John M. MacKnight
Sports medicine coverage of American football places unique demands on the sports medicine practitioner. A wide variety of football-specific conditions demand that those responsible for the care of football teams be well versed in an array of both medical and orthopedic issues.
Appropriate planning can minimize the likelihood of athlete injury and help to ensure that athletes are protected and returned to play safely and in a timely manner.
Fifty percent of football players at all levels will be injured to some degree in any given season. The majority of these injuries involve the lower extremity, with sprains, contusions, and strains being most common. Fractures account for approximately 10% of injuries.
Lower Extremity Injuries
Medial Collateral Ligament Sprain, Knee
The most common knee injury seen in football, resulting from a valgus load to the knee by another player during blocking or tackling.
Grading of medial collateral ligament (MCL) sprains:
Grade I injuries have stretched but not disrupted the ligament, and the knee examination (valgus loading of the knee at 0 and 30 degrees of flexion) reveals no laxity compared to the uninjured side.
Grade II injuries have partial ligament disruption with discernible laxity and increased excursion on valgus testing but preservation of an endpoint.
Grade III injuries represent full ligament tears with gross laxity and no discernible endpoint.
All three grades are generally managed conservatively with icing, nonsteroidal anti-inflammatory drugs (NSAIDs), and protective bracing. Even athletes with grade III injuries may resume sport in protective braces if symptoms allow.
Many football programs now use protective medial stabilizing braces to decrease the incidence of MCL injury, particularly in interior linemen. Although data have not clearly proven their efficacy, braces may enhance proprioceptive function (and thus allow the player to avoid high-risk knee positions) and are a reasonable preventative measure for at-risk players.
An injury to the medial or lateral meniscal cartilage typically resulting from a rotational injury applied to the flexed knee.
Pain may be acute or chronic, and the athlete commonly complains of mechanical symptoms including a sense of locking or giving way of the knee.
Meniscal tears are classically characterized by small effusions, focal joint line tenderness to palpation, normal ligament testing, and positive McMurray and Apley grind tests. Pain and dysfunction may also be elicited by squatting.
Definitive diagnosis is usually via magnetic resonance imaging (MRI), which demonstrates characteristic signal changes in the affected meniscus.
Most meniscal tears are amenable to arthroscopic debridement with resumption of football activities in as few as 2 weeks.
Anterior Cruciate Ligament Tear
The most devastating knee injury commonly seen in football, anterior cruciate ligament (ACL) tears, generally result from valgus loading of the slightly flexed knee, creating significant shear forces on the ACL with resultant tearing. The majority are noncontact injuries, but the ACL may be torn in a similar contact mechanism to that of the MCL noted earlier. As such, simultaneous injury of both ligaments is not uncommon.
The injury is accompanied by significant pain, often an audible “pop” or a sense of tearing inside the knee, immediate swelling, subjective instability of the knee, and laxity on the Lachman or anterior drawer test.
For competitive athletes, ACL tears generally require surgical reconstruction. Graft options include patellar tendon, hamstring tendon, or cadaveric grafts. Patellar tendon grafts are generally preferred in athletes but may lead to earlier patellofemoral arthritis than the alternatives. Caution must also be used with patellar grafting in athletes with prior patellar tendon dysfunction. After 6-9 months of aggressive rehabilitation, functional bracing to protect the reconstructed ACL is generally desirable to aid safe return to full football activities.
A common injury typically of the midsubstance of the hamstring musculature characterized by partial tearing, edema, and ecchymosis.
Clinically presents with acute onset of posterior thigh pain in association with sprinting, explosive acceleration or deceleration, or change in direction.
Physical exam reveals focal tenderness over the injured muscle belly. There may be a discernible muscular defect present. Mild warmth and edema may be present. Ecchymosis is common and can be impressive.
The athlete typically limps, holds the knee in mild flexion, and has obvious loss of knee extension range of motion.
Management focuses on acute injury modalities followed by general restoration of range of motion and full strength before resuming running or football activities.
Significant hamstring strains may take up to 6 weeks to heal.
The most common soft tissue injury in football, resulting from blunt trauma.
Treatment focuses on limitation of hemorrhage and inflammation while maintaining range of motion and strength. Ice and NSAIDs are appropriate initial interventions. Some practitioners advocate immobilizing the knee in 120 degrees of flexion to limit hemorrhage and hematoma formation.
Massage and ultrasound should be avoided early in the treatment course to allow for early stabilization of the damaged muscle and to minimize the risk of developing myositis ossificans. This complication is characterized by calcific changes in areas of damaged muscle and occurs in up to 20% of cases if treated inadequately.
Athletes may return to play when they have full range of motion and strength equivalent to that of the uninjured leg.
A sprain of the plantar-capsular ligament complex with associated articular cartilage damage to the metatarsal heads or base of the proximal phalanx.
The first metatarsophalangeal (MTP) joint is the primary area of injury, typically resulting from forced dorsiflexion of the planted toe on the turf. Athletes experience significant pain, have local swelling, and often limp.
Artificial turf surfaces and lighter, more flexible shoes have been implicated in a rising incidence of turf toe injuries.
Management centers on protection of the area with a rigid insert in the shoe to protect against dorsiflexion, donut padding, taping, ice, and NSAIDs. Activity status is as dictated by pain.
Contusion or separation of attached muscle fibers at the superior aspect of the iliac crest as a result of blunt trauma, generally resulting in a significant degree of pain and dysfunction.
X-rays are generally unnecessary at the time of diagnosis but should be strongly considered for symptoms that are prolonged or increasing.
Management includes aggressive icing, stretching of the low back and flank muscles, and additional protective padding at the time of return to play.
Local modalities such as ultrasound, corticosteroid injections, or platelet-rich plasma injections may speed the healing response as well.
Upper Extremity Injuries
Glenohumeral instability is a common shoulder malady in football athletes occurring when the glenohumeral joint is partially or completely destabilized as a result of repetitive blows to the shoulder or the unique acute loading that may arise with blocking and tackling.
Frank dislocations occur anteriorly in 95% of cases and result from excessive abduction, extension, and external rotational forces.
Physical examination classically reveals apprehension when the humeral head is moved anteriorly or posteriorly in the glenoid.
Instability events should prompt an early x-ray evaluation to assess for bony injury to the glenoid labrum (Bankart lesion) or impaction injury to the humeral head from sliding across the glenoid (Hills-Sachs lesion).
Single or recurrent instability episodes may predispose to labral cartilage tears. These typically arise in the Superior portion of the Labrum and extend Anterior to Posterior. This common pattern gives rise to the term “SLAP” tear.
Although surgery to correct shoulder instability is a frequent consideration because the recurrence rate for subluxations or dislocations is 50%, aggressive rotator cuff strengthening coupled with functional bracing may provide excellent results.
Open stabilization surgery, rather than arthroscopy, is a more predictable means of restoring shoulder stability with excellent maintenance of range of motion and postoperative stability (14).
SLAP tears in association with mild instability may be addressed arthroscopically without performing a stabilization procedure.
Offensive linemen may also develop posterior instability from blocking with outstretched arms and repetitively loading the posterior capsule of the glenohumeral joint. Except in extreme cases, aggressive rehabilitation and modification of weightlifting techniques are generally adequate for management.
This common shoulder injury, also referred to as a “separated shoulder,” is a sprain of the supporting ligaments of the acromioclavicular (AC) joint.
The typical mechanism of injury is either striking another player with the point of the shoulder or landing directly on the point of the shoulder, often when being tackled.
Initial presentation reveals exquisite point tenderness over the AC joint. A bony “step-off” with inferior displacement of the acromion relative to the clavicle may be appreciated.
X-rays are indicated to evaluate for concomitant clavicle fracture and to assess the degree of AC separation. Weighting of the injured arm may help to determine if there is widening of the AC joint with downward distraction.
Management focuses on control of inflammation and pain, protection of the AC joint via padding, early restoration of active shoulder range of motion, and preservation of shoulder strength.
Even high-grade AC sprains generally do not require surgery, and most heal completely in 6 weeks. Elite athletes may opt for surgical stabilization to speed their return to play.
Force applied to the distal interphalangeal (DIP) joint of the finger may result in a flexion injury, which either results in injury to the extensor tendon or in a fracture at its attachment point on the dorsal aspect of the distal phalanx.
Mallet finger classically presents as an “extension lag” of the DIP with drooping and an inability to fully actively extend the DIP joint.
X-rays may reveal a fracture of the dorsal base of the distal phalanx on lateral view or may be normal with a pure tendon injury.
Standard management is to splint the DIP joint in mild hyperextension continuously for 6 weeks using a Stax splint or equivalent.
If recognized and managed early, surgery is often unnecessary.
Forced extension of the actively flexed finger, as in attempting to grasp an opponent for a tackle, may result in avulsion of the flexor digitorum profundus from its insertion on the volar side of the distal phalanx.
The ring finger is most commonly involved, followed by the middle finger.
The athlete will feel a pop, and the retracted tendon may be palpable proximally in the finger. Examination will demonstrate loss of independent flexion of the DIP joint.
Early surgical repair is the treatment of choice.
SPINAL AND NEUROLOGIC INJURIES
Cervical Spine Injury
Historically, head trauma had been the most common source of morbidity and mortality in football, most commonly from subdural hematomas. Better helmet construction decreased such head injuries but fostered technique changes in play that favored leading with the head and neck for tackling and blocking, so-called “spearing.” This dangerous technique led to a marked increase in cervical spine injuries until rule changes were instituted to outlaw spearing in football.
A review of 1,300 cervical spine injuries from the National Football Head and Neck Injury Registry has documented axial loading of the cervical spine as the major mechanism of catastrophic cervical spine injuries (22).
The normal cervical spine is comprised of an arc of vertebral bodies that is able to withstand substantial loading by dissipating forces evenly across each vertebral level. However, when the neck is flexed forward 30 degrees, it becomes a straight segmented column of bones that cannot dissipate force evenly. Axial loading of the neck in this flexed position may then result in excessive forces on the vertebral bodies, leading to bony failure, fracture, and cervical spinal cord injury.
Cervical Cord Neurapraxia
Transient, reversible deformation of the spinal cord resulting from significant trauma to the neck.
The etiology of transient quadriplegia.
Athletes may experience transient bilateral (differentiating this entity from a brachial plexus neurapraxia—see next section) sensory changes, frank sensation loss, and variable motor changes including complete paralysis.
Episodes typically last less than 15 minutes but may persist up to 2 days.
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