Matthew J. Matava

Quadriceps and hamstring injuries occur frequently in football and are generally treated conservatively. While return to competition following hamstring strains is relatively quick, a high rate of injury recurrence highlights the importance of targeted rehabilitation and conditioning. This review describes the clinical manifestations of thigh-related soft-tissue injuries seen in football players. Two of these-muscle strains and contusions-are relatively common, while a third condition-the Morel-Lavallée lesion-is a rare, yet relevant injury.

American football has become one of the most popular sports in the United States. Despite the millions of players at all levels of competition who gain the physical, social, and psychological rewards that football provides, many interested stakeholders continue to ask, “Is football safe?” Although there are only approximately 1,700 players on National Football League (NFL) rosters, the injuries they sustain have garnered the most attention—and criticism—from the national media. Increased public awareness of the injury potential football possesses has led to an open debate and a major shift in public sentiment over the past 5 years. Although no sport is perfectly safe, the question is whether it can be made relatively safe and if the long-term consequences are worth the risk. This article reviews the methods by which one sports league—the NFL—has used advances in medical technology and injury surveillance to improve the health and safety of its players.

Purpose: To evaluate the time‐zero load‐to‐failure strength of 4 different constructs used to repair medial meniscal root avulsions. Methods: Sixty fresh‐frozen cadaveric knees with a mean age of 74 years were used for this study. Each knee was dissected to isolate the attachment of the posterior root of the medial meniscus to the tibial plateau. An Instron machine (Instron, Norwood, MA) with a custom‐designed clamp was used to avulse the intact posterior meniscal root in 12 control specimens. An additional 48 specimens were tested after transection of the native meniscal root to evaluate the pullout strength of 4 different repair constructs using No. 0 FiberWire suture (Arthrex, Naples, FL): a single suture (n = 12), a double suture (n = 12), a loop stitch (n = 12), and a locking loop stitch (n = 12). Analysis of variance was used to compare load to failure and stiffness of all 4 groups; pair‐wise, between‐group differences were also assessed. Results: Repair failure occurred most commonly by suture pullout in 94% of the specimens in the repair groups. For the controls, failure occurred most commonly at the meniscus‐clamp interface. Failure load was highest for the control group (mean, 359.5 ± 168 N), followed in descending order by the locking loop stitch (191.4 ± 45.1 N), loop stitch (119.6 ± 55.0 N), double suture (96.2 ± 51.4 N), and single suture (58.2 ± 29.6 N). The control group was significantly stronger than 3 of the experimental groups (single suture [95% CI, 3.8 to 11.3], double suture [95% CI, 2.1 to 6.4], and loop stitch [95% CI, 2.0 to 4.5]; P < .0001) but not the locking loop stitch ( P = .003; 95% CI, 1.2 to 3.2). The locking loop stitch was significantly stronger than the single suture ( P < .0001; 95% CI, 2.0 to 5.4) and double suture ( P = .003; 95% CI, 1.2 to 2.9). The locking loop stitch was significantly stiffer than the single suture ( P < .0001; 95% CI, 3.8 to 20.3), double suture ( P < .0001; 95% CI, 2.0 to 9.8), and loop stitch ( P = .03; 95% CI, 1.1 to 5.5) but not significantly different from the control group ( P = .93; 95% CI, 0.3 to 1.9). Age and gender had no effect on pullout strength. Conclusions: The results of this study show that the locking loop stitch provided time‐zero load‐to‐failure strength that most closely approximated the strength of the native meniscal root in addition to being significantly stronger and stiffer than 3 other commonly used repair methods. The true strength of the native meniscal root is unknown based on limitations with our testing methodology. Clinical Relevance: The locking loop stitch exhibited the highest load to failure and stiffness of the 4 fixation methods tested, despite the fact that none of the fixation methods replicated the strength of the intact meniscal root. It is currently unknown what strength of fixation is required for healing of meniscal root repairs.

The tibial tubercle–trochlear groove (TT-TG) distance and trochlear structure have become important radiographic measurements in the evaluation and management of patients with patellar instability. Many orthopaedic surgeons, however, do not have access to musculoskeletal radiologists and therefore must make such measurements independently. To determine the intra- and interobserver reliability in the measurement of the TT-TG distance and the determination of the trochlear dysplasia index (TDI) between musculoskeletal radiologists and orthopaedic surgeons. Cohort study (diagnosis); Level of evidence, 3. Magnetic resonance imaging (MRI) was obtained from 63 patients with the clinical diagnosis of patellar instability (instability group) and from 53 patients without patellar instability (control group). Three radiologists and 2 orthopaedic surgeons blinded to the group assignment independently measured the TT-TG distance and determined the TDI. Each MRI was measured on 2 occasions separated by at least 1 week. Intraclass correlation coefficients (ICCs) were calculated to determine the intra- and interobserver reliability. The instability and control groups were similarly stratified across age, sex, affected knee, athletic level, and body mass index. The mean TT-TG distances were 18.2 ± 5.6 mm and 13.7 ± 5.6 mm for the instability and control groups, respectively (P < .001). The mean TDI for the instability and control groups was 2.1 ± 1.6 mm and 4.6 ± 1.3 mm, respectively (P < .001). There was almost perfect intraobserver reliability for both the TT-TG distance and TDI measurements between the 2 time points for all observers (ICCs: ≥0.86 [TT-TG distance], ≥0.88 [TDI]). The interobserver reliability was also almost perfect between the orthopaedic surgeons and radiologists for both the TT-TG distance (ICC, 0.85 [95% CI, 0.82-0.88]) and TDI (ICC, 0.84 [95% CI, 0.79-0.88]). The results of this study suggest that the intra- and interobserver reliability in the MRI measurement of the TT-TG distance and TDI is high for both orthopaedic surgeons and musculoskeletal radiologists. In addition, the TT-TG distance may be lower than previously thought in patients with patellar instability.

Background: Anterior cruciate ligament (ACL) reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel placement. Hypothesis: Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (MARS) database. Each case included the patient’s history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-part questionnaire dealing with each surgeon’s training and practice, as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon’s opinion as to the causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK). Results: The 10 reviewers have been in practice an average of 14 years and have performed at least 25 ACL reconstructions per year, and 9 were fellowship trained in sports medicine. There was wide variability in agreement among knee experts as to the specific causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, interobserver agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK = 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17). Conclusion: This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction.

Ects of this procedure and to identify issues to emphasize in patient education. Methods: This study utilized a forty-three-question survey designed to measure an individual’s knowledge base and perception of ACL reconstruction with regard to the anatomy, function, indications, operative technique, risks, recovery time, and overall benefits of the procedure. Eligible individuals were between fifteen and sixty years of age. Study participants were recruited from an academic orthopaedic sports medicine clinic, a collegiate athletic training room, and various public venues. Results: A total of 210 individuals (106 men and 104 women) with a mean age of thirty were surveyed. Educational level of the respondents varied widely. Twenty-seven percent of the respondents were employed in a health-care setting. Sixty-five percent of the respondents rated their ACL knowledge level as “little” or “none.” Participants’ self-perception of ACL knowledge was highly correlated with their survey scores on questions with a specific correct answer (p < 0.001). Almost one-third thought that surgical treatment involved repair of the torn ligament rather than reconstruction. Over half (56%) of the respondents preferred an autograft for ligament reconstruction, compared with 4% who preferred an allograft. The ability to return to sports after ACL surgery was the most important concern, followed by the risk of developing osteoarthritis. Conclusions: There is wide variability in the lay public’s knowledge level of ACL injuries; a substantial number of misguided perceptions were identified. Return to sports and risk for future osteoarthritis following ACL surgery appear to be the most important factors to the lay public. Focusing educational efforts on areas of knowledge deficits may be particularly important for patients of physicians who treat ACL injuries....

Retrospective analysis of a prospectively collected database. To determine the overall incidence, location, and type of disc herniations in professional football players to target treatment issues and prevention. Disc herniations represent a common and debilitating injury to the professional athlete. The NFL's (National Football League's) Sports Injury Monitoring System is a surveillance database created to monitor the league for all injuries, including injuries to the cervical, thoracic, and lumbar spine. A retrospective analysis was performed on all disc herniations to the cervical, thoracic, and lumbar spine during a 12-season period (2000–2012) using the NFL's surveillance database. The primary data points included the location of the injury, player position, activity at time of injury, and playing time lost due to injury. During the 12 seasons, 275 disc herniations occurred in the spine. In regard to location, 76% occurred in the lumbar spine and most frequently affected the L5–S1 disc. The offensive linemen were most frequently injured. As expected, blocking was the activity that caused most injuries. Lumbar disc herniations rose in prevalence and had a mean loss of playing time of more than half the season (11 games). Thoracic disc herniations led to the largest mean number of days lost overall, whereas players with cervical disc herniations missed the most practices. Disc herniations represent a significant cause of morbidity in the NFL. Although much attention is placed on spinal cord injuries, preventive measures targeting the cervical, thoracic, and lumbar spine may help to reduce the overall incidence of these debilitating injuries. N/A

Sternoclavicular (SC) dislocation is a rare injury of the upper extremity. Treatment of posterior SC dislocation ranges from conservative (closed reduction) to operative (open reduction with or without surgical reconstruction of the SC joint). To date, we are unaware of any literature that exists pertaining to this injury or its treatment in elite athletes. The purpose of this case report is to describe a posterior SC joint dislocation in a professional American football player and to illustrate the issues associated with its diagnosis and treatment and the athlete’s return to sports. To our knowledge, this case is the first reported in a professional athlete. He was treated successfully with closed reduction and returned to play within 5 weeks of injury.

Background: Syndesmosis ankle sprains cause greater disability and longer duration of recovery than lateral ankle sprains. Objective: To describe the severity of syndesmosis sprains using several accepted magnetic resonance imaging (MRI) criteria and to assess the interrater reliability of diagnosing syndesmosis injury using these same criteria in professional American football players. Hypothesis: There is a high degree of interrater reliability of MRI findings in American football players with syndesmosis ankle sprains. These radiographic findings will correlate with time lost to injury, indicating severity of the sprain. Study Design: Uncontrolled retrospective review. Methods: Player demographics and time lost to play were recorded among professional football players who had sustained a syndesmosis ankle sprain and underwent standardized ankle MRI. Each image was independently read by 3 blinded musculoskeletal radiologists. Results: Seventeen players met study criteria. There was almost perfect agreement among the radiologists for diagnosing injury to the syndesmotic membrane; substantial agreement for diagnosing injury to the posterior inferior tibiofibular ligament (PITFL) and in determining the proximal extent of syndesmotic edema/injury; but only fair agreement for diagnosing injury to the anterior inferior tibiofibular ligament and in determining the width of syndesmotic separation. There was a significant correlation between the width of syndesmotic separation and time lost, but no significant correlation between individual syndesmotic ligament injury or proximal extent of syndesmotic edema/injury and time lost. Conclusion: While ankle MRI can identify syndesmotic disruption with a high degree of interobserver agreement, no association was demonstrated between the extent of injury on MRI and the time to return to play following a high ankle sprain. Clinical Relevance: In athletes with suspected high ankle sprains, MRI may help confirm diagnosis or suggest alternative diagnoses when the syndesmotic supporting structures are intact. However, the severity of ligamentous and syndesmotic disruption on MRI cannot help predict recovery times.