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Background: Platelet-rich plasma (PRP) has been established as safe and effective for knee osteoarthritis (OA). Another orthobiologic therapy, microfragmented adipose tissue (MFAT), has gained attention because of its heterogeneous cell population (including mesenchymal stem cells). However, prospective comparative data on MFAT are lacking. Because of the safety, efficacy, and simplicity of PRP, new therapeutics such as MFAT should be compared directly with PRP. Purpose: To compare patient-reported outcomes of a single injection of PRP versus MFAT for knee OA. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 58 patients with symptomatic knee OA (Kellgren-Lawrence grades 1-4) were randomized to receive a single injection of either leukocyte-rich PRP or MFAT under ultrasound guidance. PRP was created by processing 156 mL of whole blood. MFAT was created by harvesting 30 mL of adipose tissue via standard lipoaspiration. Scores for the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and visual analog scale for pain with Activities of Daily Living (VAS-ADL) were recorded at baseline and at 1, 3, and 6 months after the injection. The primary outcome was the KOOS-Pain subscore at 6 months after the injection. Results: The PRP group (n = 30) had a mean volume of 5.12 ± 1.12 mL injected. This consisted of a mean platelet count of 2673.72 ± 1139.04 × 103/µL and mean leukocyte count of 25.36 ± 13.27 × 103/µL (67.81% lymphocytes, 18.66% monocytes, and 12.33% neutrophils). The MFAT group (n = 28) had a mean volume of 7.92 ± 3.87 mL injected. The mean total nucleated cell count was 3.56 ± 4.62 million/mL. In both groups, KOOS subscale and VAS-ADL scores improved from baseline, and there was no significant difference between the PRP and MFAT groups in the final KOOS-Pain subscore (80.38 ± 16.07 vs 81.61 ± 16.37, respectively; P = .67) or any other outcome score. Conclusion: A single injection of either PRP or MFAT resulted in a clinically meaningful improvement for patients with knee OA at 6 months, with no difference between treatment groups. Registration: NCT04351087 (ClinicalTrials.gov identifier).

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BACKGROUND: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are injectable treatments for knee osteoarthritis. The focus of previous studies has compared their efficacy against each other as monotherapy. However, a new trend of combining these 2 injections has emerged in an attempt to have a synergistic effect. PURPOSE: To systematically review the clinical literature examining the combined use of PRP + HA. DESIGN: Systematic review. METHODS: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed and Embase. The following search terms were used: knee osteoarthritis AND platelet rich plasma AND hyaluronic acid. The review was performed by 2 independent reviewers who applied the inclusion/exclusion criteria and independently extracted data, including methodologic scoring, PRP preparation technique, HA composition, and patient-reported outcomes (PROs). RESULTS: A total of 431 articles were screened, 12 reviewed in full, and 8 included in the final analysis: 2 case series, 3 comparative, and 3 randomized studies. Average follow-up was 9 months. The modified Coleman Methodology Score was 38.13 ± 13.1 (mean ± SD). Combination therapy resulted in improved PROs in all studies. Of the comparative and randomized studies, 2 demonstrated that combination therapy was superior to HA alone. However, when PRP alone was used as the control arm (4 studies), combination therapy was not superior to PRP alone. CONCLUSION: Combination therapy with PRP + HA improves PROs and is superior to HA alone but is not superior to PRP alone.

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ABSTRACT: The role of orthopedic team physicians has evolved greatly over the past decade having been influenced by advances in sports science and performance, new surgical and biologic technologies, social media, medicolegal liability, marketing, and sexual misconduct cases by some team physicians. The great variety of events and sports that are covered from high school and collegiate to the Olympic and professional levels requires a myriad of skills outside of the traditional medical training curriculum. In the current climate of increasing media scrutiny from a 24-h news cycle it is imperative for orthopedic team physicians, whether operative or nonoperative, to continually adapt to the needs and expectations of athletes who also are patients. This is especially true in the wake of the COVID-19 pandemic. Orthopedic team physicians' responsibilities continue to evolve ensuring their relevance and necessity on the sidelines and in the training room as well as in the operative suite.

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Importance: Myocarditis is a leading cause of sudden death in competitive athletes. Myocardial inflammation is known to occur with SARS-CoV-2. Different screening approaches for detection of myocarditis have been reported. The Big Ten Conference requires comprehensive cardiac testing including cardiac magnetic resonance (CMR) imaging for all athletes with COVID-19, allowing comparison of screening approaches. Objective: To determine the prevalence of myocarditis in athletes with COVID-19 and compare screening strategies for safe return to play. Design, Setting, and Participants: Big Ten COVID-19 Cardiac Registry principal investigators were surveyed for aggregate observational data from March 1, 2020, through December 15, 2020, on athletes with COVID-19. For athletes with myocarditis, presence of cardiac symptoms and details of cardiac testing were recorded. Myocarditis was categorized as clinical or subclinical based on the presence of cardiac symptoms and CMR findings. Subclinical myocarditis classified as probable or possible myocarditis based on other testing abnormalities. Myocarditis prevalence across universities was determined. The utility of different screening strategies was evaluated. Exposures: SARS-CoV-2 by polymerase chain reaction testing. Main Outcome and Measure: Myocarditis via cardiovascular diagnostic testing. Results: Representing 13 universities, cardiovascular testing was performed in 1597 athletes (964 men [60.4%]). Thirty-seven (including 27 men) were diagnosed with COVID-19 myocarditis (overall 2.3%; range per program, 0%-7.6%); 9 had clinical myocarditis and 28 had subclinical myocarditis. If cardiac testing was based on cardiac symptoms alone, only 5 athletes would have been detected (detected prevalence, 0.31%). Cardiac magnetic resonance imaging for all athletes yielded a 7.4-fold increase in detection of myocarditis (clinical and subclinical). Follow-up CMR imaging performed in 27 (73.0%) demonstrated resolution of T2 elevation in all (100%) and late gadolinium enhancement in 11 (40.7%). Conclusions and Relevance: In this cohort study of 1597 US competitive athletes with CMR screening after COVID-19 infection, 37 athletes (2.3%) were diagnosed with clinical and subclinical myocarditis. Variability was observed in prevalence across universities, and testing protocols were closely tied to the detection of myocarditis. Variable ascertainment and unknown implications of CMR findings underscore the need for standardized timing and interpretation of cardiac testing. These unique CMR imaging data provide a more complete understanding of the prevalence of clinical and subclinical myocarditis in college athletes after COVID-19 infection. The role of CMR in routine screening for athletes safe return to play should be explored further.

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BACKGROUND: Percutaneous ultrasonic tenotomy (PUT) is a minimally-invasive method of treating patellar tendinosis, but its immediate effect on tendon structure has never been studied. Given the crucial nature of the extensor mechanism of the knee, it is important to understand the procedure's effect on tendon structure prior to clinical implementation. The aim of this study was to analyze the tendon structure of the extensor mechanism of the knee after PUT in a cadaveric model. METHODS: Four fresh-frozen cadaveric specimens (two patellar and two quadriceps tendons) underwent PUT. The tendons were then sectioned and stained with hematoxilin & eosin (H&E). The sections were analyzed for a clear area of debridement. The area of debridement was calculated as an average of three measurements. RESULTS: All four tendons demonstrated a clear area of debridement limited to the treatment area without damaging any surrounding tissue. The area of debridement for the patellar and quadriceps tendons treated was 2.89 mm2, 1.5 mm2, 2.98 mm2 and 7.29 mm2, respectively. CONCLUSIONS: Percutaneous ultrasonic tenotomy effectively debrided the treatment area in all tendons without damaging surrounding tissue. Further work is needed to report clinical outcomes, assess the risk of post-procedure tendon rupture and define return-to-sport progression.

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OBJECTIVE: The purpose of this study was to evaluate injury characteristics by position groups. DESIGN: Prospective, observational study. SETTING: A single, major Division I collegiate football program. PARTICIPANTS: All players on a collegiate football program each fall regular season. INDEPENDENT VARIABLES: Exposure to Division I collegiate football and position groups. MAIN OUTCOME MEASURES: Injury rates (IRs) per 1000 athlete exposures (AEs) and injury rate ratios (IRRs) were calculated and analyzed for all monitored injury variables, which included time in the season, body part, type of injury, game and practice injuries, mechanism of injury, and type of exposure. RESULTS: During the 2012 to 2016 fall regular seasons, there were 200 reported injuries sustained from 48 615 AE. The overall 5-year IR was 4.11 per 1000 AEs (3.57-4.72 95% confidence intervals). Skill players sustained the highest IR in the preseason (IR, 7.56) compared with line (IR, 4.26) and other (IR, 4.10) position groups. In addition, skill players demonstrated a significantly higher IRR compared with the line (IRR, 1.75, P < 0.05) and other (IRR, 1.85, P < 0.05) position groups. CONCLUSIONS: Skill players sustained most of their injuries in the preseason, whereas the linemen and other position groups suffered most of their injuries in the first half of the regular season. Skill players demonstrated a significantly higher IR in preseason, noncontact mechanism injuries, and injuries to the upper leg and thigh compared with line and other position groups. Efforts to reduce soft-tissue muscle strains in skill players targeting the preseason may provide one of the best opportunities to significantly decrease current football IRs, whereas efforts to reduce contact exposures may have the greatest effect on concussions and contact mechanism injuries for the other position group. There were no significant differences in IRs between position groups and type of exposure.

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BACKGROUND: Platelet-rich plasma (PRP) is an emerging orthobiologic treatment for musculoskeletal conditions like osteoarthritis. Two studies have demonstrated the influence of longer duration exercise on PRP composition, but no study has ever explored the impact of high intensity interval exercise (HIIE) on PRP content. OBJECTIVE: To quantify cellular and growth factor content changes in PRP after 4 minutes of HIIE. DESIGN: Controlled laboratory pilot study. SETTING: Academic sports medicine center. PARTICIPANTS: Ten healthy volunteers (5 male, 5 female). INTERVENTION: Volunteers had PRP prepared from 15 mL of whole blood using a single spin, plasma-based system (autologous conditioned plasma [ACP]) immediately before and after 4 minutes of HIIE on a stationary exercise bike (Tabata protocol). MAIN OUTCOME MEASURE: The PRP was sent for complete blood counts and enzyme-linked immunosorbent assay (ELISA) to quantify transforming growth factor (TGF)-ß, platelet-derived growth factor (PDGF), insulin-like growth factor (IGF)-1, and vascular endothelial growth factor (VEGF). RESULTS: Mean platelet count in PRP increased from 367.4 ± 57.5 k/µL to 497.7 ± 93.3 k/µL after 4 minutes of HIIE (P < .001). TGF-ß also increased from 8237.2 ± 7676.5 pg/mL to 21 535.7 ± 4062.6 pg/mL postexercise (P = .004). The other cellular components (leukocytes, red blood cells, and mean platelet volume) and growth factors (PDGF, IGF-1, and VEGF) were not significantly changed. CONCLUSIONS: A short 4-minute bout of HIIE significantly increased the total platelet count and TGF-ß concentration in PRP.

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A 21-year-old female lacrosse player complained of anterior thigh pain with no known mechanism of injury and failed to improve with conservative therapy. An MRI was obtained showing a closed degloving injury of the rectus femoris, an injury only previously reported in a small case series of soccer players. After a brief period of rest, she was progressed conservatively through therapy and did well, with progression back to the level of competition at 56 days. This case highlights a rare injury not previously described in sports outside of soccer and is the first case described in a female athlete. In addition, the discussion of this case focuses on the unique anatomy of the rectus femoris.

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A 13-year-old female soccer and basketball athlete presented with pain in the arch of her foot. Magnetic resonance imaging confirmed the diagnosis of a middle cuneiform stress fracture. The patient's stress fracture healed nonoperatively over a 10-week period complicated by nonadherence to a fracture boot, after which she was progressed back to full activity. Knowledge of these fractures and their treatment are important for sports medicine physicians, as they can often be overlooked, given their infrequent occurrence. There have been 8 previous case reports and 1 case series on cuneiform stress fractures, and these are summarized with this case report.

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BACKGROUND: Platelet-rich plasma (PRP) is an autologous orthobiologic treatment option for musculoskeletal conditions with favorable results in a limited number of high-quality clinical trials. Because different blood-processing methods result in PRP with varying cellular and growth factor content, it is critical that clinicians understand the content of the specific PRP being used in clinical practice. One adjustable system, the Angel System, has few independent laboratory reports on the specific composition of its PRP. The goal of this study was to quantify the cellular and growth factor composition of PRP produced by this system at its lowest hematocrit settings. HYPOTHESIS: The authors hypothesized that the system would significantly concentrate platelets over baseline and, at the lowest hematocrit settings, would reduce leukocytes to produce leukocyte-poor PRP. STUDY DESIGN: Descriptive laboratory study. METHODS: Ten healthy male volunteers donated 150 mL of whole blood for processing. Three separate processing cycles were performed for each sample at the 0%, 1%, and 2% hematocrit settings. The resultant PRP from each cycle was sent for complete blood counts and enzyme-linked immunosorbent assay to quantify the following growth factors: platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), insulin-like growth factor-1 (IGF-1), and vascular endothelial growth factor (VEGF). RESULTS: The system consistently concentrated platelets 5-fold over baseline, with no significant differences among settings. Leukocytes were concentrated at all settings, between 2 and 5 times over baseline. The 0% and 1% settings had significantly lower leukocyte concentrations than the 2% setting. Lymphocytes made up >89% of the leukocyte differential, while neutrophils represented <11% of the differential at each setting. There was a significant increase in PDGF and bFGF, a significant decrease in IGF-1, and no change in VEGF, with no difference among settings. CONCLUSION: The system consistently concentrated platelets 5 times but was unable to reduce leukocytes, therefore resulting in leukocyte-rich PRP at each setting tested. Leukocytes had a differential composition of >89% lymphocytes and <11% neutrophils. For all settings, PDGF and bFGF were concentrated; IGF-1 was reduced; and VEGF was not significantly different from baseline. CLINICAL RELEVANCE: These data can serve to guide clinicians considering using this particular PRP system. It consistently yielded leukocyte-rich PRP with a lymphocyte-predominant/neutrophil-reduced profile. Further research is needed to better understand how to apply this specific PRP in clinical practice.

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BACKGROUND: Football has one of the highest injury rates (IRs) in sports, ranging from 4.1 to 8.6 per 1000 athlete-exposures (AEs). Previous research has reported that athletes may be at an increased risk of suffering lower extremity (LE) injuries after a concussion. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the rate of LE injuries in collegiate football athletes after a concussion. We predicted that the overall LE IR would increase after a concussion and that each position group would also demonstrate a similar increase in LE injuries after a concussion. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Daily attendance and injury records were prospectively collected by licensed team medical providers for the 2012 through 2016 college football regular seasons. Each injury report included the date of injury, position group, body part injured, and type of injury. IRs per 1000 AEs with 95% CIs were calculated to evaluate LE injuries at different time points after a concussion (remainder of season, next season, any additional seasons) and by months (<6 months, 6-12 months, >12 months). Mid-P exact tests were utilized to establish injury rate ratios (IRRs) to compare the IR between variables. RESULTS: There was no significant difference in LE IRRs between the athletes post- versus preconcussion (P = .20) or between the postconcussion and no concussion (control) athletes (P = .08). There was an increased LE IR beyond 12 months in the postconcussion group (IR, 9.08 [95% CI, 3.68-18.89]) compared with the no concussion group (IR, 2.88 [95% CI, 2.04-3.96]) (IRR, 3.16 [95% CI, 1.21-7.15]; P = .02). Line position players had an increase in LE injuries after a concussion (IRR, 6.22 [95% CI, 1.31-23.68]; P = .03) compared with linemen with no concussion. CONCLUSION: There was no initial increase in LE IRs immediately after a concussion; however, there was an increased LE IR more than 12 months after a concussion. There was no increase in LE IRs demonstrated by skill and other position groups. Line position players experienced an increased LE IR the next season after a concussion or greater than 12 months after the injury.

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OBJECTIVES: The purpose of this study is to examine the epidemiology of mental health conditions in incoming American Division I collegiate athletes. METHODS: Pre-participation physical questionnaires from 1118 incoming student athletes at a Division I Institution were collected retrospectively from 2011-2017. Data collected included lifetime history of any mental health condition, musculoskeletal injuries, concussions, and post-concussion depression. History of any mental health condition was evaluated by gender and sport played. It was also evaluated in comparison to musculoskeletal injuries and concussions. RESULTS: The lifetime prevalence of any mental health condition was 14.0% for all athletes, 14.2% for male athletes, and 13.6% for female athletes. Individual sports reported a greater prevalence (17.2%) than did team sports (11.8%) (p = 0.010). The prevalence was also higher in contact sports (16.4%) than in non-contact sports (12.5%), although this difference was not statistically significant (p = 0.072). There was a significant association between mental health condition and all four major groups of injuries examined: upper extremity (p = 0.043), lower extremity (p = 0.007), axial skeletal (p < 0.001), and concussions (p = 0.039). Post-concussion depression occurred in 2.0% of all athletes reporting a concussion. CONCLUSION: The lifetime prevalence of mental health conditions in this population (14.0%) is far less than estimates in the general population. This observation may be due to a combination of factors including exercise/athletic participation mitigating depressive symptoms, competitive selection, and underreporting. History of a mental health condition may be associated with injury, although causation cannot be determined.

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CONTEXT: The fourth edition of the Preparticipation Physical Evaluation recommends functional testing for the musculoskeletal portion of the examination; however, normative data across sex and grade level are limited. Establishing normative data can provide clinicians reference points with which to compare their patients, potentially aiding in the development of future injury-risk assessments and injury-mitigation programs. OBJECTIVE: To establish normative functional performance and limb-symmetry data for high school-aged male and female athletes in the United States. DESIGN: Cross-sectional study. SETTING: Athletic training facilities and gymnasiums across the United States. PATIENTS OR OTHER PARTICIPANTS: A total of 3951 male and female athletes who participated on high school-sponsored basketball, football, lacrosse, or soccer teams enrolled in this nationwide study. MAIN OUTCOME MEASURE(S): Functional performance testing consisted of 3 evaluations. Ankle-joint range of motion, balance, and lower extremity muscular power and landing control were assessed via the weight-bearing ankle-dorsiflexion-lunge, single-legged anterior-reach, and anterior single-legged hop-for-distance (SLHOP) tests, respectively. We used 2-way analyses of variance and χ2 analyses to examine the effects of sex and grade level on ankle-dorsiflexion-lunge, single-legged anterior-reach, and SLHOP test performance and symmetry. RESULTS: The SLHOP performance differed between sexes (males = 187.8% ± 33.1% of limb length, females = 157.5% ± 27.8% of limb length; t = 30.3, P < .001). A Cohen d value of 0.97 indicated a large effect of sex on SLHOP performance. We observed differences for SLHOP and ankle-dorsiflexion-lunge performance among grade levels, but these differences were not clinically meaningful. CONCLUSIONS: We demonstrated differences in normative data for lower extremity functional performance during preparticipation physical evaluations across sex and grade levels. The results of this study will allow clinicians to compare sex- and grade-specific functional performances and implement approaches for preventing musculoskeletal injuries in high school-aged athletes.

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BACKGROUND: Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage. HYPOTHESIS: Larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Subjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery. RESULTS: A total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus ( P < .001). For the medial compartment, patients who had <33% of the medial meniscus excised at the time of the primary reconstruction had 4.8-times greater odds of progression of articular cartilage injury than those with an intact medial meniscus ( P = .02). Odds of significant chondral surface change increased by 5% in the lateral compartment and 6% in the medial compartment for each increased year of age ( P ≤ .02). For the patellofemoral compartment, the use of allograft in primary reconstruction was associated with a 15-fold increased odds of progression of articular cartilage damage relative to a patellar tendon autograft ( P < .001). Each 1-unit increase in BMI at the time of revision surgery was associated with a 10% increase in the odds of progression of articular cartilage damage ( P = .046) in the patellofemoral compartment. CONCLUSION: Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment.

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CONTEXT: The functional movement screen (FMS™) is used to identify movement asymmetries and deficiencies. While obesity has been reported to impede movement, the correlation between body mass index (BMI), body fat percentage (BF%), and FMS™ in athletes is unknown. OBJECTIVE: To determine if there is a relationship between BMI, BF%, and FMS™ scores in a sample of National Collegiate Athletic Association Division I football athletes. DESIGN: Cross-sectional study. SETTING: Biodynamics laboratory. PARTICIPANTS: A total of 38 male freshman football players (18.0 [0.7] y, 185.3 [5.5] cm, and 103.9 [20.3] kg). INTERVENTIONS: Height, weight, and BF% were collected, and subjects underwent the FMS™ conducted by a certified athletic trainer. MAIN OUTCOME MEASURES: The dependent variables were BMI, BF%, composite FMS™ score, and 7 individual FMS™ test scores. Subjects were grouped as normal BMI (BMI < 30 kg/m2) or obese (BMI ≥ 30 kg/m2). A composite FMS™ score of ≤14 and an individual FMS™ score of ≤1 were classified as cutoffs for poor movement performance. RESULTS: A negative correlation between composite FMS™ score and BMI approached significance (P = .07, ρ = .296). A negative correlation between composite FMS™ score and BF% was significant (P = .01, ρ = -.449). There was a significant difference in the number of obese subjects scoring below the composite FMS™ cutoff (χ2 = 5.179, P = .02) and the individual FMS™ cutoff on the deep squat (χ2 = 6.341, P = .01), hurdle step (χ2 = 9.870, P = .002), and in-line lunge (χ2 = 5.584, P = .02) when compared with normal BMI subjects. CONCLUSIONS: Increased BF% and BMI relate to lower composite FMS™ and individual FMS™ test scores, indicating potentially poor movement patterns in larger National Collegiate Athletic Association football athletes. Future research should focus on examining lower extremity-specific FMS™ tasks individually from composite FMS™ scores.

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OBJECTIVES: The purpose of this study is to determine the lifetime prevalence of past injuries in incoming first year football players in a Division 1 college football team. METHODS: Pre-participation questionnaires from 605 first-year football players over 20 years (1996-2015) were examined to determine the prevalence of concussions, stingers, fractures, and musculoskeletal surgeries sustained before playing at the collegiate level. Players were grouped by position: wide receiver and defensive back (WR/DB), offensive and defensive linemen (OL/DL), all other positions (OP), and unknown (UKN). Prevalence of injuries by year and position was compared using Pearson's χ2 Test (p < 0.05). RESULTS: The reported lifetime prevalence is as follows: concussion (21%), stinger (23%), musculoskeletal surgery (23%), and fracture (44%). There were no significant differences in lifetime prevalence of concussions (p = 0.49), stingers (p = 0.31), fractures (p = 0.60), or musculoskeletal surgeries (p = 0.97) based on position. There were also no significant differences in the lifetime prevalence of concussions (p = 0.14), musculoskeletal surgeries (p = 0.50), or fractures (p = 0.59) based on year. However, there was a significant difference in the lifetime prevalence of stingers based on year (p < 0.001). CONCLUSIONS: There was an expectation to observe an increase in injury prevalence by entering year, but this was not seen. A decrease in stingers was actually observed, but there was no significant difference among any other injury recorded. These results do not support the perception that football injuries are on the rise. Under reporting is a significant concern as players may fear disqualification or that they are evaluated by the coaching staff based on their medical history. More research is needed to confirm lifetime injury prevalence and evaluate differences over time among football players.

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OBJECTIVES: Achilles tendon (AT) ruptures are a potentially career-altering and ending injury. Achilles tendon ruptures have a below average return-to-play rate compared to other common orthopaedic procedures for National Football League (NFL) players. The objective of this study was to monitor the incidence and injury rates (IR) of AT ruptures that occurred during the regular season in order to evaluate the influence of player position, time of injury, and playing surface on rupture rates. METHODS: A thorough online review was completed to identify published injury reports and public information regarding AT ruptures sustained during regular season and post-season games in the National Football League (NFL) during the 2009-10 to 2016-17 seasons. Team schedules, player position details and stadium information was used to determine period of the season of injury and playing surface. IRs were calculated per 100 team games (TG). Injury rate ratios (IRR) were utilized to compare IRs. RESULTS: During eight monitored seasons, there were 44 AT ruptures in NFL games. A majority of AT ruptures were sustained in the first eight games of the regular season (n = 32, 72.7%). There was a significant rate difference for the first and second four-game segments of the regular season compared to the last two four-game segments of the regular season. Defensive players suffered a majority of AT ruptures (n = 32, 72.7%). The IR on grass was 1.00 per 100 TG compared to 1.08 per 100 TG on artificial turf (IRR: 0.93, p = .80). CONCLUSION: A significant increase in AT ruptures occurred in the first and second four game segments of the regular season compared to the last two-four game segments of the regular season. Defensive players suffered a majority of AT ruptures compared to offensive or specialist players. There was no difference between AT rupture rates and playing surface in games.

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