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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., Competing Interests: The following authors declared potential conflicts of interest: M.J.C. has received royalties or licenses from Arthrex, Stryker, and Smith & Nephew, consulting fees from Donjoy, and patents from Tenova Tenodesis Screw. M.M.H. has received consulting fees from the National Football League (NFL) and is a full-time employee of IQVIA. N.W. has received consulting fees from the NFL and is a full-time employee of the Green Bay Packers. E.M.S. has received consulting fees from the NFL and is a full-time employee of Biocore. C.M.O. has received consulting fees from the NFL and is a full-time employee of Biocore. R.B.A. has received royalties or licenses from Stryker and Artelon, and consulting fees from Stryker, Envois, Arthrex, Artelon, OsteoRemedies, and Nuvasive.

Lower limb injury rate in the National Football League (NFL) is greater on synthetic turf than on natural turfgrass. Foot loading in potentially injurious situations can be mitigated by damage to natural turfgrass that limits the peak load by allowing relative motion between the foot and the ground. Synthetic turf surfaces do not typically sustain such damage and thus lack such a load-limiting mechanism. To guide innovation in synthetic turf design, this paper reports 1) the peak loads of natural turfgrass when loaded by a cleated footform and 2) corridors that define the load-displacement response. Kentucky bluegrass [Poa pratensis, L.] and two cultivars of hybrid bermudagrass [Cynodon dactylon (L.) Pers × C. transvaalensis Burtt Davy] were tested with two cleat patterns in three loading modes (anterior-posterior or AP translation, medial-lateral or ML translation, and forefoot external rotation) at two power levels (full-power, which generated potentially injurious loads, and reduced-power, which generated horizontal forces similar to non-injurious ground reaction forces applied by an elite athlete during play). All tests generated peak force<4.95 kN and torque<173 Nm, which is in a loading regime that would be expected to mitigate injury risk. In full-power tests, bermudagrass withstood significantly (p < 0.05) greater peak loads than Kentucky bluegrass: (3.86 ± 0.45 kN vs. 2.66 ± 0.23 kN in AP, 3.25 ± 0.45 kN vs. 2.49 ± 0.36 kN in ML, and 144.8 ± 12.0 Nm vs. 126.3 ± 6.1 Nm in rotation). Corridors are reported that describe the load-displacement response aggregated across all surfaces tested., (Copyright © 2021 Elsevier Ltd. All rights reserved.)