ACL Injuries in the NFL
Abstract & Commentary
Synopsis: This study reviews the epidemiology of anterior cruciate ligament tears in the National Football League as well as provides treatment trends for this group of athletes.
Source: Bradley JP, et al. Arthroscopy. 2002;18(5):502-509.
Although there have been published epidemiologic studies on the occurrence of ACL injuries in high school and collegiate football players, there are no such studies for NFL players. This article attempts to not only fill this void, but also presents the results of a treatment survey completed by NFL physicians during the 1998-1999 season.
During the period of 1994-1998, physicians and trainers of 31 NFL teams reported 10,500 injuries (an injury was defined as any brain concussion causing cessation of participation for observation, any injury that results in the loss of 1 day of participation, or any fracture regardless of time loss) of which 1245 were knee sprains and 203 (16%) were ACL injuries (54% isolated). More injuries occurred in games than practices (142 vs 67), but no mention was made regarding the total time players spent in practice vs. play.
In games, the occurrence of ACL injuries was divided as follows: offensive players 40% (linemen 30%, running backs 32%); defensive positions 39% (linemen 39%, secondary 38%, linebackers 23%); special teams 20% (kicking unit 55%, receiving unit 30%). According to Bradley and colleagues, no marked increase in ACL injuries in NFL players was seen during the study period. ACL injuries comprise approximately 2% of all NFL injuries. Moreover, the ratio of ACL injuries to knee injuries is similar to that reported for the collegiate level.
Regarding treatment of ACL injuries by NFL team physicians (n = 31), data were collected by means of a questionnaire. Endoscopically performed patella tendon autograft was the procedure of choice selected by 84% of physicians in acute ACL injuries and 81% in chronic ACL injuries. Most recommend delaying the procedure following injury until the inflammatory response subsides (ie, until swelling decreases and there is a return of range of motion and strength). Following ACL reconstruction, 90% of NFL physicians said that their players return to sport 90-100% of the time. Ten percent of the physicians stated only 75% of players returned to sport. Sixty-five percent of physicians permitted return to sport at 6 months and 16% allowed return between 6-9 months.
All 31 team physicians recommended acute operative reconstruction for running backs, receivers, linebackers, and defensive backs whereas only 84% recommended acute reconstruction for quarterbacks. The remainder stated they would try rehabilitation and then attempt return to sport in a brace, delaying reconstruction until the off-season. There was less consensus when it came to treatment for place kickers and punters. For the dominant leg, only 61% of physicians recommended acute reconstruction for a place kicker and only 55% in punters.
Comment by Letha Y. Griffin, MD, PhD
Although the data regarding the frequency of injuries for various position players are interesting, it is unfortunate Bradley et al were unable to correlate injury with playing time. Without a denominator, the injury numerator has limited usefulness. Bradley et al highlight this problem when they state their injury percentage in linemen cannot be fairly compared to that for running backs since there are more linemen than running backs on each team. Moreover, the time played by special teams is far less than that for defensive or offensive squads.
The data collection time table is also confusing as Bradley et al reference in the abstract analyzing data from "1986 to 1995;" yet in the text, they specify the years of analysis for their study as 1994-1998.
With regards to the NFL physicians’ treatment survey, this was completed following 1998-1999 season (almost 4 years ago) which was before the widespread use of soft tissue interference screws, closed loop endobuttons, and other fixation choices used commonly now for quadruple hamstring grafts. Perhaps with greater options for graft fixations, more physicians might now choose quadruple hamstring as a graft option for these players.
Dr. Griffin, Adjunct and Clinical Faculty, Department of Kinesiology and Health, Georgia State University, Atlanta, GA, is Associate Editor of Sports Medicine Reports.
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