Worse football career after tendon repair than fractures

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americanfootballwebAmerican football players who undergo surgical procedures for tendon injuries experience a worse career trajectory than players who have surgery to fix fractures and sports hernia, found a Northwestern Medicine study.

In the hard-hitting world of US football, injuries are an inherent risk of the game with players in the National Football League (NFL) experiencing a higher rate of injury than in any other professional sport. Orthopaedic surgeries are often required to manage player injuries, but until recently little information was available to assess the effect these procedures may have on players’ future performance and career trajectory. To better understand surgery’s impact, Northwestern Medicine researchers created the NFL Orthopaedic Surgery Outcomes Database (NO-SOD), a comprehensive injury database that compares return-to-play rates (RTP) and performance-based outcomes in NFL players who had orthopaedic surgery.

Analysing data from the NO-SOD, the Northwestern Medicine researchers published a study that finds that players who undergo surgical procedures for tendon injuries experience a worse career trajectory than players who have surgery to fix fractures and sports hernia. Patellar tendon repair has the greatest effect on NFL careers, with anterior cruciate ligament repair (ACLR) and Achilles tendon repair also having a strong impact on players’ careers.

“NFL rosters have a very high turnover rate, so an athlete’s career longevity is often dependent on his ability to return to baseline performance following an injury and recovery from surgery,” said Dr Wellington K Hsu, an orthopaedic surgeon at the Centre for Comprehensive Orthopaedic and Spine Care at Northwestern Memorial Hospital and study’s senior author. “While previous studies have reported outcomes for specific procedures, ours is the first that looks at the effect these injuries and surgeries have in comparison with others.”

Hsu and his team created the NO-SOD using team injury reports and other public records, including newspaper archives, player profiles and press releases, over a 10-year time period to identify NFL athletes who had orthopaedic surgeries. They then developed performance-based outcome measures based on preoperative and post-operative statistics including games played, games started, seasons played and performance score. A total of 559 athletes were included in the database, with nearly 80 percent returning to play after an orthopaedic procedure.

“The existing NFL Injury Surveillance System tracks the incidence of injuries, but does not allow for outcome studies, which significantly limits league and medical personnel from identifying trends following common orthopaedic procedures,” said Hsu, who is also the Clifford C Raisbeck distinguished professor of orthopaedic surgery and director of research for the department of orthopaedic surgery at Northwestern University Feinberg School of Medicine.

Included in the NO-SOD are players who had procedures for anterior cruciate ligament (ACL) tears, Achilles tendon tears, patellar tendon tears, cervical disc herniation, lumbar disc herniation, sports hernia, knee articular cartilage repair (microfracture technique), forearm fractures, tibial shaft fractures and ankle fractures.

The researchers found that players who had knee surgeries experienced the most significant decline in performance. Athletes who had surgery to repair the patellar tendon, the tendon connecting the knee bone to the shin, fared the worst with respect to the RTP rate, career length after surgery, games played and performance at one year, two years and three years after surgery.

Players had a RTP rate of only 50% after patellar tendon repair, which was significantly lower compared to all other procedures analysed. After ACLR, players experience significant declines in statistical performance even three seasons after their injury.

“Our findings related to patellar repair and ACLR highlight how devastating a tendon or ligament injury to the knee can be for an NFL athlete,” said Hsu. “A healthy knee is crucial to a player’s ability to pivot, jump, run, kick and make stopping movements – all elements of the game of football – so it’s not surprising these procedures would have strong impact on performance.”

Athletes who underwent Achilles tendon repair fared slightly better than those who required knee procedures. While they experienced longer recovery periods and decreases in games played and performance the first season after surgery, these players were able to return to baseline performance two and three seasons after surgery. Procedures for traumatic bony fractures and sports hernia lead to the best post-operative outcomes with RTP rates of more than 90%.

“Understanding performance outcomes for common orthopaedic procedures may lead to alterations in training regimens for NFL athletes as well as help guide short- and long-term post-operative expectations for an athlete’s career,” said Hsu. “Knowing the relative differences in recovery after orthopaedic procedures may be interesting to NFL players, coaches and fans alike.”

Abstract
Background: Injuries are inherent to the sport of American football and often require operative management. Outcomes have been reported for certain surgical procedures in professional athletes in the National Football League (NFL), but there is little information comparing the career effect of these procedures.
Purpose: To catalog the postoperative outcomes of orthopaedic procedures in NFL athletes and to compare respective prognoses and effects on careers.
Study Design: Case series; Level of evidence, 4.
Methods: Athletes in the NFL undergoing procedures for anterior cruciate ligament (ACL) tears, Achilles tendon tears, patellar tendon tears, cervical disc herniation, lumbar disc herniation, sports hernia, knee articular cartilage repair (microfracture technique), forearm fractures, tibial shaft fractures, and ankle fractures were identified through team injury reports or other public records. Game and performance statistics during the regular season were collected before and after surgery. Statistical analysis was performed with significance accepted as P < .05.
Results: A total of 559 NFL athletes were included. Overall, 79.4% of NFL athletes returned to play after an orthopaedic procedure. Forearm open reduction and internal fixation (ORIF), sports hernia repair, and tibia intramedullary nailing (IMN) led to significantly higher return-to-play (RTP) rates (90.2%-96.3%), while patellar tendon repair led to a significantly lower rate (50%) (P < .001). Athletes undergoing ACL reconstruction (ACLR), Achilles tendon repair, patellar tendon repair, and ankle fracture ORIF had significant declines in games played at 1 year and recovered to baseline at 2 to 3 years after surgery. Athletes undergoing ACLR, Achilles tendon repair, patellar tendon repair, and tibia IMN had decreased performance in postoperative season 1. Athletes in the Achilles tendon repair and tibia IMN cohorts recovered to baseline performance, while those in the ACLR and patellar tendon repair cohorts demonstrated sustained decreases in performance.
Conclusion: ACLR, Achilles tendon repair, and patellar tendon repair have the greatest effect on NFL careers, with patellar tendon repair faring worst with respect to the RTP rate, career length after surgery, games played, and performance at 1 year and 2 to 3 years after surgery.

Authors
Harry T Mai, Andrew P Alvarez, Ryan D Freshman, Danielle S Chun, Shobhit V Minhas, Alpesh A Patel, Gordon W Nuber, Wellington K Hsu

Northwest Medicine material
American Journal of Sports Medicine abstract


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