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Background:The purpose of this study was to evaluate the incidence of lower extremity compartment syndrome in National Football League (NFL) athletes and report the mechanisms of injury, methods of treatment, and subsequent days missed. We review the existing literature on lower extremity compartment syndrome in athletic populations.Hypothesis:Lower extremity compartment syndrome occurs with a low incidence in NFL athletes, and there is a high return-to-play rate after surgical management of acute compartment syndrome.Study Design:Case series.Level of Evidence:Level 4.Methods:A retrospective review of recorded cases of lower extremity compartment syndrome from 2000 to 2017 was performed using the NFL Injury Surveillance System and electronic medical record system. Epidemiological data, injury mechanism, rates of surgery, and days missed due to injury were recorded.Results:During the study period, 22 cases of leg compartment syndrome in 21 athletes were recorded. Of these injuries, 50% occurred in games and 73% were the result of a direct impact to the leg. Concomitant tibial fracture was noted in only 2 cases (9.1%) and there was only 1 reported case of chronic exertional compartment syndrome. Surgery was documented in 15 of 22 cases (68.2%). For acute nonfracture cases, the average time missed due to injury was 24.2 days (range, 5-54 days), and all were able to return to full participation within the same season.Conclusion:NFL athletes with acute leg compartment syndrome treated with surgery exhibited a high rate of return to play within the same season.Clinical Relevance:Although compartment syndrome is a relatively rare diagnosis among NFL players, team physicians and athletic trainers must maintain a high index of suspicion to expediently diagnose and treat this potentially limb-threatening condition.

OBJECTIVE Statistical challenges exist when using diffusion tensor imaging (DTI) to assess traumatic axonal injury (TAI) in individual concussed athletes. The authors examined active professional American football players over a 6-year time period to study potential TAI after concussion and assess optimal methods to analyze DTI at the individual level. METHODS Active American professional football players recruited prospectively were assessed with DTI, conventional MRI, and standard clinical workup. Subjects underwent an optional preseason baseline scan and were asked to undergo a scan within 5 days of concussion during gameplay. DTI from 25 age- and sex-matched controls were obtained. Both semiautomated region-of-interest analysis and fully automated tract-based spatial statistics (TBSS) were used to examine DTI at individual and group levels. Statistical differences were assessed comparing individual DTI data to baseline imaging versus a normative database. Group-level comparisons were also performed to determine if longer exposure to professional-level play or prior concussion cause white matter microstructural integrity changes. RESULTS Forty-nine active professional football players were recruited into the study. Of the 49 players, 7 were assessed at baseline during the preseason and after acute concussion. An additional 18 players were assessed after acute concussion only. An additional 24 players had only preseason baseline assessments. The results suggest DTI is more sensitive to suspected TAI than conventional MRI, given that 4 players demonstrated decreased fractional anisotropy (FA) in multiple tracts despite normal conventional MRI. Furthermore, the data suggest individual assessment of DTI data using baseline premorbid imaging is more sensitive than typical methods of comparing data to a normative control group. Among all subjects with baseline data, 1 reduced FA tract (± 2.5 standard deviations) was found using the typical normative database reference versus 10 statistically significant (p < 0.05) reduced FA tracts when referencing internal control baseline data. All group-level comparisons were statistically insignificant (p > 0.05). CONCLUSIONS Baseline premorbid DTI data for individual DTI analysis provides increased statistical sensitivity. Specificity using baseline imaging also increases because numerous potential etiologies for reduced FA may exist prior to a concussion. These data suggest that there is a high potential for false-positive and false-negative assessment of DTI data using typical methods of comparing an individual to normative groups given the variability of FA values in the normal population.

Objective To assist sideline medical staff and to augment detection of concussion in National Football League (NFL) players during preseason and regular season games via the use of certified athletic trainer (ATC) spotters. Background Detecting concussive injuries in contact-sport athletes can be a challenging task for health care providers on the sideline. Over the past 8 years, professional sport leagues have begun to use additional sets of eyes (medical spotters along with video review) to help identify athletes with possible concussive injuries. Description The NFL first began a program using spotters in 2011, and the ATC Spotter Program has undergone systematic enhancements each year. This article describes the evolution of the ATC Spotter Program, the requirements and training of its participants, and the program data available to date. Directions for future improvement and research are addressed. Clinical Advantages The use of ATC spotters stationed in the broadcast booth has enhanced the real-time detection of concussed players in the NFL.

One of the National Football League’s (NFL) Head, Neck and Spine Committee’s principal goals is to create a ‘best practice’ protocol for concussion diagnosis and management for its players. The science related to concussion diagnosis and management continues to evolve, thus the protocol has evolved contemporaneously. The Fifth International Conference on Concussion in Sport was held in Berlin in 2016, and guidelines for sports concussion diagnosis and management were revised and refined. The NFL Head, Neck and Spine Committee has synthesised the most recent empirical evidence for sports concussion diagnosis and management including the Berlin consensus statement and tailored it to the game played in the NFL. One of the goals of the Committee is to provide a standardised, reliable, efficient and evidence-based protocol for concussion diagnosis and management that can be applied in this professional sport during practice and game day. In this article, the end-of-season version of the 2017–18 NFL Concussion Diagnosis and Management Protocol is described along with its clinical rationale. Immediate actions for concussion programme enhancement and research are reviewed. It is the Committee’s expectation that the protocol will undergo refinement and revision over time as the science and clinical practice related to concussion in sports crystallise

Background:Thumb collateral ligament injuries occur frequently in the National Football League (NFL). In the general population or in recreational athletes, pure metacarpophalangeal (MCP) abduction or adduction mechanisms yield isolated ulnar collateral ligament (UCL) and radial collateral ligament (RCL) tears, respectively, while NFL athletes may sustain combined mechanism injury patterns.Purpose:To evaluate the incidence of simultaneous combined thumb UCL and RCL tears among all thumb MCP collateral ligament injuries in NFL athletes on a single team.Study Design:Case series; Level of evidence, 4.Methods:A retrospective review of all thumb injuries on a single NFL team from 1991 to 2014 was performed. All players with a thumb MCP collateral ligament injury were included. Collateral ligament injuries were confirmed by review of both physical examination findings and magnetic resonance imaging. Player demographics, surgical details, and return-to-play data were obtained from the team electronic medical record and surgeons’ records.Results:A total of 36 thumbs in 32 NFL players were included in the study, yielding an incidence of 1.6 thumb MCP collateral ligament injuries per year on a single NFL team. Of these, 9 thumbs (25%) had a simultaneous combined UCL and RCL tear injury pattern confirmed on both physical examination and MRI. The remaining 27 thumbs (75%) were isolated UCL injuries. All combined UCL/RCL injuries required surgery due to dysfunction from instability; 63.0% of isolated UCL injuries required surgical repair ( P = .032) due to continued pain and dysfunction from instability. Repair, when required, was delayed until the end of the season. All players with combined UCL/RCL injuries and isolated UCL injuries returned to play professional football the following season.Conclusion:Simultaneous combined thumb UCL and RCL tear is a previously undescribed injury pattern that occurred in 25% of thumb MCP collateral ligament injuries on a single NFL team over a 23-year period. All players with combined thumb UCL/RCL injuries required surgical repair, which was significantly higher compared with players with isolated UCL injuries. Team physicians and hand surgeons treating elite football players with suspected thumb collateral ligament injuries should examine for RCL and UCL instability and consider MRI if any concern exists for a combined ligament injury pattern, as this injury is likely frequently missed.

Background: Despite the frequency of distal fibula fractures in elite athletes and the significant potential impact on the athletes’ season and future careers, little data exist characterizing the epidemiology of these injuries or, more importantly, return to competition. Purpose: To (1) evaluate the incidence of acute distal fibula fractures in National Football League (NFL) athletes, including isolated distal fibula and combined ankle fracture patterns; (2) analyze distal fibula fracture rates in NFL athletes by position, type of play, and contact type; (3) determine the rates of distal fibula fracture surgery in NFL athletes; and (4) report the days missed due to distal fibula fractures in NFL athletes. Study Design: Descriptive epidemiology study. Methods: A retrospective review of distal fibula fractures reported to the NFL from 2000 to 2014 was performed using the NFL Injury Surveillance System. All distal fibula fractures were included, along with isolated and combined fracture patterns. Stress fractures and proximal fibula fractures were excluded. Epidemiological data and rates of surgery were determined. Return to sport was calculated and stratified by injury pattern and management. Results: Overall, 237 distal fibula fractures in NFL athletes from 2000 to 2014 were included; 197 (83%) were isolated distal fibula fractures. A mean of 16 distal fibula fractures occurred each year (median, 16 per year). Fractures occurred most frequently on running (38%) and passing (24%) plays, but the frequency was next highest on kickoffs (16%), despite the relative infrequency of kickoffs during the average game compared with other play types. Surgery was reported for more than half of all distal fibula fractures (n = 128, 54%). Overall, patients who underwent surgery missed significantly more days (mean, 123.8 days) than players who did not undergo surgery (mean, 75.3 days) (P < .001). Players with isolated distal fibula fractures had significantly fewer days missed (mean, 93.6 days) compared with those with combined patterns (mean, 132.3 days) (P = .0004). Conclusion: Fibula fractures affect a number of NFL athletes and result in significant time missed from competition. Further research is required to determine the optimal management of fibula fractures in NFL athletes. In this study, time to return to play depended on both the fracture pattern and whether surgery was required and ranged from 72 to 145 days.

Administering local anesthetic or corticosteroid injections in professional athletes to allow return to play is common but has traditionally been viewed as suspect and taboo. The skepticism surrounding therapeutic injections stems predominantly from anecdotal experience as opposed to scientific data.The purpose of this paper is to evaluate the current use of corticosteroid injections for muscle strains and ligaments sprains in the National Football League to document player's ability to return to play and possible adverse effects.Athletes from a single National Football League team who received at least one corticosteroid or anesthetic injection for either a muscle strain or ligament sprain during three consecutive seasons were retrospectively reviewed. Thirty-seven injections were given over the three seasons. Injections were either performed blindly or by using ultrasound guidance.Twice as many defensive players were injected than offensive players. The average number of days of conservative treatment before injection was 6.5 days. All players returned to play after injection. There were no complications from any of the injections. Seventeen (55%) players did not miss a single game, and nine (30%) did not miss a single day. Quadriceps strains were associated with the most missed games (four) and the most missed days (36.5). Proximal hamstring strains were second with an average of three missed games and 28 missed days.Corticosteroid injections are a safe and effective therapeutic intervention for treating muscle strains and ligament sprains in order to enable athletes to return to competition earlier.

Background:Prior to the annual National Football League (NFL) Draft, the top college football prospects are evaluated by medical personnel from each team at the NFL Scouting Combine. On the basis of these evaluations, each athlete is assigned an orthopaedic grade from the medical staff of each club, which aims to predict the impact of an athlete’s injury history on his ability to participate in the NFL.Purpose:(1) To identify clinical predictors of signs, symptoms, and subsequent professional participation associated with football-related injuries identified at the NFL Combine and (2) to assess the methodological quality of the evidence currently published.Study Design:Systematic review; Level of evidence, 3.Methods:A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We reviewed all studies that examined musculoskeletal injuries identified among athletes at the NFL Combine and associated outcomes. Data on signs, symptoms, and subsequent NFL participation were collected, and the methodological quality of the studies was assessed.Results:Overall, 32 studies, including 30 injury-specific studies, met the inclusion criteria. Twenty studies analyzed data collected at the NFL Combine from 2009 and later. When compared with matched controls, athletes with a history of a cervical or lumbar spine injury, rotator cuff repair, superior labrum anterior-posterior repair, anterior cruciate ligament reconstruction, full-thickness chondral lesions of the knee, or Lisfranc injury played in significantly fewer games early in their NFL careers. Additionally, athletes with a history of a cervical or lumbar spine injury, rotator cuff repair, and navicular injury had decreased career lengths versus controls. Defensive players and linemen were found to have decreased participation in the NFL for several injuries, including prior meniscectomy, anterior cruciate ligament reconstruction, and shoulder instability. Career length follow-up, measures of athletic participation, and matching criteria were highly variable among studies.Conclusion:For medical professionals caring for professional football athletes, this information can help guide orthopaedic grading of prospects at the NFL Combine and counseling of athletes on the potential impact of prior injuries on their professional careers. For future studies, improvements in study methodology will provide greater insight into the efficacy of current treatments and areas that require further understanding.

Background: Limited evidence exists to guide clinical decision making regarding cervical disc herniations in professional athletes playing for the National Football League (NFL) in the United States. Purpose: To describe the presentation and treatment outcomes of cervical disc herniations in NFL athletes with a focus on safety and return to sport. Study Design: Case series; Level of evidence, 4. Methods: The records of a single NFL team and its consulting physicians were reviewed from 2000 to 2011. Only athletes with magnetic resonance imaging (MRI)–proven disc herniation concordant with the reported symptoms were included. Results: A total of 16 athletes met inclusion criteria. Linemen, linebackers, and defensive backs were the most represented positions (13/16 athletes; 81%). The most common presentation was radiculopathy after a single traumatic event (9/16 athletes; 56%). Three players had transient paresis. Three players underwent one-level anterior cervical discectomy and fusion. These 3 players had failed nonoperative therapy and had evidence of spinal cord compression with signal change on MRI, but only 1 returned to sport. Three players received epidural steroid injections, which provided transient symptomatic relief. Five players were treated nonoperatively and did not return to sport. Two of these 5 athletes had cord compression with signal change and retired rather than undergo surgery. The other 3 were cleared but were released by the team. Eight players were treated nonoperatively and returned to sport. Three of these 8 athletes had evidence of disc material abutting the cord without cord signal change but had a normal examination finding and returned to sport after resolution of their symptoms and repeat MRI that demonstrated no cord compression. Five of the 8 players had evidence of root compression and were treated symptomatically. There were no subsequent traumatic spinal cord injuries at a minimum of 1-year follow-up. Conclusion: Data regarding the treatment of this unique population are limited but suggest that NFL athletes can safely return to sport after the treatment of cervical disc herniations. In the treatment algorithm for this study, cord compression with signal change in the cord on MRI was a consistent operative indication. Discs abutting the cord can be treated nonoperatively but do not allow for return to sport until symptoms have improved and repeat imaging demonstrates no cord compression. Isolated nerve root compression has a more favorable prognosis. It can be treated symptomatically and return to sport allowed when symptoms permit.

Purpose: To our knowledge, there is no published information on the efficacy of epidural steroid injections for the treatment of lumbar disc herniation in an athletic population. The purpose of this study was to evaluate the efficacy of epidural corticosteroid injection for treatment of lumbar disc herniation in a group of National Football League (NFL) players. Methods: We retrospectively reviewed the records of all NFL players who underwent an epidural steroid injection at our institution for incapacitating pain secondary to an acute lumbar disc herniation (confirmed on magnetic resonance imaging) from 2003 to 2010. Our primary outcome was success of the injection, defined as return to play. The secondary outcome of the study was to evaluate risk factors for failure of this treatment approach. Results: Seventeen players had a total of 37 injections for 27 distinct lumbar disc herniation episodes from 2003 to 2010. The success rate of returning an athlete to play for a given episode of disc herniation was 89% (24 of 27 episodes) with an average loss of 2.8 practices (range = 0�12) and 0.6 games (range = 0�2) after the injection. Four players required a repeat injection for the same episode. Three of these four players ultimately failed conservative management and required surgical intervention. Risk factors for failing injection therapy included sequestration of the disc herniation on magnetic resonance imaging (P = 0.01) and weakness on physical examination (P = 0.002). There were no complications reported. Conclusions: In this highly selective group of professional athletes, our results suggest that epidural steroid injections are a safe and effective therapeutic option in the treatment of symptomatic lumbar disc herniation.

Background: Shoulder instability and surgical stabilization are common in college football athletes. The effect of shoulder stabilization during college on the length of an athlete’s career in the National Football League (NFL) has not been well examined.Hypothesis: Athletes with a history of shoulder stabilization before the NFL combine have a shorter career than do matched controls.Study Design: Cohort study; Level of evidence, 3.Methods: A database containing the injury history and career NFL statistics of athletes from 1987 to 2000 was used to match athletes with a history of shoulder stabilization and no other surgery or significant injury to controls without a history of any previous surgery or significant injury. Athletes were matched by position, year drafted, round drafted, and additional minor injury history.Results: Forty-two athletes with a history of shoulder stabilization were identified and matched with controls. A history of shoulder stabilization significantly reduced the length of career in terms of years (5.2 ± 3.9 vs 6.9 ± 3.6 years; P = .01) and games played (56 ± 53 vs 77 ± 50, P = .03) as compared with controls. By position, linemen and linebackers (20 athletes) with a history of shoulder stabilization had a significantly shorter career in years (4.7 ± 3.8 vs 6.7 ± 3.4 years; P = .049) and games played (51 ± 58 vs 81 ± 48; P = .046) than did controls. Among the other positions (22 athletes), the difference was not statistically significant in this small cohort.Conclusion: A history of shoulder stabilization shortens the expected career of a professional football player, particularly for linemen and linebackers. Further research is warranted to better understand how these injuries and surgeries affect an athlete’s career and what can be done to improve the long-term outcome after treatment.

Background Avulsion of the rectus femoris origin is a rare injury. The only previous report of this injury in professional American football has been limited to the kicking athlete. Purpose To describe the incidence and treatment of proximal rectus femoris avulsion in the National Football League (NFL). Study Design Case series; Level of evidence, 4. Methods The NFL Injury Surveillance System (NFLISS) was reviewed for any proximal rectus femoris avulsion injuries from 1986 to 2006, including the type and mechanism of injury, player demographics, method of treatment, and time to return to play. The NFL team physicians and trainers were surveyed as to their experience with these injuries as well. Results A total of 11 cases of proximal rectus femoris avulsion were identified starting in 1997. These injuries occurred in athletes in a variety of positions. All of these were treated nonoperatively, and the mean return to play was 69.2 days. Conclusion Rectus femoris avulsions are uncommon injuries in the NFL, occurring about once a year in the entire league (once magnetic resonance imaging facilitated correct diagnosis of these injuries). Conservative treatment of these injuries usually results in return to play after 6 to 12 weeks. Clinical Relevance Proximal avulsions of the rectus femoris can be treated nonoperatively with a high degree of predictability for return to full, unrestricted participation in professional American football.

Background The National Football League holds an annual combine where individual teams evaluate college football players likely to be drafted for physical skills, review players’ medical history and imaging studies, and perform a physical examination. Purpose The purpose of this study was to test the effect of specific diagnoses and surgical procedures on the likelihood of playing and length of career in the league by position. Study Design Cohort study; Level of evidence, 3. Methods A database for all players reviewed at the annual National Football League Combine by the medical staff of 1 National Football League team from 1987 to 2000 was created, including each player's orthopaedic rating, diagnoses, surgical procedures, number of games played, and number of seasons played in the National Football League. Athletes were grouped by position as follows: offensive backfield, offensive receiver, offensive line, quarterback, tight end, defensive line, defensive secondary, linebacker, and kicker. The percentage of athletes who played in the National Football League was calculated by position for each specific diagnosis and surgery. Results The effect of injury on the likelihood of playing in the league varied by position. Anterior cruciate ligament injury significantly lowered the likelihood of playing in the league for defensive linemen ( P = .03) and linebackers ( P = .04). Meniscal injury significantly reduced the probability of playing ( P < .05) and length of career ( P = .002) for athletes in the defensive secondary. Shoulder instability had a significant effect on playing in the league for offensive ( P = .03) and defensive linemen ( P = .02), and shortened the length of career for defensive linemen ( P = .016). Spondylolisthesis did not significantly reduce the chance of playing in the league for any position, while a history of spondylolysis had a significant effect for running backs ( P = .01). Miscellaneous injuries (eg. acromioclavicular joint, knee medial collateral ligament, carpal fractures) had isolated position-specific effects. Conclusion The significant injuries and diagnoses appear congruent with the position-specific demands placed on the athletes. This information is useful to physicians and athletic trainers caring for college football athletes as well as those assessing these athletes at the National Football League Combine.

This study describes the epidemiology of knee articular cartilage injuries in the National Football League (NFL) and the typical treatment approach by NFL team physicians. All knee articular cartilage injuries in the league database from 1992 to 2006 were reviewed, and team physicians were surveyed about their treatment approach to these injuries. A total of 118 cases were identified, for an average of 8 per year, with a higher injury rate during games compared with practice. Approximately half of the injuries occurred in linemen, and the most common site of injury was the femoral condyle. Forty-six percent of these injuries were treated surgically, with slower return to play after surgery (124 versus 36 days, P < .01). Among team physicians, microfracture was the most popular treatment approach (43%), followed by debridement (31%) and nonoperative management (13%). More research is needed to compare long-term outcomes based on lesion size in these athletes.

Purpose: The National Football League (NFL) holds an annual combine to evaluate college football athletes likely to be drafted for physical skills, to review their medical history, and to perform a physical examination. The athletes receive an orthopedic grade on their ability to participate in the NFL. The purpose of this study was to test the hypothesis that this orthopedic rating at the combine predicts the percent of athletes who play in the NFL and the length of their careers. Methods: A database for all athletes reviewed at the combine by the medical staff of one team from 1987 to 2000 was created and linked to a data set containing the number of seasons and the games played in the NFL for each athlete. Players were grouped by orthopedic grade: high, low, and orthopedic failure. The percent of players who played in the NFL and the mean length of their careers was calculated and compared for these groups. Results: The orthopedic grade assigned at the NFL combine correlated with the probability of playing in the league. Whereas 58% of athletes with a high grade and 55% of athletes with a low grade played at least one game, only 36% of athletes given a failing grade did so (P < 0.001). Players with a high grade had a mean career of 41.5 games compared with 34.2 games for players with a low grade and 19.0 games for orthopedic failures. Conclusion: This is the first study to report on the predictive value of a grading system for college athletes before participation in professional sports. Other professional sports may benefit from using a similar grading system for the evaluation of potential players

Background Hyperconcavity of the vertebral endplates is a previously unreported radiologic phenomenon. Purpose To analyze hyperconcavity of the vertebral endplates with expansion of the disk space in pre–National Football League lineman and to determine its clinical significance. Study Design Descriptive anatomical study. Methods Over a 2-year period (1992-1993), 266 elite football linemen were evaluated at the National Football League scouting combine held in Indianapolis, Indiana. Evaluation focused on the lumbosacral spine and included history, physical examination, and lateral radiographs. Measurements were taken of all the vertebral endplate defects of involved vertebrae and compared with an age-matched control group of 110 patients. Results The analyzed data revealed the following: (1) hyperconcavity of the vertebral endplates appeared as a distinct entity in a high percentage of pre–National Football League lineman (33%) compared with age-matched controls (8%), (2) there was a trend toward a lower incidence of lumbosacral spine symptoms in those players who displayed hyperconcavity of the vertebral endplates (16%) versus those who did not (25%), and (3) when hyperconcavity of the vertebral endplates was present, all 5 lumbosacral disk spaces were commonly affected. Conclusions Hyperconcavity of the vertebral endplates and hypertrophy of the disk space are likely adaptive changes occurring over time in response to the repetitive high loading and axial stress experienced in football line play.

Background Quarterbacks are at risk for shoulder injury secondary to both the throwing motion as well as from contact injury. Objective To delineate the incidence and etiology of shoulder injuries to quarterbacks in the National Football League (NFL). Methods Using the NFL Injury Surveillance System (NFLISS), all reported injuries to quarterbacks between 1980 and 2001 were identified. Results A total of 1534 quarterback injuries were identified with a mean of 18.8 and a median of 6.0 days of playing time lost. The majority of these injuries occurred during a game (83.8%). Passing plays were responsible for 77.4% of all quarterbackrelated injuries. Shoulder injuries were the second most common injury reported (233 or 15.2%), following closely behind head injuries (15.4%). Direct trauma was responsible for 82.3% of the injuries, with acromioclavicular joint sprains being the most common injury overall (40%). Overuse injuries were responsible for 14% of the injuries, the most common being rotator cuff tendinitis (6.1%) followed by biceps tendinitis (3.5%). Conclusion In this review, the vast majority of shoulder injuries in quarterbacks occurred as a result of direct trauma (82.3%), and less than 15% were overuse injuries resulting from the actual throwing motion.

Background: Traumatic posterior hip subluxation is a potentially devastating injury that is often misdiagnosed as a simple hip sprain or strain. The purpose of the present study was to outline the injury mechanism, pathoanatomy, clinical and radiographic findings, and treatment of traumatic hip subluxation in an athletic population. Methods: Over a nine-year period, eight participants in American football who had sustained a traumatic posterior hip subluxation were evaluated and treated. The injury mechanism, clinical findings, and radiographic findings were reviewed. The mean duration of follow-up was thirty-four months. Results: The most common mechanism of injury was a fall on a flexed, adducted hip. Physical examination revealed painful limitation of hip motion. Initial radiographs demonstrated a characteristic posterior acetabular lip fracture. Initial magnetic resonance images revealed disruption of the iliofemoral ligament, hemarthrosis, and a viable femoral head. Two players were treated acutely with hip aspiration, and all eight players were treated with a six-week regimen of toe-touch weight-bearing with use of crutches. Six players recovered and returned to the previous level of competition. Two players had development of severe osteonecrosis and ultimately required total hip arthroplasty. Conclusion: The pathognomonic radiographic and magnetic resonance imaging triad of posterior acetabular lip fracture, iliofemoral ligament disruption, and hemarthrosis defines traumatic posterior hip subluxation. Patients in whom large hemarthroses are diagnosed on magnetic resonance images should undergo acute aspiration, and all players should be treated with a six-week regimen of toe-touch weight-bearing with use of crutches. Patients who have no sign of osteonecrosis on magnetic resonance imaging at six weeks can safely return to sports activity. Patients in whom osteonecrosis is diagnosed at six weeks are at risk for collapse and joint degeneration, and they should be advised against returning to sports. Level of Evidence: Prognostic study, Level IV (case series). See Instructions to Authors for a complete description of levels of evidence.

Venous air embolism (VAE) is a potentially life-threatening event that is most commonly associated with certain surgical procedures, although this theoretical complication of pressurized rapid infusion of intravenous (IV) fluids has been described. This series of cases describes 4 athletes who presented with continuous coughing and other chest complaints after peripheral IV infusion of normal saline through manual pressurized infusion. Symptoms resolved within 20 minutes, and these incidences did not interfere with resuming athletic competition with no recurrence of symptoms or complications. These cases are most consistent with varying degrees of VAE and reveal the risk of VAE associated with pressurized peripheral IV fluid administration along with the unique clinical presentation of more modest forms of VAE in an awake patient. Becoming more knowledgeable about IV infusion technique and understanding potential pitfalls can be helpful in reducing future incidences of VAE.

Syndesmosis sprains in the National Football League (NFL) can be a persistent source of disability, especially compared with lateral ankle injuries. This study evaluated syndesmosis and lateral ankle sprains in NFL players to allow for better identification and management of these injuries. Syndesmosis and lateral ankle sprains from a single NFL team database were reviewed over a 15-year period, and 32 NFL team physicians completed a questionnaire detailing their management approach. A comparative analysis was performed analyzing several variables, including diagnosis, treatment methods, and time lost from sports participation. Thirty-six syndesmosis and 53 lateral ankle sprains occurred in the cohort of NFL players. The injury mechanism typically resulted from direct impact in the syndesmosis and torsion in the lateral ankle sprain group ( P =.034). All players were managed nonoperatively. The mean time lost from participation was 15.4 days in the syndesmosis and 6.5 days in the lateral ankle sprain groups ( P ⩽.001). National Football League team physicians varied treatment for syndesmosis sprains depending on the category of diastasis but recommended nonoperative management for lateral ankle sprains. Syndesmosis sprains in the NFL can be a source of significant disability compared with lateral ankle sprains. Successful return to play with nonoperative management is frequently achieved for syndesmosis and lateral ankle sprains depending on injury severity. With modern treatment algorithms for syndesmosis sprains, more aggressive nonoperative treatment is advocated. Although the current study shows that syndesmosis injuries require longer rehabilitation periods when compared with lateral ankle sprains, the time lost from participation may not be as prolonged as previously reported.

We performed a retrospective review to evaluate acute medial collateral ligament injuries of the elbow in professional football players from 1991 to 1996 (5 seasons). There were 5 acute medial collateral ligament injuries in 4 players (1 player with bilateral involvement). All injuries occurred with the hand planted on the playing surface while a valgus or hyperextension force was applied to the elbow. There were 2 centers, both involved with long-snapping situations, 1 running back, and 1 quarterback. All elbows had valgus instability on physical examination. Despite this instability, all players were able to function without operative reconstruction of the medial collateral ligament. No evidence of valgus instability was seen at the time of follow-up (average, 3.4 years). Next, we reviewed all acute elbow injuries in the National Football League from the same 5-season period. Ninety-one acute elbow injuries were reviewed. Overall, there were 70 (76.9%) elbow sprains, 16 (17.6%) dislocation/subluxation patterns, 4 (4.4%) fractures, and 1 (1.1%) miscellaneous injury. Review of the acute elbow sprains revealed 39 (55.7%) hyperextension injuries, 14 (20%) medial collateral ligament injuries, 2 (2.9%) lateral collateral ligament sprains, and 15 (21.4%) nonspecific sprains. The epidemiology of the 14 medial collateral ligament injuries was studied in more detail. The 2 most common mechanisms of injury were blocking at the line of scrimmage (50%) and the application of a valgus force with the hand planted on the playing surface (29%). There were 8 linemen, 4 receivers, 1 running back, and 1 quarterback. All injuries were managed with nonoperative treatment. The average time lost was 0.64 games (range, 0 to 4). We report 19 acute medial collateral ligament injuries of the elbow in elite football players, 2 of whom are considered overhead throwing athletes, who were able to function at a competitive level without surgical repair or reconstruction, in contrast to baseball players, in whom the mechanics and demands may differ.

PURPOSE A 28-year-old hypertensive professional football player suffered a lacunar stroke. Given the rarity of stroke at this young age, the contributory roles of hypertension and competitive athletics merit consideration. CASE SUMMARY A 28-year-old defensive lineman, with long-standing, albeit recently well-controlled hypertension, experienced slurred speech and veering to his right after a game. Computerized tomography revealed a small internal capsule infarct. Diagnostic investigation, including coagulation profiling, sickle screen, antiphospholipid antibody, carotid imaging, and echocardiography did not reveal a cause. The patient recovered within days with no residual impairment. DISCUSSION Despite the extreme blood pressure elevation associated with isometric straining in young athletes, stroke almost never occurs. Vascular changes resulting from chronic hypertension and/or marked volume depletion, and hemoconcentration resulting from restricted salt intake, diuretic use, and heavy sweating, offer the only explanations for this stroke. RELEVANCE The case suggests physicians should exercise caution in using diuretics and salt-restricted diets to treat hypertensive athletes. Guidelines for treatment are discussed.

Ankle syndesmosis sprains are common injuries in collegiate and professional football. Several reports have documented that patients with syndesmosis injuries require a longer time to return to full athletic participation than patients with lateral ankle sprains. Here we present the cases of two professional football players with ankle pain secondary to syndesmosis ossification following documented syndesmosis ankle sprains. Both patients eventually required resection of the heterotopic ossification to allow a pain-free return to football. We conclude that syndesmosis ossification may be symptomatic in some patients, and surgical excision of the ossification may be required to allow an asymptomatic return to sports.

BACKGROUND AND IMPORTANCE:: Injuries in professional football players are common due to the nature of the collisions, and the frequency of axial loading to the cervical spine. These injuries should be thoroughly evaluated, as they can put the player at risk for future injury and even paralysis. The focus of this article is to present two cases of this injury and review the current body of literature. CLINICAL PRESENTATION:: We present two cases of professional football players who suffered injuries to the lower posterior elements of their cervical spine simultaneously on a kickoff during a game. Both players described transient symptoms consistent with a 'stinger', which is commonly encountered.Work-up revealed fractures of the lower cervical spine in both patients. One patient was able to be managed conservatively and returned to football the following season. The second case had an unstable fracture that ultimately required operative intervention and the patient retired from professional football. CONCLUSION:: Cervical spine injuries in football players need to be adequately evaluated and in many cases can be career-threatening. We recommend that players with persistent pain after a transient neurapraxia receive radiographs and CT of the cervical spine to evaluate for a fracture. Language: en

Background Hyperconcavity of the lumbar spine has been found in a disproportionate percentage of college football lineman evaluated at the National Football League (NFL) Combine compared with age-matched controls. Hypothesis College football linemen with hyperconcavity of the lumbar spine are more likely to play in the NFL and to have a longer career in professional football. Study Design Cohort study; Level of evidence, 3. Methods Ninety three linemen from the 1992 and 1993 NFL Combines with hyperconcavity of the lumbar spine were compared with 191 linemen from the same combines without these changes in the lumbar spine. The percentage of athletes who played at least 1 game for an NFL team and the average length of career was calculated for both groups. In addition, the length of career for players with these changes was compared with those of matched controls based on other injuries and surgeries, year drafted, and round drafted. Results There was no difference in the likelihood of playing professional football between linemen with lumbar spine changes (54 of 93 [58%]) and those without (101 of 191 [53%]) (P = .41). There was no significant difference between the 2 groups in length of career in terms of years played, games played, or games started. Conclusion Hyperconcavity of the lumbar spine does not appear to have any effect on the potential professional American football careers of college football linemen entering the NFL. Endplate changes on radiographs are not a significant screening tool for elite American football linemen. Further study of larger populations is needed to definitively answer whether these adaptive changes in the lumbar spine have any clinical relevance to these athletes.

Disruptions of the lateral soft tissue restraints of the elbow, including the lateral ulnar collateral ligament, are a well-recognized clinical entity which may result in chronic elbow instability. When symptomatic, most authors recommend surgery to reconstruct the LUCL. We report on a case of a professional football player who sustained complete disruption of the lateral collateral ligamentous complex from the lateral humeral epicondyle with extension of his injury into his common extensor origin. He was treated conservatively and returned to play after 4 weeks. Treatment algorithm and a review of the literature are discussed.

BackgroundMeniscal and anterior cruciate ligament (ACL) injuries are common in college football athletes. The effect of meniscectomy and/or ACL surgery on the length of an athlete’s career in the National Football League (NFL) has not been well examined.HypothesisAthletes with a history of meniscectomy or ACL surgery before the NFL combine have a shorter career than matched controls.Study DesignCase-control study; Level of evidence, 3.MethodsA database containing the injury history and career NFL statistics of athletes from 1987–2000 was used to match athletes with a history of meniscectomy and/or ACL surgery, and no other surgery or major injury, to controls without previous surgeries. Athletes were matched by position, year drafted, round drafted, and additional injury history.ResultsFifty-four athletes with a history of meniscectomy, 29 with a history of ACL reconstruction, and 11 with a history of both were identified and matched with controls. Isolated meniscectomy reduced the length of career in years (5.6 vs 7.0; P = .03) and games played (62 vs 85; P = .02). Isolated ACL surgery did not significantly reduce the length of career in years or games played. Comparing the athletes with meniscectomy or ACL reconstruction to athletes with combined ACL reconstruction and meniscectomy, a history of both surgeries, resulted in a shorter career in games started (7.9 vs 35.1; P ConclusionA history of meniscectomy, but not ACL reconstruction, shortens the expected career of a professional football player. A combination of ACL reconstruction and meniscectomy may be more detrimental to an athlete’s durability than either surgery alone. Further research is warranted to better understand how these injuries and surgeries affect an athlete’s career and what can be done to improve the long-term outcome after treatment.

Background Injuries to the hip account for approximately 10% of all injuries in football, but definitive diagnosis is often challenging. Although these injuries are often uncomplicated contusions or strains, intra-articular lesions are increasingly found to be sources of hip pain. Purpose The objective was to define the incidence and etiologic factors of intra- and extra-articular hip injuries in the National Football League (NFL). Study Design Descriptive epidemiology study. Methods The NFL Injury Surveillance System was used to define all hip-related injuries from 1997 to 2006. Injuries were included if the athlete missed more than 2 days. All hip and groin injuries were included for evaluation. The authors also report on NFL players with intra-articular injuries seen at their institution outside of the NFL Injury Surveillance System. Results There were a total of 23 806 injuries from 1997 to 2006, of which 738 were hip injuries (3.1 %) with an average of 12.3 days lost per injury. Muscle strains were the most common injury. Intra-articular injuries resulted in the most time lost. Contact injuries most likely resulted in a contusion, and noncontact injuries most often resulted in a muscle strain. In the authors’ institutional experience, many of the athletes with labral tears have persistent adductor strains that do not improve despite adequate therapy. Conclusion Hip injuries represent a small but substantial percentage of injuries that occur in the NFL. A majority of these injuries are minor, with a return to play within 2 weeks. Intra-articular injuries are more serious and result in a significant loss of playing time. The “sports hip triad” (labral tear, adductor strain, and rectus strain) is described as a common injury pattern in the elite athlete.

Background Football is one of the leading causes of athletic-related injuries. Injury rates and patterns of the training camp period of the National Football League are unknown. Hypothesis Injury rates will vary with time, and injury patterns will differ between training camp practices and preseason games. Study Design Descriptive epidemiology study. Methods From 1998 to 2007, injury data were collected from 1 National Football League team during its training camp period. Injuries were recorded as a strain, sprain, concussion, contusion, fracture/dislocation, or other injury. The injury was further categorized by location on the body. Injury rates were determined based on the exposure of an athlete to a game or practice event. An athlete exposure was defined as 1 athlete participating in 1 practice or game. The injury rate was calculated as the ratio of injuries per 1000 athlete exposures. Results There were 72.8 (range, 58-109) injuries per year during training camp. Injuries were more common during weeks 1 and 2 than during weeks 3 to 5. The rate of injury was significantly higher during games (64.7/1000 athlete exposures) than practices (12.7/1000 athlete exposures, P < .01). The rate of season-ending injuries was also much higher in games (5.4/1000 athlete exposures) than practices (0.4/1000 athlete exposures). The most common injury during the training camp period was a knee sprain, followed by hamstring strains and contusions. Conclusion Muscle strains are the most common injury type in practices. Contact type injuries are most common during preseason games, and the number of significant injuries that occur during preseason games is high.

Background The frequency and severity of kidney injuries and their impact on return to play in American football has not been described in the literature. Purpose Our objective is to identify the number of kidney injuries in the National Football League (NFL) and the effect of these injuries. Study Design Case series; Level of evidence, 4. Methods All kidney injuries in the NFL from 1986 to 2004 were reviewed, including the type and mechanism of injury, treatment, and time to return to play. In addition, NFL physicians and athletic trainers were asked if they were aware of any football player at the professional, collegiate, or high school levels who had lost a kidney and how they would advise a football player with only 1 functioning kidney. Results A total of 52 cases of renal injuries were identified, an average of 2.7 cases per season. The rate of kidney injury was 10 times greater during games (0.000055 per exposure) than practices (0.000005 per exposure) ( P < .0001). The most common injury was kidney contusion (42), followed by kidney laceration (6) and kidney stones and dysfunction (2 each). Almost all the injuries were contact related (49). More than a third of the players required hospitalization for their injury (18), although none required surgery. All the athletes returned to play. The most days missed were after a kidney laceration (mean, 59.8), followed by kidney contusion (15.1) and dysfunction (14.0). While 61% of respondents would allow a professional athlete with only 1 kidney to play, approximately 50% would advise a college athlete with only 1 functioning kidney not to play football, and 60% would advise a similar high school athlete not to play. Conclusion Renal trauma is a rare but potentially debilitating injury in the NFL, with players at greater risk during games. Most players recover to play, but it may take some time, especially with a kidney laceration. It may be safe for players with only 1 functioning kidney to play in the NFL.

Purpose: The National Football League holds an annual combine where individual teams evaluate college football players likely to be drafted. As part of the combine, the players are evaluated with a medical history, physical exam, and review of imaging studies, and then they are rated medically as to their ability to participate in the NFL. The purpose of this study was to review the prevalence of musculoskeletal disorders in this population and to test the hypothesis that fewer players were medically disqualified over calendar time from 1987 to 2000. Methods: The available summary data for all players reviewed at the annual combine by the medical staff of one NFL team from 1987 to 2000 was analyzed, including each player's position, collegiate division, medical rating, and their diagnoses and surgical procedures. Results: A total of 5047 complete records were available for analysis. The average number of diagnoses per player was 2.45, and the average number of procedures was 0.53. The most common diagnoses were ankle sprain, burner, hand/wrist soft-tissue injury, knee MCL injury, and AC-joint injury. The most common procedures were meniscectomy, knee arthroscopy, ACL reconstruction, shoulder stabilization, and ORIF ankle fracture. Overall, 5.63% of the players were rejected for medical reasons. The risk of failure dropped during the study period (P < 0.0002). Over time, fewer players with a history of ACL reconstruction received a failing grade (P = 0.0005). Conclusion: The percentage of athletes with a failing grade, particularly those with a history of ACL reconstruction, decreased over the study period. Knowing the trends in prevalence of injury and treatment for these athletes may help optimize their care and aid the development of injury-prevention and treatment strategies.

This study investigates whether there is a systematic relationship between a firm's market value (as measured by its market to book ratio) and the variability of its quarterly earnings stream. Using data from the Compustat full coverage, industrial and research quarterly files from 1973 to 1998 inclusive I find that, after controlling for firm size, leverage, current profitability, the level of current investment and sales growth, there is a significantly negative relationship between the market to book ratio and earnings volatility (defined as the coefficient of variation of various earnings measures). I further find that this negative relationship remains even after controlling for operating cash flow volatility, indicating that "accounting-driven" earnings volatility does indeed have an economic impact as has long been claimed. My results are robust to various specifications (including fixed effects, the inclusion of industry dummies, the inclusion of year-quarter dummies and adjusting all variables relative to the relevant industry year median) and to the inclusion of additional control variables such as future cash flow volatility and future profitability. In addition to being statistically significant, my results also have economic significance. For example, there is on average a 0.04 difference in market to book ratios between a firm whose earnings volatility is in the 5th percentile and one in the 95th percentile. If we compare the 1st and 99th percentiles, we obtain a difference in market to book ratios of 0.23, approximately 15% of the median.

In this paper, I discuss the issue of how non-financial corporations should report the results of their use of derivative financial instruments. Using the recently issued SFAS 133 as a framework, I introduce three possible accounting regimes (mark to market, mark to market hedge and deferral hedge) and characterize the information provided to users of financial statements under each of the three alternatives. I then present a simple economic model with which to analyze the effect (if any) on corporate risk management policies of the different regimes. My main result is that hedging distortions (defined as deviations from the optimal hedge position in the absence of any accounting considerations) may occur in a mark to market regime but not in a mark to market hedge or deferral hedge regime. Finally, I discuss the policy implications of this result and explain how the ability to make voluntary disclosures may eliminate these distortions - this conclusion is, however, valid only if the underlying risk exposures of firms are ex-post verifiable.

A retrospective review was performed of records for players who suffered fractures about the orbit during participation in officially sponsored activities of the National Football League from 1980 to 1997. Clinical information was obtained on 19 of 29 players who sustained orbital fractures. The most common signs and symptoms included decreased visual acuity (74%, 14), decreased eye movement (42%, 8), hyphema (37%, 7), and infraorbital numbness (21%, 4). The mechanisms of injury were a digital poke (74%, 14) and blunt facial trauma (26%, 5). There were significantly more orbital fractures than zygomatic fractures suffered by offensive linemen as compared with all other positions. Fifteen of 19 players were managed with surgical reconstruction; 4 players were treated nonoperatively. The mean time from injury to surgical procedure was 7.7 days (range, 0 to 42). The mean interval to follow-up was 45.6 months (range, 3 to 146). At follow-up examination, eight (53%) of the patients treated surgically still reported diplopia with upper field gaze. Three of the four patients treated nonoperatively were asymptomatic. The mean time lost from games or practice was 25 days (range, 5 to 56). Ultimately, 17 (89%) players with orbital fractures were able to return to full football activities. Two patients were unable to resume their careers because of residual visual impairment.

This article reviews the existing literature in the following areas of sports neuropsychology: Dementia Pugilistica, concussion and Post Concussion Syndrome, Second Impact Syndrome, and the emerging role of the sports neuropsychologist regarding return to play decisions. Dementia Pugilistica is discussed as a condition that exists along a continuum: Although many boxers will develop mild neurocognitive deficits, it is not yet known what percent of these mild presentations will progress to diagnosable Dementia Pugilistica. Factors contributing to both increased and reduced risk are detailed. The role of neuropsychological assessment in research and clinical management is reviewed. Existing studies of concussion incurred during contact sports provide evidence of an important role for neuropsychology in assessment and management of mild head injuries. Issues in clinical assessment of concussion are reviewed. The importance of grading of concussions, monitoring of postconcussive symptom resolution, and the use of neuropsychological test results in return to play decisions is detailed. The Second Impact Syndrome is discussed with regard to return to play decisions. Recommendations are proposed for research and for clinical application of findings in sports neuropsychology.

Nitric oxide, a free radical inter- and intracellular messenger molecule, is important in exercise physiology. This study tested the hypothesis that serum nitric oxide concentrations change after strenuous exercise with severe generalized muscle cramps. The study group consisted of 77 professional football players in preseason training. All players' concentrations of serum nitrite and of other serum chemicals were determined during their preseason evaluations and compared with the concentrations in 40 serum samples taken from 25 of those same players who required intravenous rehydration for severe generalized muscle cramps after a training session. Player weight and percentage of body fat were significantly higher in players who received intravenous fluids than in players who did not. The serum of players requiring intravenous hydration showed evidence of skeletal muscle breakdown (increases in lactate dehydrogenase, creatinine phosphokinase, aspartate aminotransferase, and alanine aminotransferase) and of dehydration (elevations in protein, blood urea nitrogen, and cholesterol). The major finding, however, was a nearly 300% increase in serum nitrite concentrations in players requiring rehydration. There were no correlations between concentrations of nitrate and of any of the other serum chemicals. These data support the hypothesis that large amounts of nitric oxide are synthesized in professional football players after strenuous exercise with severe muscle cramps. The study design did not allow us to determine whether this increase in nitric oxide was due to exercise or muscle cramps or both, but it does provide a basis for evaluating these relationships.

Introduction Standard MRI is normal following the vast majority of concussions. Diffusion tensor imaging (DTI) and susceptibility-weighted imaging (SWI) are advanced MRI techniques hypothesized to be more sensitive in detecting subtle evidence of structural brain injury. Using DTI and SWI in National Football League (NFL) players, we aim to elucidate and localise the presence of such injury following concussions. Methods This ongoing prospective study has recruited active NFL players with and without history of concussion within 6 months prior to entry. Neurological and neurocognitive examination, DTI, and SWI were performed on each subject. Blinded neuroradiologists performed radiographic analysis. Fractional anisotropy (FA) values were measured for 11 distinct white matter tracts on DTI. A global FA value was calculated. SWI was utilised to assess for microhemorrhage. Statistical comparisons between players with and without recent concussion, and to civilian controls, were made. Results Seven of eighteen evaluated players to date had a concussion within 6 months of entry. On DTI, of the 11 tracts evaluated, a significant decrease in FA for concussed players was seen in one tract. There was no significant difference in global FA assessment between players with and without recent concussions. Civilian control comparisons are ongoing. SWI was negative in all players. Conclusions To our knowledge this is the largest prospective brain imaging study, and the first utilising DTI and SWI to assess anatomical injury secondary to concussion, in NFL players. Minimal changes have been observed in players with recent concussion. The clinical significance of these findings remains under investigation. Learning Objectives By the conclusion of the session, participants should be able to (1) understand the role of DTI and SWI in the evaluation of mild traumatic brain injury (2) discuss to what degree long-term football play poses risk in terms of structural brain injury. References Concussion, football, MRI, NFL. How will your Research Improve Patient Care There is no reliable objective test to evaluate the severity of brain injury suffered secondary to concussion, and concussion is a growing area of concern in football and other contact sports. This study evaluates to what degree brain injury as detected by highly sensitive MR technologies (DTI and SWI) is suffered by those who have had long-term, high-level participation in football and now play at the professional level. Information from this study could play an important role in establishing neurological risks of football.

Injury to the metatarsophalangeal (MP) joint of the great toe, often termed “turf-toe”, is a common occurrence in football. We have identified four cases of first MP plantar capsular injury with diastasis of a bipartite sesamoid. In three cases, observation and protection resulted in progressive widening of the fragments associated with pain and disability. These players required resection of the distal sesamoid fragment and repair of the volar capsule. The fourth player underwent acute repair of the medial retinaculum and capsule. All players have had a full return to sports activity. Diastasis of components of a partite sesamoid provides objective evidence of disruption of the plantar capsular mechanism. Early recognition of this condition confirmed by stress radiographs is recommended. Treatment may include early protection followed by resection, if painful, or acute repair of the retinaculum. Previous descriptions of turf-toe have not included injuries to the sesamoid complex of the first MP joint. In our opinion, the term turf-toe should represent the consequences of a hyperextension injury to the first MP joint in which the volar capsule has been disrupted proximal to the sesamoid. A classification for first MP joint injuries is presented.

Metatarsophalangeal joint injuries of the great toe (turf- toe) are receiving increasing attention in the literature because of the prevalence of synthetic surfaces and lighter, more flexible shoes. Eighty active professional football players were evaluated. The mechanism of injury was hyperextension in 85% of the players. Eighty-three percent reported their initial injury on arti ficial turf ( P < 0.05). Other factors significantly related to the incidence of turf-toe included player age ( P < 0.01), number of years in professional football ( P < 0.01), and range of ankle dorsiflexion ( P < 0.05). Turf- toe injury resulted in significantly decreased range of motion of the first metatarsophalangeal joint ( P < 0.01).

Method: The study group consisted of 77 professional American Football players undertaking preseason training. Serum samples of nitrite (a stable end product of NO) and serum chemistries were obtained from all players during their pre-season evaluation and compared with 40 serum samples tal~en from 25 of those same players (eight players on more than one occasion) who required intravenous (IV) rehydration for severe generalised muscle cramps after a training session.

In brief: The prevalence of artificial playing surfaces on football fields and the use of lightweight shoes on these surfaces have been associated with an increased incidence of metatarsophalangeal joint sprains of the great toe, a condition commonly known as turf toe. Artificial turf tends to decrease shock absorption, and lightweight shoes do not give the player adequate support. Signs and symptoms include pain, hyperemia, and swelling around the joint. Roentgenograms show only generalized soft-tissue swelling unless there is a concomitant fracture. The authors review the pertinent anatomy, mechanisms of injury, differential diagnosis, and possible long-term sequelae of turf toe. In addition, they present guidelines for treatment, return to activity, and prevention.