents (aged 12-18 years) with an outpatient prescription fill for an oral fluoroquinolone or comparator broad-spectrum antibiotic. The primary outcome was Achilles, quadricep, patellar, or tibial tendon rupture identified by diagnosis and procedure codes. Tendinitis was a secondary outcome. We used weighting to adjust for measured confounding and a negative control outcome to assess residual confounding. RESULTS: The cohort included 4.4 million adolescents with 7.6 million fills for fluoroquinolone (275 767 fills) or comparator (7 365 684) antibiotics. In the 90 days after the index antibiotic prescription, there were 842 tendon ruptures and 16 750 tendinitis diagnoses (crude rates 0.47 and 9.34 per 1000 person-years, respectively). The weighted 90-day tendon rupture risks were 13.6 per 100 000 fluoroquinolone-treated adolescents and 11.6 per 100 000 comparator-treated adolescents (fluoroquinolone-associated excess risk: 1.9 per 100 000 adolescents; 95% confidence interval -2.6 to 6.4); the corresponding number needed to treat to harm was 52 632. For tendinitis, the weighted 90-day risks were 200.8 per 100 000 fluoroquinolone-treated adolescents and 178.1 per 100 000 comparator-treated adolescents (excess risk: 22.7 per 100 000; 95% confidence interval 4.1 to 41.3); the number needed to treat to harm was 4405. CONCLUSIONS: The excess risk of tendon rupture associated with fluoroquinolone treatment was extremely small, and these events were rare. The excess risk of tendinitis associated with fluoroquinolone treatment was also small. Other more common potential adverse drug effects may be more important to consider for treatment decision-making, particularly in adolescents without other risk factors for tendon injury.

Epidemiology of Anterior Cruciate Ligament Tears in the National Football League.

BACKGROUND: Anterior cruciate ligament (ACL) tears are common in contact athletics and have a significant effect on the athletic performance and well-being of affected players. The prevalence, timing, and characteristics of ACL tears in National Football League (NFL) athletes are lacking. PURPOSE: To define the epidemiology of ACL tears among NFL athletes. STUDY DESIGN: Descriptive epidemiology study. METHODS: This retrospective study includes all ACL injuries entered into the NFL injury database through the centralized leaguewide electronic health record system for the 2015-2019 seasons. RESULTS: A total of 314 ACL injuries occurred during the 5-year study period, with a mean of 62 per year. The overall 1-season injury risk of an NFL player sustaining an ACL injury was 1.9% (95% CI, 1.7%-2.1%). Most ACL injuries occurred during games (n = 199), with a higher rate observed in the preseason games as compared with the regular season games (6.1 vs 2.7 per 10,000 player-plays; P < .01). NFL players with ≤3 of experience had a higher preseason injury rate (9.57 ACL tears per 1000 player-seasons) than those with ≥4 years of experience (5.12 ACL tears per 1000 player-seasons; P < .01). NFL athletes playing on special teams had the highest rate of ACL injuries (7.6 per 10,000 player-plays) in comparison with all other player positions. CONCLUSION: ACL injury incidence was fairly consistent across all years studied and occurred more frequently in players with ≤3 years of NFL experience. Tears were more common during games, special teams play, and the preseason.

Sports Performance and Injury Research: Methodologic Limitations and Recommendations for Future Improvements.

Evidence-based research has resulted in incredible advances in sports medicine and is an important component of minimizing injury risk. Such research is similarly important when applied to care delivery to athletes after injury. For research into injury reduction and treatment outcomes to be most impactful, however, the methods must be of sufficient rigor to generate high-quality evidence. Two recent trends in sports injury research have led to specific concerns about evidence quality: 1) use of athletic performance metrics as an injury or treatment outcome and 2) use of publicly available data for injury or treatment research.

Oral contraceptive use and anterior cruciate ligament injury: comparison of active comparator new user cohort and case-control study designs.

BACKGROUND: This study further investigates a protective association between oral contraceptive (OC) use and anterior cruciate ligament (ACL) injury noted in prior case-control studies. METHODS: Active comparator new user cohort analysis of women aged 13-45 years in the United States from the IBM MarketScan Commercial Claims and Encounters database who newly-initiated low-dose OCs (exposed) or underwent intrauterine device (IUD) insertion (comparison group) from 2000 to 2014. Women were followed for ACL injury starting 90 days after OC initiation or IUD insertion until OC or IUD discontinuation or end of continuous enrollment. Adjusted hazard ratios (adjHR) and 95% confidence intervals (CI) were estimated controlling for age. Secondary analysis replicated previously-published case-control studies assessing "ever" versus "never" OC use over 1- and 5-year periods among women who underwent ACL reconstruction compared to age-matched controls. RESULTS: In the cohort analysis, 2,370,286 women initiated OCs and 621,798 underwent IUD insertion. There were 3571 (0.15%) ACL injuries during an average 370.6 days of continuous OC use and 1620 (0.26%) during an average 590.5 days of IUD use. No difference in risk of ACL injury was observed between OC initiators and IUD users (adjHR = 0.95; 95%CI 0.89, 1.01). The case-control analysis replicated the slight protective association observed in prior studies over a 5-year period (OR = 0.90; 95%CI 0.85, 0.94). CONCLUSIONS: This cohort study suggests no association between OC use and ACL injury, while the case-control study suggested bias from uncontrolled confounding and selection factors may have influenced previous findings that suggested a protective association between OC use and ACL injury.

Hip Arthroscopy in Patients Aged 40 Years and Older: Greater Success With Labral Reconstruction Compared With Labral Repair.

PURPOSE: To assess the outcomes of complete, primary, arthroscopic hip labral reconstruction among patients aged 40 years and older compared with those who underwent primary labral repair and compared with patients aged 30 to 39 years who underwent complete, primary labral reconstruction. METHODS: We recruited all patients who underwent arthroscopic labral reconstruction between March 2010 and June 2015 and were aged 30 to 65 years or who underwent arthroscopic labral repair between June 2009 and June 2015 and were aged 40 to 65 years. The modified Harris Hip Score (mHHS), Lower Extremity Function Score, and visual analog scale score for average pain were collected preoperatively and at minimum 2-year follow-up. Failure was defined as the need for revision ipsilateral hip surgery. The rate of conversion to total hip arthroplasty (a subset of failure) was assessed separately. RESULTS: A total of 363 hips in 343 patients met the inclusion criteria. Follow-up was available for 312 hips (86.0%), and the average time to follow-up was 4.2 years (range, 2.0-8.5 years). After adjustment for differences in follow-up time between groups, failure was 3.29 times more likely for hips in the repair group aged 40 years and older than for hips in the reconstruction group aged 40 years and older (relative rate, 3.29; 95% confidence interval, 1.25-8.69; P = .02), and there was no difference in the failure rate for hips in the reconstruction group aged 40 years and older compared with hips in the reconstruction group aged 30 to 39 years (relative rate, 0.58; 95% confidence interval, 0.18-1.89; P = .37). The rate of conversion to total hip arthroplasty was not meaningfully different between the 3 groups. Among hips for which treatment did not fail, average improvement in the mHHS measured 35 points and both labral reconstruction groups saw a greater mHHS improvement than the labral repair group of patients aged 40 years and older (P = .01 and P < .01). CONCLUSIONS: Labral reconstruction led to a lower failure rate, greater average improvement in the mHHS, and equivalent postoperative patient-reported outcome scores compared with labral repair among patients aged 40 years and older in this study population, and the outcomes of labral reconstruction were similar between patients aged 40 years and older and those aged 30 to 39 years. Complete labral reconstruction may be particularly advantageous in patients aged 40 years and older. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Ankle Sprains in the National Basketball Association, 2013-2014 Through 2016-2017.

BACKGROUND: Ankle sprains are one of the most common injuries in basketball. Despite this, the incidence and setting of ankle sprains among elite basketball players are not well described. PURPOSE: To describe the epidemiology of ankle sprains among National Basketball Association (NBA) players. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All players on an NBA roster for ≥1 NBA game (preseason, regular season, or playoffs) during the 2013-14 through 2016-17 seasons were included. Data were collected with the NBA electronic medical record system. All NBA teams used the electronic medical record continuously throughout the study period to record comprehensive injury data, including onset, mechanism, setting, type, and time lost. Game incidence rates were calculated per 1000 player-games and per 10,000 player-minutes of participation, stratified by demographic and playing characteristics. RESULTS: There were 796 ankle sprains among 389 players and 2341 unique NBA player-seasons reported in the league from 2013-14 through 2016-17. The overall single-season risk of ankle sprain was 25.8% (95% CI, 23.9%-28.0%). The majority of ankle sprains occurred in games (n = 565, 71.0%) and involved a contact mechanism of injury (n = 567, 71.2%). Most ankle sprains were lateral (n = 638, 80.2%). The incidence of ankle sprain among players with a history of prior ankle sprain in the past year was 1.41 times (95% CI, 1.13-1.74) the incidence of those without a history of ankle sprain in the past year (P = .002). Fifty-six percent of ankle sprains did not result in any NBA games missed (n = 443); among those that did, players missed a median of 2 games (interquartile range, 1-4) resulting in a cumulative total of 1467 missed player-games over the 4-season study period. CONCLUSION: Ankle sprains affect approximately 26% of NBA players on average each season and account for a large number of missed NBA games in aggregate. Younger players and players with a history of ankle sprain have elevated rates of incident ankle sprains in games, highlighting the potential benefit for integrating injury prevention programs into the management of initial sprains. Research on basketball- and ankle-specific injury prevention strategies could provide benefits.

Time to Return to School After 10 Common Orthopaedic Surgeries Among Children and Adolescents.

BACKGROUND: Return to school among adolescents is often overlooked in orthopaedic outcome studies. The purpose was to measure the time missed from school after 10 common orthopedic surgeries. METHODS: Patients, 5 to 19 years old enrolled in elementary, middle, or high school, who underwent treatment for fixation of type III supracondylar humerus fracture, midshaft femur fracture fixation, isolated anterior cruciate ligament reconstruction, isolated partial menisectomy, adolescent idiopathic scoliosis fusion, closed reduction of both-bone forearm fracture, arthroscopic Bankart repair, hip arthroscopy with femoroacetabular impingement correction, limb length discrepancy correction, or surgical fixation of slipped capital femoral epiphysis during the 2014/2015 and 2015/2016 school years were identified for this Institutional Review Board-approved study. All patients were contacted after surgery to determine date of return to school, number of days in session, and number of school days missed. RESULTS: Two hundred six patients met the inclusion criteria for this study. Mean age at time of surgery was 13.0±3.8 years. There were 105 males (51%). Mean time to return to school overall was 13.0±15.2 days. Very few students (n=9; 4%) did not miss any school days during recovery from the procedure of interest. The average number of days missed from school for males was 6.6 days compared with 8.4 days in females (P=0.20). There was no difference between patients aged 5 to 12 years compared with those aged 13 to 19 years (7.1 vs. 7.7 d, respectively; P=0.69). On average, patients who underwent closed reduction of a both-bone forearm fracture returned to school the quickest following surgery (3.4±1.2 d) and missed the least amount of in-session school days (1.9±0.9 d), and those who underwent adolescent idiopathic scoliosis fusion were out of school the longest (42.3±21.4 d) and missed the greatest number of in-session school days (27.6±14.7 d). CONCLUSIONS: Information regarding average time missed from school for 10 common orthopaedic surgeries can be used by clinicians to counsel patients and their families regarding expected recovery time. LEVEL OF EVIDENCE: Level IV.

Epidemiology of Ankle Sprains and Chronic Ankle Instability.

OBJECTIVE: To provide a focused overview of the existing literature on the epidemiology of acute ankle sprains (lateral, medial, and high/syndesmotic) with an emphasis on incidence studies from the United States. In addition, we provide a brief overview of chronic ankle instability (CAI), posttraumatic osteoarthritis, and injury prevention to contribute to our understanding of the epidemiology of these injuries and the current state of the science on ankle sprains and ankle instability in sports medicine. BACKGROUND: Acute ankle sprains are one of the most common musculoskeletal injuries, with a high incidence among physically active individuals. Additionally, acute ankle sprains have a high recurrence rate, which is associated with the development of CAI. Understanding the epidemiology of these injuries is important for improving patients' musculoskeletal health and reducing the burden of lower limb musculoskeletal conditions. DESCRIPTION: Acute ankle-sprain incidence rates are summarized among the general population, as well as among physically active populations, including organized athletics and military personnel, with a focus on incidence in the United States. The link between a prior ankle sprain and a future acute ankle sprain is described. We also discuss the association between the incident ankle sprain and adverse, long-term outcomes such as CAI and posttraumatic osteoarthritis. Finally, we summarize injury-prevention successes and future directions for research and prevention. CLINICAL APPLICATIONS: This information is useful for health care providers to understand the expected incidence rates of acute ankle sprains, be aware of the association between ankle sprains and negative short- and long-term outcomes, and be familiar with existing injury-prevention programs.

Allograft Augmentation of Hamstring Anterior Cruciate Ligament Autografts Is Associated With Increased Graft Failure in Children and Adolescents.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction in adolescents is commonly performed with hamstring tendon autografts. Small graft diameter is one risk factor for graft failure and options to upsize the autologous hamstring graft include allograft augmentation and tripling one or both of the hamstring tendons. PURPOSE: To evaluate the association of upsized hamstring graft constructs and graft rupture after ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review was performed of patients 19 years of age and younger who underwent hamstring autograft ACL reconstruction with or without soft tissue allograft augmentation from 2012 to 2016. All patients were skeletally mature or had less than 2 years of growth remaining. Graft constructs included 4-strand doubled semitendinosus and gracilis autograft (4-STG), 5-strand tripled semitendinosus and doubled gracilis autograft (5-STG), and 6-strand doubled gracilis and semitendinosus autograft augmented with a soft tissue allograft (6-STGAllo). The primary outcome measure was graft rupture. RESULTS: A total of 354 patients with a mean age of 15.3 years (range, 10-19 years) were included. Graft constructs included 4-STG (198 knees), 5-STG (91 knees), and 6-STGAllo (65 knees). The average diameter of the graft constructs was 8.3 mm for 4-STG, 8.9 mm for 5-STG, and 9.2 mm for 6-STGAllo ( P < .001). The mean follow-up was 26 months (range, 6-56 months). There were 50 (14%) graft ruptures and 24 (7%) contralateral ACL tears. The graft failure rates were 14% for 4-STG, 12% for 5-STG, and 20% for 6-STGAllo ( P = .51). The average time to graft failure was 16 months (range, 2-40 months). After adjusting for age and graft size, patients who had allograft-augmented grafts (6-STGAllo) had 2.6 (95% CI, 1.02, 6.50) times the odds of graft rupture compared with 4-STG. There was no significant difference in failure rate between patients who had 5-STG grafts compared with 4-STG (OR, 1.2; 95% CI, 0.5, 2.7). CONCLUSION: ACL reconstruction with hamstring tendon autografts augmented with allografts has a significantly increased risk of graft rupture compared with comparably sized hamstring tendon autografts. In situations where the surgeon harvests an inadequately sized 4-strand autograft, we recommend obtaining a larger graft diameter by tripling the semitendinosus rather than augmenting with an allograft.

The Establishment and Refinement of the National Basketball Association Player Injury and Illness Database.

The National Basketball Association (NBA; also referred to as "the league") has established a centralized, audited electronic medical record system that has been linked with external sources to provide a platform for robust research and to allow the NBA to conduct player health and safety reviews. The system is customized and maintained by the NBA and individual teams as part of the employment records for each player and is deployed uniformly across all 30 teams in the league, thereby allowing for standardized data on injuries, illnesses, and player participation in NBA games and practices. The electronic medical record data are enriched by linkage with other league external data sources that provide additional information about injuries, players, game and practice participation, and movement. These data linkages allow for the assessment of potential injury trends, development of injury-prevention programs, and rule changes, with the ultimate goal of improving player health and wellness. The purpose of this article is to describe this NBA injury database, including the details of data collection, data linkages with external data sources, and activities related to reporter training and data quality improvement.

Trends in Incidence of ACL Reconstruction and Concomitant Procedures Among Commercially Insured Individuals in the United States, 2002-2014.

BACKGROUND:: Few population-based descriptive studies on the incidence of anterior cruciate ligament (ACL) reconstruction and concomitant pathology exist. HYPOTHESIS:: Incidence of ACL reconstruction has increased from 2002 to 2014. STUDY DESIGN:: Descriptive clinical epidemiology study. LEVEL OF EVIDENCE:: Level 3. METHODS:: The Truven Health Analytics MarketScan Commercial Claims and Encounters database, which contains insurance enrollment and health care utilization data for approximately 158 million privately insured individuals younger than 65 years, was used to obtain records of ACL reconstructions performed between 2002 and 2014 and any concomitant pathology using Current Procedures Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes. The denominator population was defined as the total number of person-years (PYs) for all individuals in the database. Annual rates were computed overall and stratified by age, sex, and concomitant procedure. RESULTS:: There were 283,810 ACL reconstructions and 385,384,623 PYs from 2002 to 2014. The overall rate of ACL reconstruction increased 22%, from 61.4 per 100,000 PYs in 2002 to 74.6 per 100,000 PYs in 2014. Rates of isolated ACL reconstruction were relatively stable over the study period. However, among children and adolescents, rates of both isolated ACL reconstruction and ACL reconstruction with concomitant meniscal surgery increased substantially. Adolescents aged 13 to 17 years had the highest absolute rates of ACL reconstruction, and their rates increased dramatically over the 13-year study period (isolated, +37%; ACL + meniscal repair, +107%; ACL + meniscectomy, +63%). Rates of isolated ACL reconstruction were similar for males and females (26.1 vs 25.6 per 100,000 PYs, respectively, in 2014), but males had higher rates of ACL reconstruction with concomitant meniscal surgery than females. CONCLUSION:: Incidence rates of isolated ACL reconstruction and rates of concomitant meniscal surgery have increased, particularly among children and adolescents. CLINICAL RELEVANCE:: A renewed focus on adoption of injury prevention programs is needed to mitigate these trends. In addition, more research is needed on long-term patient outcomes and postoperative health care utilization after ACL reconstruction, with a focus on understanding the sex-based disparity in concomitant meniscal surgery.

Fundamentals of Sports Analytics.

Recently, the importance of statistics and analytics in sports has increased. This review describes measures of sports injury and fundamentals of sports injury research with a brief overview of some of the emerging measures of sports performance. We describe research study designs that can be used to identify risk factors for injury, injury surveillance programs, and common measures of injury risk and association. Finally, we describe measures of physical performance and training and considerations for using these measures. This review provides sports medicine clinicians with an understanding of current research measures and considerations for designing sports injury research studies.