NFL Injury Reference

A high ankle sprain involves stretching or tearing the ligaments at the lowest end of the tibia and fibula, and possibly some of the fibres of the fascia. The severity of the injury is largely dependent on how much of the fascia is torn.

The two long bones in the lower leg (tibia and fibula) are held together with ligaments and a wide sheet of connective tissue (fascia) that runs nearly the entire length of the lower leg.

The most common mechanism for a high ankle sprain is external rotation of the shin on a fully flexed, planted foot. This happens most often to running backs and linemen whose torsos get forcibly twisted while they have their foot planted in the ground.

An MRI will show the damage to the ligaments and fascia, and any additional damage. These injuries may also de diagnosed with x-ray, where the spacing between bones will indicate that the tissue holding them together is stretched or torn.

Initial management includes stabilizing the joint with a splint or boot, and limiting weight bearing.

Some high ankle sprains are paired with a break in the fibula. If that break is near the top of the fibula, it’s called a Maisonneuve fracture.

Many high ankle sprains can be treated with a period of immobilization and non-weight bearing, followed by a gradual progression adding weight bearing back, then range of motion and strengthening.

Partial injuries (grades 1-2) recovery averages around 6 weeks. Complete tears of the ligaments need 9-16 weeks for healing and are more likely to need surgery.

Surgery for high ankle injuries involves securing the long bones of the lower leg together to allow the tissue between them to heal. This can be done with screws (rigid) or with sutures (flexible). Cases that include a break in the fibula may also use a plate and screws to fix the bone.

The time to return to play after high ankle sprain surgery is highly dependent on if there were other injuries associated with the sprain (like a bone fracture). For more straight forward cases, return to sport may be possible about 8 weeks after surgery.

A stable ankle with pain free running, jumping and strength to perform on field.

Since many high ankle sprains are from forced rotation of the lower leg, turf is a higher risk than grass. If a cleat it pinned in the turf, it can’t rotate as the body pivots, so the ankle rotates instead of the foot.

The ligaments on the outer side of the ankle are the most commonly sprained ligaments in football. Most rolled ankles involve the foot rolling inward, which stretches the structures on the outside. Ankle sprain are graded 1-3: Gr 1 is where the ligament fibres are stretched but intact; Gr 2 is some of the ligament fibres are torn but not all; Gr 3 is a complete tear.

The outside (lateral side) of the ankle is stabilized by ligaments that attached to the ankle bone (lowest part of the fibula) to the bones of the foot. These ligaments stop the foot from rolling inward.

Lateral ankle sprains often happen when an athlete jumps then lands on another player’s foot, or when they step on another player while running. They can also happen if the player missteps during a change of direction, causing the ankle to roll.

Imaging for a lateral ankle sprain usually starts with an Xray to see if there is any break in the end of the fibula (ankle bone), or any of the other bones in the foot and ankle. After the xray, an MRI will show the specific ligaments involved in the sprain and how much they are stretched or torn.

The first thing is to make sure the joint is stable until you know if there are any broken bones. Treating pain and avoiding excessive swelling through elevation and compression are also recommended.

Rehabilitation for a lateral ankle sprain includes restoring range of motion and strength. It’s also important to work on balance and stability, then progressively adding change of direction and jumping.

Complete recovery often takes 4-6 weeks, however for low grade sprains, many NFL players are back on the field in 1-2 weeks with supportive taping and ongoing rehabilitation.

Surgery for ankle sprains is uncommon and usually considered a last resort for athletes with chronic instability that doesn’t get better with non-surgical rehabilitation. Surgical options include tightening the ligaments on the outer ankle that have been stretched, or fully reconstructing them using graft tissue.

Recovery from surgery includes immobilization followed by gradual return to weight bearing. Many athletes can begin running around 8 weeks post op and resume playing 10+ weeks post op. These timelines become longer if there are any additional injuries like damage to the joint cartilage, or the ligaments along the inside of the

https://link-springer-com.proxy1.lib.uwo.ca/article/10.1007/s00167-015-3815-1

Return to play criteria include the ability to sprint, jump, and make unexpected changes of direction at full game speed.

Lateral ankle (or low ankle) sprains are an injury that tend to recur. Once the ligaments have been stretched out, it becomes easier and easier to re-roll the ankle. Maintaining the strength of the stabilizing muscles is important for minimizing risk of re-injury.

The pectoralis major muscle attaches the chest to the front of the shoulder and is the primary muscle used to push forward (ie bench press). Pec injuries can be partial or complete tears of the muscle fibres, or of the tendon that attaches the muscle to the bone. Most pec tears happen at the shoulder end of the muscle or tendon, not the chest side. The tear is often right where the tendon attaches to the arm bone.

The pec major muscle is located in the chest and runs from the rib cage out to the upper arm. The muscle is responsible for pushing type movements (like bench press), and it rotates the arm inwards. The muscle is fan shaped, with the wide side attaching to the rib cage and the narrow end at the upper arm.

The pec can be strained or torn when the athlete pushes forward against a force that’s stronger than their muscle. For example a lineman may push against an opponent too big or strong to move. The muscle is often trying to contract while at it’s most stretched length when it tears (ie in a position like the lowest phase of a bench press)

An MRI will best show the amount of tearing and the location of the tear in the muscle or tendon.

Treat the inflammation and pain. Immobilize in a sling and avoid stretching to prevent further damage

Immediate/fast bruising and significant weakness may indicate bigger muscle tears.

Complete muscle or tendon tears may retract, pulling away from where they should attach making it difficult for them to heal without intervention. Even after a successful surgery, there is a possibility of re-tearing which usually happens at the same site as the repair.

Non-surgical management is a good optionfor strains where muscle fibres are stretched but not torn, or where the tearing is minimal and not through the full tendon or muscle. In these cases, immobilization in a sling followed by progressive range of motion and strengthening helps get the athlete back to full functioning.

4-6 weeks is an average recovery timeline for strains treated without surgery. Higher grade strains/partial tears treated without surgery may take more than the 6 weeks to fully regain function and they may never return to the same strength as pre-injury.

Pec major tears with significant or full tearing are best treated with surgical repair. The surgery involves stitching the torn ends back together, or re-attaching the end of the tendon to the arm bone.

The recovery and return to sport after surgery is approximately 4-6 months.

UCL sprains are the stitching or tearing of the ligament along the inside of the elbow. These sprains can be from repetitive use, or from a traumatic incident. Most UCL injuries in football are from a traumatic incident.

The ulnar collateral ligament of the elbow (aka the medial collateral ligament of the elbow) runs along the inside of the elbow, connecting the upper arm and forearm. The ligament is under tension when throwing, particularly a more sidearm style, or if the elbow is forced inwards.

Elbow ulnar collateral (medial collateral) ligament injuries can be overuse injuries, most common in overhead throwing athletes, or from a single event where the elbow is force inward while the hand is fixed to something (like the ground or another player). In football, running backs have some of the higher likelihood of UCL injuries from stiff arming opponents and blocking.

An MRI will show how much of the ligament is stretched or torn, and if there’s additional damage to the bones or muscles in the area.

Stabilize the elbow in a sling for comfort and manage the pain.

Damage to the ulnar nerve. A UCL tear is associated with strain or tearing of the forearm flexor and pronator muscles.

UCL sprains that aren’t full tears and don’t have significant instability or loss of function are treated without surgery. The focus of non-surgical management is strengthening the forearm flexor-pronator muscle group, which reinforces the elbow, and in addressing movement patterns that may have put the elbow under stress.

Complete healing take about 4-6 weeks. Very mild sprains may ge back on the field faster than this, often supported with tape or a brace.

The surgical procedure for elbow UCL injuries is known as Tommy John surgery, where the ligament is reconstructed with a graft. This is not common in football players, where most UCL sprains are grade 1 or 2 and respond to non-surgical management.

There is little data about return to football after Tommy John surgery since it’s fairly uncommon. In sports like baseball, return to professional baseball after surgery is typically about a year.

Despite being an upper body injury, there is data showing a higher number of elbow UCL tears when playing on turf vs on natural grass.

https://pmc-ncbi-nlm-nih-gov.proxy1.lib.uwo.ca/articles/PMC6732864/

A Jones fracture is a break in the base of the 5th metatarsal.

The metatarsals are 5 long bones that make up part the forefoot. The ends of each metatarsal join to a toe. The metatarsals are numbered 1 to 5 so the 5th metatarsal is along the outside edge of the foot and meets up with the pinky toe. The base of the 5th metatarsal is the end of the bone closest to the ankle and most people have a small bump around the middle of the outer edge of the foot where the base of the 5th is located.

These fractures often happen from jumping/landing, particularly when the athlete twists the foot to pivot or change direction at the same time.

Xray, MRI or CT scans can show Jones fractures

Immobilization (boot or cast), among pain and refer for imaging and decision making about surgery or non-surgical management

Evidence suggests returning to football in 10 weeks or less after surgery is related to high likelihood of needing a second surgery.

Immobilization (boot or cast) for 6-8 weeks followed by gradual return to performance.

8-12 weeks

Open reduction internal fixation (ORIF) where the surgeon re-aligns the bone and stabilizes it with a plate and screws.

Athletes might get cleared to begin running around 8 weeks post op and potentially play around 10+ weeks post op.

Complete fracture healing on x-ray paired with the ability to run, jump, cut and pivot as needed with no pain.

https://pmc.ncbi.nlm.nih.gov/articles/PMC7251008/

Lisfranc injuries can be fractures in the mid foot bones, or sprains/tears of the ligaments that hold the midfoot joints together. These injuries typically allow the midfoot bones to slide upward or spread apart, disrupting the arch structure of the foot.

Lisfranc injuries are injuries to the mid foot, where the long bones (metatarsals) that run to the bases of the toes meet the smaller bones in the middle of the foot. These small mid footbones are wedge shaped to form the arched structure of the foot. The bones are secured to the other bones around them by ligaments.

In football, the most common method of sustaining a lisfranc injury is twisting hard while pushing off or landing on the ball of the foot. The combination of the twisting while the toes are fixed in the turf but the heel is lifted stresses the joints in the middle of the foot. The lisfranc injury can be caused by one incident, or from repetitive stress.

Xray show fractures or misalignment/spreading between the bones. MRI may show injuries where the ligaments are torn with no bony fracture or displacement.

Immobilize and limit weight bearing. Refer for imaging to assess how severe the injury is.

incomplete bone healing (non-union), or incorrect re-alignment of the bones can lead to long term foot pain and dysfunction including an unstable arch of the foot.

Immobilization in a cast for 2-8 weeks is an option when the bones haven’t shifted out of place and the arch of the foot is still stable. After the immobilization, the athlete should have repeat X-raysto make sure alignment is still good and there’s complete healing.

4-9+ weeks depending on the length of immobilization and how long it takes the athlete to regain strength and range of motion.

There are a few surgicaloptions for Lisfranc injuries. The first option is stabilizing the bones and joints with plates and screws. This option is good for injuries where the bones have moved more than 2mm out of place, or where there are breaks in the bones along with the displacement. Another option is a fusion, where the smaller midfoot bones get fused either to each other or to the longer metatarsal they join to. Fusions are recommended for injuries where the bones are intact but the ligaments holding them together are completely torn, injuries that extend all the way across the foot or chronic (>6weeks) Lisfranc injuries where non-surgical management has failed. Both techniques have shown good results with inconclusive evidence of either one being better than the other.

NFL injury data suggests around 11 months is an average return to play estimate following Lisfranc surgery. After the surgery the athlete is non-weight bearing in a cast for 6-8 weeks followed by gradual return to weight bearing in a walking boot. The timeline for returnto sport can also be delayed if the athlete needs to have pins or plates removed because of hardware irritation. Hardware removal is often done 4+ months after surgery, once the bones have healed. (https://pubmed-ncbi-nlm-nih-gov.proxy1.lib.uwo.ca/27166291/)

Complete fracture healing and proper alignment of the bones and joints. The athlete also needs to have full strength and be able to run/jump/pivot on the field without pain or dysfunction.

Although not specific to Lisfranc surgeries, NFL injury tracking data suggests that foot injuries that need surgical stabilization are more likely on artificial turf than on grass. This is likely because the toes of the cleats stick into turf more than natural grass, so the twisting/pivoting on the foot puts more force through the joints in the foot. (https://pmc.ncbi.nlm.nih.gov/articles/PMC11483763/)

Turf toe is a hyperextension of the joint where the big toe meets the foot. The seriousness of turf toe ranges from mild inflammation of the ligaments and tendons on the bottom of the toe all the way to complete rupture. The small round bones under the big toe joint can also be broken in these injuries.

At the base of each toe the toe bones line up with the long bones in the foot. The joints between these long foot bones and the toes allow the toes to flex and extend which is very important for pushing off the toes when walking, running or jumping. The big toe is different than the others because it has 2 small round bones that sit right under the joint where it meets the foot. These two small bones give the toe better leverage and strength for pushing off when running, making the big toe the strongest and most important toe for football players.

Most athletes get turf toe from pushing hard off the toes while the heel is raised off the ground. Turf toe can come from repeatedly pushing off and chronic irritation/inflammation, or from a single incident of pushing off too hard and injuring the ligaments.

MRI will show the damage to the tendons and ligaments and show inflammation.

Limit toe hyperextension with rigid insoles and treat the inflammation and pain. If there is any swelling in the toe, avoid tape that wraps all the way around the toe.

Low grades of turf toe might be playable, where the athlete needs to wear tape and/or an insole on the field and get treatment but is still able to sprint and jump. More severe cases might be immobilized in a walking boot and treated with anti-inflammatories.

Up to 10 weeks. The recovery time depends on the amount of damage to the bottom of the toe, how long the athlete is immobilized and how long it takes them to regain a normal running gait and strength. Grade II injuries are often in a walking boot for around 2 weeks, grade II for up to 6 weeks.

Very few cases of turf toe need surgery, however it is an option. Surgery for turf toe may include fixing sesamoid bone fractures, cleaning out damaged joint cartilage and repairing the ligaments, tendons and/or joint capsule of the bottom of the big toe. Turf toe surgery is typically only tried after an athlete doesn’t heal well with non-surgical treatment, or more very severe, full tears of the tissue on the bottom of the toe.

Recovery from the surgery is typically around 3-5 months. The timeline depends on how long the surgeon wants the toe immobilized and how quickly the athlete regains a normal walking and running gait, strength and range of motion.

Non-surgical criteria is typically a return of normal gait, function and 50-60 degrees of pain-free motion. The criteria for return to play after surgery is similar but range of motion criteria may be different depending on the type of procedure performed.

NFL injury tracking data suggests foot and toe injuries are more likely on artificial turf than natural grass. The way cleats stick in turf pins the toes or foot in place, putting more force through the joints.

Bursitis happens when the bursa gets inflamed, causing it to be painful and possibly swollen.

A bursa is a small sac of fluid that works as a cushion between other structures in the body. They are often found between tendons and bones to stop the tendon from getting worn or frayed from rubbing against the bone. They also sit between skin and bone in places where the bone doesn’t have anything cushioning it, like the point of the elbow.

Bursitis can happen from a trauma, like getting hit with a direct blow (ex: smacking the point of the elbow on something hard), or from repetitive friction or compression (ex: repeated overhand throwing causing a bursa in the shoulder to be pinched over and over again).

An MRI may show excess fluid or increased size of a bursa.

Treat the inflammation and modify or restrict activity to prevent more irritation.

Bursae can get infected. These infections need to be seen by a doctor as soon as possible to begin antibiotics and prevent the infection from spreading.

Treat the inflammation and address the cause of the bursitis. If the cause was direct trauma, pad the area. If the cause was overuse and/or dysfunctional movement patterns, a strength and mobility program should improve function and decrease pain. Some doctors may also treat the bursitis with anti-inflammatory injections.

Many cases never miss playing time.

Bursitis is not usually managed surgically but it is possible to remove it surgically. This happens most often in combination with some other more significant procedure.

A bursa removal is usually in combination with other surgical procedures, the timeline for return is dependant on that other procedure.

Most athletes play through bursitis, or return to play as soon as range of motion and strength are sufficient.

Tendinitis is when a tendon becomes inflamed.

Tendons are the tissue that connects the muscle fibres to the bones. They are made mostly of collagen, which allows them some stretch.

Tendinitis is most often caused by overuse or poor mechanics that place excess stress on the tendon. For example, poor control of the shoulder blade can increase the friction on the rotation cuff tendons, leading to shoulder tendinitis.

Tendinitis can also be triggered by direct trauma, where getting hit starts the inflammatory process and continuing to use the tendon increases it.

Tendinitis is usually diagnosed in clinic without imaging, but an MRI would show the inflammation and any tearing or tendon degeneration that may have started. If the issue progresses to calcific tendinitis, the calcium chunks will be visible on an Xray.

Treat the inflammation and identify the root cause. I

Chronic tendinitis can weaken the tendon, increasing the likelihood of a tendon rupture. Another complication is calcification tendinitis, where chronic inflammation in the tendon leads to chucks of calcium forming in the tendon.

In cases that began because of poor movement patterns, fixing mechanics through strengthening and mobility work should decrease strain on the tendon. Managing workloads by adjusting repetitions on the field or in the gym may also help the tendinitis resolve.

Note: tendons respond very well to load. A strengthening program for tendinitis should load the tendon with isometric and eccentric exercises.

The timeline for return is dependent on the severity of the tendinitis. Some athletes can play through it with load management. Once treatment starts, tendinitis can take anywhere from 2-3 weeks to several months to resolve.

Surgery is a last resort treatment for tendinitis. If there are calcium deposits in the tendon, a surgeon may choose to remove them. Alternative treatments to try before surgery include steroid injections to treat the inflammation, or Platelet Rich Plasma (PRP) which isolates healing factors from the athlete’s own blood and injects them into the injured area.

The timeline for return to play after the removal of calcium deposits in the tendon is dependent on the location and size of the calcium deposit.

A disturbance in brain function affecting the way neurons (brain cells) send signals and use energy.

The brain is the primary control centre of the body. It’s protected inside the skull, where it floats in cerebrospinal fluid. At the base of the brain, the brain stem is the connection between the brain and spinal cord. The spinal cord runs down the spine to deliver messages between the brain and the rest of the body.

Direct or indirect impact to the head. Examples of direct impact include contact with another player or the turf. Indirect contact includes a whiplash motion where contact to a different part of the body transmits forces to the head.

Not identifiable on MRI, CT or EEG

Remove from play, assess for red flags and progress with further testing.

Loss of consciousness, repeated vomitting, rapid worsening of headache and/or pressure in the head

Short term complications to concussion include increased risk of a second brain injury if an athlete is hit again before fully recovered. In youth athletes, this second injury has been fatal. Long term complications include the development of CTE (chronic traumatic encephalopathy) which can have seriouss mental health and cognitive effects. CTE is an ongoing area of study and not fully understood.

Treating concussion involves identifying and addressing the symptoms the athlete is experiencing. For instance, some athletes get dizziness and balance problems, so their therapy would focus on their balance and spacial awareness system. Over the course of concussion recovery, the athlete will be reassessed multiple times to track recovery.

The average time lost per concussion in the NFL is 9 days. Despite the average being only one game missed, there is a wide range of recovery times and some athletes continue to have symptoms for months. Concussion recovery is a very individualized timeline.

https://pubmed.ncbi.nlm.nih.gov/36315827/

Concussions are not managed surgically. There are traumatic brain injuries that may need surgery, but they would be different or in addition to a concussion.

Absence of any remaining symptoms with exertional and cognitive testing and clearance by a doctor.

Over stretching or tearing of the groin muscle or the tendons that attach the muscles to bone.

The groin muscles run along the inner part of the thigh, connecting the pelvis to the thigh. When they contract, they pull the leg inward.

Groin strains are commonly caused by the leg getting pulled too far sideways, or through pushingtoo hard against an immovable object, like double kicking the turf.

Ultrasound or MRI will show the muscle or tendon damage. An xray may show possible avulsion fractures.

Manage pain and inflammation.

Tendon strains at the attachment to the pubic bone may pull off a small piece of bone (avulsion fracture)

Initial management includes rest, with possible time on crutches with partial or non weight bearing depending on severity. The athlete will progressively resume walking and then strengthening once range of motion is normal with a focus on strengthening all around the hip including groin muscles, hip flexors, and glutes.

Typically athletes are looking at about 3-4 weeks to return to competition for grade 1 or 2 strains. A grade 3 tear that’s treated without surgery averages 6-8 weeks for a return to sport.

https://pubmed.ncbi.nlm.nih.gov/19329786/

Full tears may be reattached or repaired surgically.

Return to sport after groin repair is often 3-4 months. The first few weeks after surgery usually include crutches and a hip brace to prevent stretching the repair site. Once the initial phase is past, gradual return of range of motion, normalizing walking and progressive strengthening begins.

https://pmc.ncbi.nlm.nih.gov/articles/PMC6990618/

A tear in the labrum can cause pain, a clicking or catching feeling and/or a feeling of instability in the hip.

The hip is a ball and socket joint. The hip labrum is a cartilage ring around the edge of the hip socket. The labrum acts like a gasket to help hold the ball (the head of the femur) in the socket.

Labral tears in the hip can be caused by a traumatic event, like getting tackled by the legs, pulling or twisting the hip too far. Labral tears can also be caused by repetitive stress, often involving positions like deep hip flexion (like the lowest part of a squat), where the labrum gets pinched between the hip socket and the top of the thigh bone.

MRI may show the tear, or show fluid that accumulates around the tear, meaning the area is inflamed and the the torn labrum allows that inflammation to move around.

Manage pain and inflammation.

Limit moving the hip into positions that cause more damage (ie limit deep squatting positions). Depending on the severity and how chronic the injury is, focus on strengthening the muscles around the hip, particularly the core muscles and glutes.

Some labral tears are asymptomatic, meaning that athletes can play through them with no impact on performance. When athletes do get pain, weakness or instability, return to play is guided by those symptoms resolving and the athlete returning to pre-injury performance.

Surgery is usually recommended for athletes who fail conservative management, particularly when the hip continues to feel unstable or feels like it gets stuck or caught as the athlete moves. Surgery involves using a camera and small tools through scope holes to repair the labrum, and often includes trimming down extra bony areas that may be pinching the labrum.

Return to football is typically 6-12 months. The progression back to sport includes a period of non-weight bearing, physical therapy to get back normal walking and then progressive strengthening. Gradual return to jogging, running, change of direction and jumping are key factors for getting back into playing shape.

Associated with femoral acetabular impingement (FAI)

A tear in the lower abdominal wall which allows organs such as the intestines to protrude through the opening.

The inguinal ligament runs from the front of the pelvis near the waistline (commonly called the “hip bones”) down to the pubic bones, creating a “V” shape. The lower end of the abdominal muscles attach to the inguinal ligament. The abs and inguinal ligament are important for holding the organs inside the abdomen and as a base for athletic movement.

Inguinal hernias in athletes are usually caused by repetitive core muscle contractions, where overuse weakens the lower abdominal wall. They can also be caused by a weakness in the abdominal tissues that someone is born with.

Ultrasound imaging or a CT can show the hernia, although many can be diagnosed by the doctor feeling the bulge.

Devices like compression shorts or a hernia belt can reinforce the hernia area and prevent the internal organs from bulging through.

When organs protrude through the abdominal wall, there is a possibility that they get pinched and damaged.

Compression, rest and avoiding aggravating movements. Depending on the size of the hernia. conservative management may not allow an athlete to return to play without significant risk of the hernia worsening.

The goal of hernia repair surgery is to put the bulging organs back into the abdomen and repair and patch the hole. Sometimes the patch is reinforced with tissue from elsewhere in the patient’s body, or with a synthetic patch.

The timeline for return to play is varied, but 10-12 weeks to resume full play is a common expectation.

A muscle or tendon strain at the highest part of the groin muscles or the lowest part of the abdominal muscles. These strains can be from a single event or from repetitive overuse.

The pubic bones are where the two side of the pelvis meet in the front. They are the attachment point for the bottom of the ab muscles and the top of the groin muscles.

Excessive or repetitive abdominal hyperextension or thigh abduction

MRI will show muscle and/or tendon damage and inflammation. Bone scan will show damage to the bone at the sites where the tendons attach. Imaging for these is important to differentiate between a sports hernia and a true inguinal hernia.

Rest and pain management.

Initial phase focuses on limiting pain and inflammation through rest and assisted range of motion. Second phase includes progressive strengthening, focus on core, hip and pelvic floor control. Third phase includes progressive re-introduction of running, jumping, cutting and sport specific activities. Non surgical management of athletic pubalgia may also include therapeutic injections like a steroid to help reduce inflammation, or Platelet Rich Plasma (PRP), which takes the athlete’s own blood and re-injects a concentrated amount of the parts of blood that help with healing.

Return to sport with non-surgical management typically takes 10-12 weeks. This timeline is influenced by the severity of symptoms, how long the athlete has had symptoms and what types of treatments and rehabilitation they do.

Adductor or abdominal repair

Around 12 weeks (often getting back to sport specific activity between 10-12 weeks post op).

Ability to resume pain free sport specific activity at previous level.

Very important to differentiate between inguinal hernia and core muscle injury.

Tearing the ACL makes the knee unstable when doing cutting/pivoting activities or landing after jumping.

The ACL is a ligament in the knee that connects the end of the thigh bone to the top of the shin bone. It prevents the thigh bone from sliding forward and/or rotating on the shin.

Single leg landings where the knee buckles inwards, or twisting on a planted foot are both common ways of tearing the ACL. Getting hit in the knee when the foot is planted is another common way this happens.

An MRI is the most common method of diagnosing an ACL tear. Some ACL injuries include a Segond fracture, which is a small chip off the outer edge of the top of the shin bone which can be seen on X-ray.

Treat swelling and pain and fit the athlete for crutches and/or a brace. If ACL injury is suspected, the athlete typically gets an MRI to confirm and consults with a surgeon.

Weakness in the hips and poor body control during landing, cutting or pivoting tasks may make an athlete more at risk of tearing their ACL. There are also genetic structural factors at play.

Re-tear, additional surgeries and increased risk of tearing the ACL on the other side. There are also common injuries that happen at the same time as ACL injuries, like MCL and/or meniscus tears.

Complete ACL tears are rarely treated without surgery in the NFL. Cases where the ligament isn’t fully torn and the athlete has no knee instability might be treated with progressive strengthening, but again this is rare. Non-surgical options are more suited to people without a high need for stability during cutting and pivoting activities.

N/A

ACL reconstruction is the most common surgical option for ACL tears. This involves removing the torn pieces, creating tunnels in the thigh and shin, and rebuilding the ligament using other tissue, usually taken from the athlete’s own patellar tendon, quad tendon or hamstring.

Full return to play is typically 9-12 months after surgery. While there are cases of return to play closer to 6 months post op, there is a much higher risk of re-tearing the ACL graft at that time point.

Near equal strength between legs (within 10% is the common requirement) and the ability to pass on-field, position specific testing.

NFL injury tracking data suggests there is a higher rate of ACL injury when playing on FIeldTurf than on natural grass. More teams play on grass than turf, so absolute numbers don’t show the full picture, but when calculated based on athlete exposures to both surfaces, the numbers suggest the risk of ACL injury is higher on turf than grass. This is likely because shoe cleats tend to grip more on turf, so any twisting forces go through the knee instead of happening at the foot.

Tearing the ACL makes the knee unstable when doing cutting/pivoting activities or landing after jumping. The additional damage to the LCL makes the knee even more unstable, particularly with rotation like when a player cuts or pivots while running.

The ACL is a ligament in the knee that connects the end of the thigh bone to the top of the shin bone. It prevents the thigh bone from sliding forward and/or rotating on the shin. The lateral collateral ligament (LCL) connects the outside edge of the thigh bone to the top of the fibula (outer lower leg bone). The LCL stops the knee from bucking outward and limits knee rotation.

Combined ACL and LCL injuries in football are usually from contact to the inside of the knee, forcing the knee to buckle and rotate outwards.

An MRI is the best way to see the extent of the injury to the ACL and LCL, and to catch additional injuries to the meniscus or other structures in the knee.

Treat swelling and pain and fit the athlete for crutches and a brace.

The most common multiligament knee injury is the ACL and MCL, and these injuries usually also include a meniscus injury. The ACL is usually a complete tear (grade 3), while the MCL may be gr 1, 2, or 3. The ACL, MCL and meniscus all play important roles for knee stability during cutting/pivoting/rotational movements.

The ACL is a ligament in the knee that connects the end of the thigh bone to the top of the shin bone. It prevents the thigh bone from sliding forward and/or rotating on the shin. The medial collateral ligament (MCL) connects the outside edge of the thigh bone to the top of the tibia (shin bone). The MCL stops the knee from bucking inward and limits knee rotation.

Since all these structures support the knee during rotation, the most common way of injuring them is the knee buckling and rotating inwards. Usually this motion is accompanied by some excessive force, either from the player themselves (like landing hard), or contact from another player.

MRI is the most common imaging for diagnosing multiligament knee injuries.

Initial management includes immobilizing the knee in a brace and treating the swelling and pain. Bracing these injuries is important to start the healing process for the MCL and decrease the chance that it pulls away from its attachment spot.

NFL players need a high level of knee stability to be successful, so non-surgical treatment of multiligament injuries isn’t a realistic option.

The process of treating combined ACL and MCL injuries usually begins with a phase of knee immobilization in a brace to allow the MCL to heal. Once that phase is complete, the ACL reconstruction is done, and any meniscus injury is treated at the same time. If at the time of surgery it’s clear that the MCL is not healing properly, a repair or reconstruction can be done at the same time.

9-12 months is the typical timeframe fro returning to sport. While some players have come back sooner than that, the general understanding is that return before 9 months puts them at higher risk of re-injury.

The lateral collateral liagement (LCL) connects the end of the thigh to the lower leg on the outer (lateral) side of the knee. The LCL stops the knee from bending out sideways.

The LCL is a ligament that stabilizes the outside of the knee by connecting the bottom of the femur (thigh bone) to the top of the fibula (thinner, outer lower leg bone).

The LCL is most often injured when the knee gets hit from the inside, pushing the knee out while the foot is planted.

An MRI will show the tear in the ligament.

Treat pain, swelling and provide a brace and crutches to help the athlete move around.

Bracing to limit knee motion allows the fibres of the LCL to scar down as much as possible. Progressive range of motion and strengthening bring the athlete back to playing shape, and improve knee stability. Continued bracing upon return to lay can improve the feeling of stability and may help prevent re-injury.

There have been cases in the NFL of full LCL tears (without additional injuries) that have returned in 3-6 weeks.

LCL reconstruction is recommended when athletes have significant instability or gapping on the outer side of the knee after tearing the LCL, or when there are other structures included (see multiligament knee injuries). Reconstructing the LCL usually includes replacing the ligament with a graft taken from either the athlete’s body or from donor tissue.

LCL surgery is typically season-ending. NFL injury data shows that players who had LCL reconstruction but no other injuries missed the rest of that season, taking an average of 14.5 weeks to return.

A stable knee when cutting/pivoting and the ability to perform all position specific tasks on the field.

Isolated LCL injuries are rare, so the data is inconclusive, but it’s likely that the more a cleat is stuck in the turf when a player gets hit, the more likely they’ll have a significant knee injury.

The vast majority of LCL injuries are accompanied by other injuries, often ACL and/or meniscus tears.

When the MCL is overstretched some or all of the fibers become loose or torn. A 1st degree sprain is when the ligament is stretched but there’s no tearing. A 2nd degree sprain is when some fibers are torn but some remain intact. A 3rd degree sprain is a full tear of the ligament.

The MCL is a ligament that stabilizes the inner side of the knee by connecting the bottom of the femur (thigh bone) to the top of the tibia (shin bone). Some fibres of the MCL also attach to the edge of the meniscus. The MCL restricts the knee from buckling inward or from rotating too far.

The MCL is often injured when a football player is hit on the outside of the knee while their foot is planted, pushing the knee inward. Since the meniscus also limits some knee rotation, excessive rotation on a planted foot is another way of injuring it.

An MRI will show the ligament damage.

Bracing and crutches, manage swelling and pain. Make sure to assess for other injuries that may accompany the MCL injury.

Parts of the MCL attach to the meniscus (a cartilage ring inside the knee), so many MCL injuries also involve the meniscus.

Evidence shows that most MCL sprains or tears heal well without surgery. Stabilizing the knee in a brace allows the torn/damaged end of the ligament to scar back down. Progressively restoring range of motion and strength is key to recovery. The return to play process needs to include jumping/landing and unexpected changes of direction.

2-8+ weeks depending on the severity of the injury.

The MCL is most often repaired in cases where there is another injury getting treated at the same time (see multiligament knee injuries). Isolated MCL repair may be recommended when the torn end of the ligament pulls a chunk of bone away from it’s attachment place or if the torn end of the ligament pulls away and gets stuck between other structures around the knee. Athletes who go through non-surgical rehabilitation and continue to have instability and dysfunction may also chose surgery repair or reconstruction.

Since surgery for an MCL tear alone is uncommon, there are not many examples of NFL players returning after this surgery.

A stable knee when cutting/pivoting and the ability to perform all position specific tasks on the field.

The more a cleat is stuck in the turf when a player gets rolled up on, the more likely they’ll injure the MCL since the foot can’t slide.

See Multiligament knee injuries for combined MCL/ACL injuries

Tears in the menisci can run in any direction, and can cause flaps of cartilage to come loose or flip over. When the cartilage flips over, it can block the knee from straightening or bending properly.

The menisci are cartilage rings that sit inside the knee on the top surface of the tibia (shin bone). Each knee has two menisci, one on the inner aspect and one on the outer half of the joint. The purposes of the menisci are to provide cushion between the thigh and shin bones and improve joint stability by resisting the thigh bone sliding or rotating on the shin.

Meniscus injuries usually happen when there’s too much knee rotation. They can be traumatic, like one quick twist that may or may not include contact from another player. They can also be chronic, where repeated twisting and impact on the meniscus causes fraying and/or tearing that gets worse over time.

An MRI is the best form of imaging to see a meniscus tear.

Manage pain and swelling. If the knee is stuck (unable to bend or extend), place the athlete in an immobilizing brace or splint.

Gradual return to weight bearing, increasing range of motion and progressive strengthening.

The timeline is very dependent on the size and location of the tear in the meniscus. Some athletes play through minor meniscal tears, often with a brace.

A surgeon can use a scope (camera and tools inserted through small port holes) to clean up and trim out torn pieces of the meniscus. Tears in specific parts of the cartilage rings can also be repaired using sutures that get anchored into the bone under the meniscus. Surgery is considered necessary for tears that flip over inside the knee and block the knee from moving.

Return to play in 5-7 weeks may be possible for athletes who get a pieces of the meniscus trimmed, particularly if the injury was on the medial/inner ring of the meniscus. Meniscus injuries that get fixed with stitches and anchors tend to take 5-8 months for full return to sport.

https://pmc-ncbi-nlm-nih-gov.proxy1.lib.uwo.ca/articles/PMC10183423/

Return of full strength (within 10% of uninjured side). A stable knee when cutting/pivoting and the ability to perform all position specific tasks on the field.

Since many meniscus injuries happen when the knee twists, if a cleat is is pinned in the turf stopping the foot from twisting on the ground, the twisting motion gets transferred up to other joints like the knee.

Many meniscal injuries happen at the same time as other knee injuries like ACL or MCL tears. In those cases, the timeline for return is guided by the more significant ligament injury recovery.

Complete tears of the patellar tendon aren’t very common but they are season ending injuries that need surgery.

The quadriceps muscle runs along the front of the thigh and attaches below the knee the tendon that attaches the muscle to the bone is divided into the quadriceps tendon and the patellar tendon by the kneecap, which sits inside the tendon. The portion of the tendon below the kneecap (attaches the kneecap to the shin) is the patellar tendon. The quad muscle, quad tendon, patella and patellar tendon together act to straighten the knee.

The most common way to tear the patellar tendon is eccentric overload, meaning putting too much force through it while it’s lengthening. In football this is often when a player is moving forward then uses their quads to try to stop quickly.

An MRI will show the extent of the tear. An xray will show the kneecap sitting higher than normal since the patellar tendon anchors it down.

Immobilize the knee in full extension, manage pain and inflammation.

ACL tear at the same time.

Partial tears where the athlete is still able to straighten their knee may be treated with immobilization with a fully straight knee. They may be allowed to walk, but in a brace keeping the knee locked out.

Bracing usually lasts about 6 weeks. Rehabilitation includes very gradually resuming range of motion, starting with active flexion then building up to active extension. The goal is for full range of motion and able to walk without the brace around 6 weeks. Return to play might be around 6 months depending on the extent of the tear.

Most patellar tendons are repaired, where the surgeon uses a technique to rejoin the torn ends together. There are a variety of techniques for this with some methods for reinforcing the repair. Chronic tears (>6-8 weeks old) or very degenerative tears might need reconstruction, where the tendon gets replaced with a graft.

https://www.orthobullets.com/knee-and-sports/3024/patellar-tendon-rupture

Recovery from surgery is similar to non-operative, starting with 6 weeks locked in a brace keeping the knee straight. Some protocols start passive motion early (7-10 days post op). At 6 weeks the athlete should have full range of motion and be able to walk without the brace. It takes about 6 months to fully regain strength to be able to return to play.

Within 10% strength compared to the other side and fully able to complete on-field testing/skills.

Many athletes who have patellar tendon tears have a history of previous knee pain or patellar tendinitis (jumper’s knee).

An achilles tear severs the connection between the calf muscles and the foot. Without the achilles tendon, athletes can’t extend their foot to push off. When the injury happens many athletes describe a feeling of being kicked in the back of the knee and then not being able to push off their toes at all.

The achilles tendon is located at the back of the ankle. The calf muscles pull through the achilles tendon to move the foot, so the forces for pushing off the foot are transmitted through the achilles.

The achilles is most often torn when the tendon is at its most stretched position, like pushing off their back foot when knee and shin are bent out over their toes. Achilles injuries are usually non-contact and in football they’re often seen when a player transitions from backpedaling to running forward, or rocks back to push off into forward running.

An MRI will show full vs partial tears, the location of the tear and any additional damage to muscle and/or fascia.

Immobilize the ankle and manage pain and inflammation. The recommendation for immobilization is a walking boot with a wedge under the heel.

Many achilles tears in non-athletes are treated without surgery by keeping the foot in a walking boot with a heel wedge. As the tendon heals, the height of the wedge gradually lowers until they are flat footed again.

There is very little data for return to NFL level football after non-surgical achilles ruptures since the vast majority of athletes require surgery to regain strength and function.

The majority of NFL players with complete achilles tears get them repaired surgically. There are a few techniques for these repairs, but generally they include stitching the ends of the tendon back together through an incision in the back of the ankle. Different surgeons may use slightly different methods for reinforcing the repair.

An achilles tear is a season ending injury, with an average return to play about a year after surgery.

https://journals-sagepub-com.proxy1.lib.uwo.ca/doi/10.1177/0363546516651426?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed#table-fn2-0363546516651426

Athletes must pass on field testing including sprinting, change of direction and jumping before gradually resuming practice then game play.

NFL injury data shows that only about 65-70% of players with achilles ruptures return to play in the NFL and there is a statistical drop in performance when they return compared to before injury. https://pubmed-ncbi-nlm-nih-gov.proxy1.lib.uwo.ca/20400426/

A calf strain is when some of the muscle fibres that make up the muscle are stretched or torn. Strains are graded 1-3 with a grade 1 meaning the injured muscle fibres are stretched but not torn. In a grade 2 strain some but not all of the muscle fibres are torn, so there can be a wide range of severity in grade 2 strains since it could be 10% are torn, or it could be 90% are torn but both are considered grade 2. A grade 3 strain is a full tear. In the calf muscles, grade 3 strains are most common at the point where the muscles join at the achilles tendon (see achilles rupture).

The calf muscles are located at the back of the lower leg and include two major muscles, the gastrocnemius and the soleus. The gastrocs start just above the knee, the soleus starts just below the knee. They both join through the achilles tendon to attach to the heel bone. Together they are they pull to point the foot and provide force for pushing off the foot. The gastrocs also help with bending the knee.

One way to strain the calf muscles is pushing hard off a planted foot, when the shin and knee are extended over the toes, which stretches the calf muscles. Forceful pushing off the foot like jumping, sprinting or quick changes of direction on the field can also cause calf strains.

An MRI will show the location and degree of stretching or tearing in the calf muscles.

Initially treatment includes rest and managing inflammation and pain. Resting does not need to be full immobilization, but the athlete should avoid overstretching or aggressive muscle contraction to prevent further damage.

Sudden swelling, heat and redness in the calf may indicate a DVT

A deep vein thrombosis (DVT) is a blood clot that may form in the calf after a calf strain. Bleeding in the muscle from the injury can form a clot that causes intense pain and swelling. If the clot gets dislodged, it can travel up to the lungs or heart, which are medical emergencies.

Calf strains are usually treated non-operatively with a rehabilitation program. More severe cases may start with a heel wedge, either in a regular shoe or a walking boot, to reduce stretch on the calf muscles, or with crutches to assist with walking.

Mild calf strains may return to play in 2-6 weeks. Severe strains can take 6-12 weeks for full return to play.

Calf strains are not usually managed surgically unless there is a full or near full rupture, which typically happens where the muscle meets the achilles tendon (see achilles tendon rupture).

Fibula fractures can occur anywhere along the length of the bone. They include breaks that complete cross the shaft of the bone and may include shards of bone, or be smaller chips off the bone that get pulled off where ligaments or tendons attach. Specific types of fibula fractures are associated with other injuries, like a Maissoneuve fracture near the top of the shaft that’s paired with a high ankle sprain.

The fibula is the longer, thinner bone along the outside of the lower leg. The fibula is not the main weight bearing bone of the lower leg, but plays an important role in the structure of the ankle and is an attachment point for muscles and ligaments at both the knee and ankle.

Fibula fractures can be contact or non-contact. A contact fracture is often from being struck in the lower leg by an opponent or getting rolled up on. Non-contact fractures can be from landing on a rolled ankle, or be paired with a high ankle sprain (often from twisting on a planted foot).

An Xray is the standard imaging for a fibular fracture. An MRI might be ordered to see additional soft tissue injury like a high ankle sprain.

Immobilization in a walking boot or splint until the injury can be evaluated by a doctor.

Immobilization in a walking boot or sometimes a cast is the primary treatment for fibula fractures. Depending on the location and stability of the break, some people can keep weight bearing in the boot, others will need crutches and be non-weight bearing for the initial healing phase. Bone healing

Player miss an average of 10 weeks for a fibula fracture treated without surgery. Bone healing typically takes 6-8 weeks, and there is a period of strengthening and reconditioning once healed before they are ready for full return. More complicated fractures may need longer periods of immobilization and rehab. `

Surgery for fibula fractures often includes realigning the bone and securing it with plates and screws. Fibua fractures combined with other injuries like a high ankle sprain may include other techniques (see high ankle sprains).

Return to play after surgery for a fibula fracture in the NFL takes an average of 17.7 weeks. The longer recovery time for surgical management compared to non-surgical may be because surgery is most often done for more severe or complex cases that often have additional injuries that need to be addressed.

Once the player has full bone healing based on an xray or other imaging, they need to show that they have regained the strength and range of motion to complete all necessary skills on the field.

Overuse of one or more of these muscles pulls at their attachment sites on the bone causing inflammation of the bone surface. Shin splints usually start as a dull ache in the bone after activity. If the condition progresses, it becomes sharp pain during activity, particularly impact activity.

The tibia (shin bone) is the thicker, weight bearing bone in the lower leg. Muscles of the lower leg attach along the shaft of the tibia. These muscles include tibialis anterior, which works to pull the foot up (toes towards the shin), or tibialis posterior which stabilizes the back of the foot and the arch of the foot.

Shin splints are an overuse injury. Sudden increases in training load, changes in playing surface or footwear or changes in running mechanics because of muscle tightness or other injuries can contribute to overloading the muscles of the lower leg.

An MRI shows the inflammation along the edges of the shin bone. In chronic cases, an xray may show remodelling or extra hardening of the bone where there has been a lot of tension. An xray may also show stress fractures, although a bone scan is more sensitive for this.

Reduce load and treat the pain.

Swelling, heat, redness and/or loss of feeling or movement in the foot can indicate compartment syndrome (see Compartment syndrome). Another red flag is a thin line across the shin bone on an xray, indicating a stress fracture.

Compartment syndrome is an emergency and can cause long term disability for the leg if not addressed quickly. A black line stress fracture may progress and turn into a complete or displaced fracture.

The primary goal of treating shin splints is identifying and addressing the underlying cause. Evaluating work load, body mechanics, muscle tightness, and surfaces or footwear may point to the cause. Gradual strengthening that targets areas of weakness and reintroducing impact activities like running and jumping help get the athlete back on the field. There is often a need to continue with mobility and strengthening once they’re back to prevent the shin splints from returning.

The return from shin splints is around 2-6 weeks but is highly dependant on severity. Some athletes dont miss any time, they play through the injury by treating the pain and adjusting workload. More severe cases can take 6+ weeks and the athlete may spend some of that recovery time non-weight bearingon crutches.

Surgery is reserved for cases that fail non-surgical management and the success of surgery for shin splints is unclear. The procedure often includes releasing the fascia (tissue that wraps around muscles) and/or some of the muscle fibres that attach to the shin to reduce the tension.

After surgery it takes about 8-12 weeks to return to play. Return to play is guided by the ability to slowly regain strength and endurance without having symptoms resume.

The ability to run, jump and change direction on field for the duration of practices and games without the return of pain and inflammation.

Playing surface is a known risk factor for shin splints. Turf fields tend to be firmer than natural grass, contributing to more force going through the shins and muscles of the lower leg.

Contact to the rib cage can cause bruising to the ribs and the muscles around the ribs. Bruised ribs make certain movements like bending, twisting and sometimes shoulder motions painful and it can be painful to breathe.

The rib cage is made up of 24 ribs - 12 per side. Ribs 1-7 on each side connect directly to the sternum (breastbone), 8-10 connect to the sternum through cartilage connectors. Ribs 11 and 12 don’t have attachments in the front. In the back, all 24 ribs connect to the spine. The rib cage protects vital organs, and expands and contracts to breathe.

Ribs get bruised from direct contact. In football, it’s often another player’s helmet or knee, or from hitting the ground with the football tucked against the chest.

An xray is useful to rule out breaks in the ribs.

Bruised ribs usually come with a feeling of being “winded” or difficulty breathing. Get the athlete into a comfortable position to make breathing easier. Padding the area with a pillow or rolled up blanket can also help.

Loss of consciousness, inability to catch their breath, vomiting or peeing blood.

Damage to the organs inside the rib cage including the liver, lungs, spleen and kidneys. Displaced rib fractures may puncture the lungs. These complications are less common with rib contusion than fracture, but important to be aware of.

Bruised ribs heal with time. Manage pain with ice and anti inflammatories. Gentle stretching and mobility work to keep the spine moving well often helps loosen up tight muscles as they recover. If the ribs are still tender when the athlete is cleared to play, add extra padding as needed.

Some players are able to play through mildly bruised ribs, but the team doctor must rule out fractures or additional complications. Playing with bruised ribs can also be very painful and make it hard to catch their breath. Full healing often takes 3-6 weeks.

There is no surgical treatment for bruised ribs. An athlete may need emergency surgery for organ damage inside the rib cage if the hit that caused the bruise was significant enough.

Organs most at risk with blunt trauma to the chest/torso include the spleen, kidneys and liver. Blunt force trauma to the chest directly over the heart can also stop the heart.

Direct or indirect contact to the rib cage can break ribs in one or more places.

The rib cage is made up of 24 ribs - 12 per side. Ribs 1-7 on each side connect directly to the sternum (breastbone), 8-10 connect to the sternum through cartilage connectors. Ribs 11 and 12 don’t have attachments in the front. In the back, all 24 ribs connect to the spine. The rib cage protects vital organs, and expands and contracts to breathe.

Fractures from direct contact are when the break in the rib(s) are at the point of contact. Indirect contact breaks are where contact to one part of the rib cage pushes on the rib(s) enough to cause a break at a different spot (ie contact to the front left of the ribcage causes fractures at the back left aspect of the ribcage).

Xray may the fracture. Ultrasound imaging may be preferred to show fractures in the bone or the rib cartilage, and can show damage to the lungs. CT scan is more thorough than xray to show the extent of the fracture.MRI may be called for to check for internal damage caused by the trauma or by sharp ends of the broken ribs.

Manage pain, check for red flag signs of internal damage and send for imaging.

Loss of consciousness, inability to catch their breath, vomiting or peeing blood.

Damage to the organs inside the rib cage including the liver, lungs, spleen and kidneys. Displaced rib fractures may puncture the lungs. Multiple rib fractures can also cause a flail chest, where an entire segment of the ribs move separately from the rest of the rib cage. Fractures of the upper ribs may cause damage to the blood vessels and/or nerves running from the neck to the shoulder and arm.

Rest and padding the area as needed when returning to sport.

Rib fractures usually take 6-8 weeks to heal enough to play football again. Injuries that involve more than one rib may take longer.

Surgery for broken ribs might be needed if the ends of the break aren’t aligned enough to heal on their own, or when the sharp ends of the bone might do damage to internal organs. Ion these cases, the breaks are usually re-aligned and stabilized with a plate.

Since surgery for broken ribs is usually saved for cases with unstable break, the return to play is longer. It may take 12-16 weeks for the bones to heal and the player to regain strength and endurance of the muscles that enable breathing and more the torso.

Stretching or tearing of the ligament that holds the end of the collarbone to the acromion (a pat of the shoulder blade).

The acromioclavicular joint is the “point of the shoulder”, where the outer point of the top of the shoulder blade meets the furthest end of the collarbone. The AC joint is an important connection joining the shoulder to the torso, and rotator cuff tendons that stabilize the shoulder run under the AC joint.

A fall on the point of the shoulder.

Visible on Xray as a misalignment of the joint between the collarbone and acromion. MRI will show bony misalignment, soft tissue damage and possible inflammation.

Pain management and support the joint through taping or a sling depending on severity.

Rehabilitation focused on regaining range of motion and strength around the shoulder. Particular focus on controlling the shoulder blade positioning. Tape for play as needed.

Players can return to play as soon as range of motion and strength return. This can be as soon as the same game or following week, or may take 3-6 weeks depending on severity. The timeline may also be influenced by player position, with quarterbacks taking longer to return to play since the AC joint is involved in throwing.

AC reconstruction involves re-attaching the collarbone to the acromion using a graft (donor tissue) or sutures.

A review of AC joint injuries in the NFL showed an average return to play for AC surgery is about 2 months.

https://journals-sagepub-com.proxy1.lib.uwo.ca/doi/full/10.1177/0363546513504284

Full shoulder range of motion and strength.

Rockwood Classification (1-6)

A break in the collarbone, most commonly in the middle 1/3 where the bone curves.

The collarbone is a long, thin, “S” shaped bone. It connects the shoulder to the sternum (chest).

Falls/impact on the point of the shoulder (85%) or direct contact to the collarbone (15%)

Xray will show the fracture

Sling, manage pain and inflammation

Numbness and/or tingling in the arm. A cold and/or blue arm with absent or decreased pulse.

Damage to blood vessels or nerves caused by jagged edges of fractured bone. Increased infection risk if bony edges pierce through skin (uncommon)

Immobilization with a figure 8 brace or sling with gradual resumption of shoulder range of motion and strengthening as the bone heals.

6-8 weeks is a typical timeline for the bone to heal.

Fixation with a plate and screws

The average return to contact sport is 3-4 months after surgery.

The fracture needs to be fully healed based on xray or other imaging, and the athlete needs to have full range of motion and strength to do their job on the field.

Both surgical and non-operative treatment have shown good long term results, but the trend in sports medicine is leaning towards surgical fixation. Stabilizing the break may lead to faster return to sport and less chance of re-injury.

https://pmc.ncbi.nlm.nih.gov/articles/PMC6196964/

A shoulder dislocation involves the ball portion of the joint (head of the humerus) coming out of the socket (glenoid). A full dislocation requires assistance to put it back in the socket. A shoulder subluxation is where the ball comes out of the socket and shifts back in without additional help.

The socket of the shoulder is a shallow dish at the outer end of the shoulder blade. The socket is deepened by the labrum, a cartilage ring that acts like a gasket. The ball of the shoulder is the top end of the humerus (upper arm bone). The ball is held in the socket mostly by the rotator cuff muscles.

Forced external rotation with the arm raised to the side, like a high five position.

Xray may show fractures of the glenoid or humerus. MRI will show fractures, labral tears and other soft tissue damage. CT scan will provide a more detailed visualization of bony injuries.

Stabilize the limb until the dislocation is reduced by a doctor or self-reduces.

damage to blood vessels and nerves in the area (axillary artery and brachial plexus)

Damage to the labrum. Fracture of the glenoid or head of the humerus. Possible damage to nerves and blood vessels.

The major goal of treating a shoulder dislocation without surgery is strengthening the rotator cuff muscles which hold the shoulder in the socket.

Shoulder subluxations typically result in less time lost, with an average return to pay being about 2 weeks. Full dislocations take longer, averaging about 6 weeks. There is a lot of variation in return to play timelines depending on how much damage is done to the structures around the shoulder during the injury.

There are a few options for stabilizing unstable shoulders. Generally, these techniques are classified as either bony or not bony procedures. Not bony procedures include repairing and tightening structures that help hold the shoulder in place like the labrum and joint capsule. Bony procedures include changing the the shoulder socket anatomy by attaching extra bone. The extra bony piece can be taken from the athlete’s body, or they can use a graft from a donor.

Players often return to football about 8-10 months after shoulder stabilization surgery. Since there’s more than one method to stabilize the shoulder, the specific technique influences the time to return.

The direction the shoulder dislocates affects treatment decisions and return to play timelines. Shoulders that are unstable in more than one direction typically need more aggressive treatment and take longer to return.

The labrum lines the edge of the shoulder socket, deepening the socket and increasing joint stability.

The socket of the shoulder is a shallow dish at the outer end of the shoulder blade. The socket is deepened by the labrum, a cartilage ring that acts like a gasket. The ball of the shoulder is the top end of the humerus (upper arm bone).

Can be from a traumatic shoulder injury, or from repetitive use. Trauma to the shoulder joint, like a shoulder dislocation, or fall on an outstretched hand may cause a labral tear. Repetitive overhead activities that may damage the labrum include overhand or windmill pitching, volleyball hitting or swimming.

An MRI will show the tear and possible damage to other structures in and around the shoulder.

For a traumatic injury, the athlete may be most comfortable in a sling. Many labral tears start over time, so there may not be a clear initial management phase.

Since the labrum helps with shoulder stability, once it’s torn there is a higher risk of having an injury like a full shoulder dislocation.

Allow time for inflammation to settle down while strengthening the rotator cuff muscles that support the shoulder.

Return to play with a torn labrum in the shoulder is determined by regaining range of motion and strength. In particular, the rotator cuff muscle need to be strong enough to stabilize the shoulder to prevent another injury like a dislocation.

A surgeon may use a camera and tools through small incisions to repair the labrum by looping stitches around the tear and anchoring it back down to the edge of the shoulder socket.

Like other tissue, nerves can get bruised or stretched. The injured nerves aren’t able to send their messages properly, leading to numbness or tingling in the arm and hand, a feeling of the arm being “dead”, or muscle weakness in the arm and hand.

Nerves run from the neck down the arms that send messages to the muscles to cause movement, or back to the brain to send information about touch and pain.

Stingers or burners happen in one of three ways: 1) compression of the nerve where it runs between the neck and the shoulder; 2) stretching the nerve by pulling the arm while the head bent or rotated away from that side; 3) compression of the nerve in the tunnel where it comes out of the spine from a whiplash or rotation motion in the neck.

Stingers/burners that cause lingering symptoms may call for an MRI. The MRI shows damage or inflammation of the nerve, or of the structures around the nerve that might be compression it to cause the lasting symptoms.

The first step is to rule out significant spine injury by checking neck range of motion and pain. Evaluate sensation and strength in the shoulder, arm and hand.

Persistent numbness or tingling that does not resolve. Muscle weakness without pain may also indicate more severe nerve injury.

long term nerve damage

Most stingers and burners resolve on their own in a few minutes. Re-checking sensation and strength will guide when it’s safe to return to play. If the symptoms don’t fade on their own, the athlete should be evaluated for more significant spine or neural injury.

Most stingers and burners resolve in a few minutes.

There is no specific surgery for stingers or burners. If symptoms don’t go away on their own, there is likely a more serious injury or underlying structural concern which may need surgery.

A full or partial tear/stretching of the hamstring muscle or tendon which run along the back of the thigh.

The hamstring muscles are a group of muscles that run along the back of the thigh. Their job is to extend the hip and bend the knee.

Quick accelerations or explosive movements are the most common way to strain or tear the hamstrings. Activities where the muscle is contracting while the hip is bent and the knee is extended put the hamstrings in a more vulnerable position.

Ultrasound imaging or MRI will show the damage to the muscle or tendon. If the tendon pulls off the bone right at the attachment point, an xray may show a small piece of bone pulled away from attachment place on the pelvis.

Manage pain and inflammation,

Extremely high rate of re-injury

A hip flexor strain involves overstretching, partial tearing, or full tearing of one or more of the hip flexor muscles.

The hip flexor muscles run along the front of the hip and their job is to lift the upper leg (like marching). One of the hip flexor muscles runs through the pelvis and attaches to the vertebrae in the low back.

The most common way to strain the hip flexors is with a hard or quick contraction while the muscle is in its most stretched position. For example, in sprinting, trying to drive the knee forward when the leg is extended behind the body.

An MRI will show which of the hip flexor muscles is injured and help determine how significant the injury is.

Start by managing pain and inflammation. Keep the hip slightly bent or neutral to avoid further stretching to the injured muscle.

The majority of hip flexor strains are treated with physical therapy focused on strengthening all around the hip and regaining range of motion gradually. Getting back to on the field is a progression from walking to jogging to running to sprinting and explosive cutting and jumping.

A quad contusion is a bruise to the muscle along the front of the thigh. Impact damages the muscle fibres and the blood vessels around the muscle, causing swelling, pain and weakness. It’s also very painful stretching the muscle by bending the knee.

The quad muscles are a group of 4 muscles that run along the front of the thigh and their main job is to straighten the knee. One of the quad muscles starts higher than the others, above the hip joint, and has an additional job of helping to bend the hip.

Traumatic compression, ie getting hit with a helmet or knee. Since football players wear thigh pads, it’s more common to see these contusions along the outside edge of the quad, or slightly lower than the pad where they are unprotected.

MRI or diagnostic ultrasound can show damage or inflammation in the soft tissue of the muscle. If the injury progresses to bony formation (myositis ossificans), the bone mass is visible on xray.

Managing initial swelling and maintaining knee range of motion is key to successful treatment. This includes compression, gently flushing out swelling with therapeutic modalities and keeping the knee fully bent as much as possible. Ice and anti inflammatories may help with the pain. Close monitoring is important to avoid developing complications.

Quad bruises are more likely to develop complications when left untreated for 3+ days and the inability to bend the knee beyond 120 degrees, or if there’s a history of repeated trauma to the muscle.

Bruises in the quad muscles may develop pockets of pooled blood/swelling (hematoma). These pockets of fluid can harden and turn into small deposits of bone within the muscle, called Myositis Ossificans. These small masses of bone limit the function and strength of the muscle and are very painful.

Swelling management, NSAIDs and keeping the knee bent are key to initial management. As the bruise begins to heal, starting with light exercise and progressing into more strengthening helps the athlete return to playing shape.

The timeline for return is largely based on the extent of the damage and whether or not a hematoma develops. Athletes are able to return to the field once they have full knee range of motion and strength. Often they will wear a donut pad around/over the bruise to prevent further damage.

If a hematoma develops, a doctor might consider draining it to relieve the pressure in the area. If a bony deposit does form, there is the option to have it surgically removed.

The criteria for return to play is the same as for non-surgical management. Typically quad contusions that need draining or surgery are more significant so the recovery can be weeks to months.

Full knee range of motion and quad strength that’s near equal to the other side. The athlete needs to be able to perform all their position tasks on the field without pain or weakness.

A quad strain can happen in any of the 4 muscles, but is commonly in the rectus femoris which crosses the hip and the knee. Quad strains involve damage or tearing to some or all of the muscle fibres. A grade 1 strain means the muscle fibres are stretched but not torn, grade 2 means some but not all fibres are torn and a grade 3 strain is a complete tear.

The quad muscles are a group of 4 muscles that run along the front of the thigh and their main job is to straighten the knee. One of the quad muscles starts higher than the others, above the hip joint, and has an additional job of helping to bend the hip.

Quad strains are usually from an excessive amount of force through the muscle while it’s in a stretched position with the knee bent. In football this can happen if a kicker catches their toe on the turf while swinging their leg through, or in positions like DB or LB during backpedaling.

An MRI can show the location and severity of the muscle damage.

Rest, ice and compression help with swelling and pain.

Rehabilitation for a quad strain includes exercises and therapy to regain range of motion and strength as the muscle fibres heal. The program will also include a return to runningp program to ease the athlete back into sport.

The average timeframe for return to play in the NFL for a quad strain is between 1-4 weeks.

https://journals-sagepub-com.proxy1.lib.uwo.ca/doi/full/10.1177/03635465231175479

Quad strains are rarely treated with surgery unless there is a complete tear. Full tears usually happen at/near the tendon that attaches the muscle to the bone. See patellar tendon rupture.

Breaking or dislocating a finger

Other than the thumb, each finger has three bones that meet at the knuckles. The thumb has two bones. Any of the bones of the fingers can be broken and any of the joints can be dislocated. It is more common for the middle or end knuckle to dislocate than where the finger meets the hand.

Jamming the finger directly into a hard surface is the most common way of breaking a finger.

An xray will show the location of the break and whether the pieces are all aligned in a way that will heal well.

Splint or buddy tape for stability. Reduction of dislocation by a medical professional.

Possible complications to broken or dislocated fingers include the bones piercing through the skin, which adds a risk of infection. The pieces of bone can also damage the ligaments that hold the joints together, or the tendons that control finger movement.

Buddy tape and splinting, manage inflammation and progressively build back range of motion and strength.

Closed dislocations with no fracture may return to play with added support as soon as swelling and pain allow. Fractures

Complex or unusable fractures may be pinned. Once the bone is healed, the pin is often removed.

Breaking a bone at the base of the thumb. If the break separates the sides with and without blood supply, the side without blood may not heal and the bone tissue could die.

The scaphoid is a small, saddle shaped bone at the base of the thumb. The shape of the scaphoid helps the thumb’s big range of motion. In many people, there is only blood supply to one half of the bone.

Fall on an outstretched hand

Xray may not show initial scaphoid fractures, but a repeat xray in 10-14 days would show signs of fracture healing to confirm the diagnosis. Bone scan, MRI or CT will be more sensitive to detecting the initial fracture.

Splint and get imaging. Manage inflammation.

Higher risk of non-union when the fracture is at the near end (proximal pole) of the bone, when the pieces of the fracture are displaced >1mm and with specific fracture patterns shown on imaging.

Non-union, where the two pieces of the bone do not heal together properly. In some people, there isn’t enough blood supply to one of the broken pieces, so the bone tissue starts to die (avascular necrosis).

Casting/immobilization of the wrist and thumb for 6-12 weeks with repeat imaging to check for healing.

9-12 weeks or longer, with a period of of regaining motion and strength after getting out of the cast. If the break is at the furthest end of the bone, it tends to heal better and may be closer to a 6 week recovery.

https://pmc.ncbi.nlm.nih.gov/articles/PMC5344853/

Surgery for a scaphoid fracture involves pinning the pieces of the bone back together. The pins might go through the skin and are removed once the fracture is healed. Other surgical options include screwing the bone back together with hardware that doesn’t stick out of the skin, and/or bone grafting to fill in any gaps.

The return to football after surgery is position dependent and specific surgeons have different timelines for this. Players who can play in a cast or splint may return sooner, around 4-6 weeks after surgery. Positions needing more wrist motion (like a QB) may need 6-12+ weeks before returning.

To return to sport the goal is for the athlete to have wrist range of motion and grip strength near equal the non injured side.

Scaphoid fractures that are left untreated for the first few weeks have higher risk of complications like not healing or healing in a poor position (non union or Mal union). Players with these complications will likely have long term wrist pain and difficulty with motion and gripping.

Breaking one or both of the long bones in the forearm, or one of the 8 small bones that connect the hand to the forearm.

The wrist is an area made up of 8 small bones that sit between the ends of the forearm bones (radius and ulna), and the hand bones. Any of these bones can be broken, but most wrist fractures refer to breaking the radius or ulna.

Falling on an outstretched hand,

Xray. MRI will show additional soft tissue damage.

Splint and get imaging. Manage inflammation.

Cold, blue hand with absent or decreased pulse. Numbness or tingling in the hand.

Damage to blood vessels or nerves going into the hand

Casting/immobilization of the wrist. Possible additional immobilization of the elbow to limit forearm rotation.

6-12 weeks, with 4-6 weeks immobilized.

Fractures where there are multiple pieces of bone broken or where the edges of the break aren’t aligned or multiple often need to be fixed surgically. The bones are realigned and held in place with plates and screws.

10-12 weeks with 10-14 days of full immobilization post op followed by a removable splint and gradual resumption of range of motion. Begin progressive strengthening around week 8.

Strength within 10% of other side, no pain or instability with functional tasks (sport specific needs)

There is a wide range of forearm fracture types that are have different classifications and might follow different treatment guidelines depending on the injury, patient needs and doctor recommendations.

This is a non-specific term that describes the stretching or tearing of one or more of the ligaments that connect the small bones in the wrist to each other or the bones of the hand or forearm.

The wrist is an area made up of 8 small bones that sit between the ends of the forearm bones (radius and ulna), and the hand bones. All of these bones are connected by ligaments that hold them in place.

Falling on an outstretched hand, forced hyperextension, forced hyper flexion or repeatedly jamming the wrist into flexion or extension.

MRI shows the soft tissue damage (ligaments). Xray may show slight widening of the space between the bones. Xray is also useful to rule out fractures in these injuries.

Manage pain and inflammation, stabilize with bracing, tape or splint for more severe cases.

If the ligaments holding the small bones in the wrist are torn or stretched enough, the bones can slide out of place. The lunate bone, which sits at the base of the middle finger is a bone that dislocates.

Splinting or bracing is most common, possibly casted for highly unstable cases.

2-10 weeks for healing depending on the severity of the injury. Many football players will return to play with tape or bracing before full healing, sometimes as early as the same day for less severe cases.

Rare, however can be treated with arthroscopy (inserting a camera to see the damage first hand and use small tools to clean up the joint), or with open surgery where the surgeon may reset the bones in the correct spot and repair or reconstruct the ligaments as needed.

3-6 months, with full healing possibly taking up to 12 months. Range of motion work begins after a few weeks, followed by progressive strengthening.