Team Approach: Diagnosis, Management, and Prevention of Sudden Cardiac Arrest in the Athlete.

¼ Sudden cardiac events during sports competition are rare but tragic occurrences that require a timely, comprehensive response by well-prepared athletic trainers and medical providers. This sequence should prioritize prompt emergency medical system activation, immediate initiation of cardiopulmonary resuscitation (CPR), automated early defibrillation (AED), and comprehensive advanced life support efforts.¼ Exercise-induced cardiac remodeling, referred to as the "athlete's heart," refers to a host of adaptive changes that increase cardiac chamber size and wall thickness to allow for greater pressures and volumes during exercise. This remodeling phenotype may overlap with other inherited cardiomyopathies and cardiac abnormalities, which can complicate clinical care. The long-term implications of this electrical and structural remodeling on cardiac function are unknown.¼ Although the best screening strategies to optimize primary prevention of sudden cardiac arrest is an evolving topic, the effectiveness of CPR and early defibrillation use in treating out-of-hospital sudden cardiac arrest has been well-established, despite their reported underuse.

Lower Extremity Compartment Syndrome in National Football League Athletes.

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

Increased sensitivity to traumatic axonal injury on postconcussion diffusion tensor imaging scans in National Football League players by using premorbid baseline scans.

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

Engaging Athletic Trainers in Concussion Detection: Overview of the National Football League ATC Spotter Program, 2011-2017.

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

Athletes With Musculoskeletal Injuries Identified at the NFL Scouting Combine and Prediction of Outcomes in the NFL: A Systematic Review.

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

National Football League Head, Neck and Spine Committee's Concussion Diagnosis and Management Protocol: 2017-18 season.

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

Distal Fibula Fractures in National Football League Athletes.

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

Acute Gastrocnemius-Soleus Complex Injuries in National Football League Athletes.

BACKGROUND: Lower extremity muscle injuries are common in professional football. Although less common than hamstring or quadriceps injuries in National Football League (NFL) athletes, calf injuries occur with relative frequency and have not previously been studied. PURPOSE: To evaluate gastrocnemius-soleus complex muscle injuries over the past 13 years from a single NFL team to determine the incidence of such injuries, their imaging characteristics, and return to play after such injuries and any correlation between imaging findings and prolonged return to play. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of all acute calf muscle injuries on a single NFL team from 2003 to 2015 was performed. Player demographics and return-to-play data were obtained from the medical records. All available magnetic resonance images (MRIs) were reviewed by a musculoskeletal radiologist for specific imaging findings that correlated with return to play. RESULTS: A total of 27 calf injuries in 24 NFL players were reviewed, yielding an incidence of 2.3 acute calf injuries per year on a single NFL team. Of these 27 injuries, 20 (74%) were isolated injuries to the gastrocnemius muscle, 4 (15%) were isolated injuries to the soleus muscle, and the remaining 3 injuries (11%) involved both. Defensive players were more likely to sustain injuries (P = .043). The mean time to return to play for all 27 players was 17.4 ± 14.6 days (range, 3-62 days). MRIs were available in 14 of the 27 injuries. The average size of the fascial defect (P = .032) and the presence of a fluid collection (P = .031) both correlated with return to play of longer than 2 weeks. CONCLUSION: Although less common than hamstring or quadriceps muscle injuries, calf muscle injuries occur with relative frequency in the NFL, and more so in defensive players. The majority of these injuries occur in the gastrocnemius and result in significant disability, with at least 2 weeks of missed playing time on average. MRI may have an important role in the evaluation of calf injuries in NFL players, as certain injury imaging characteristics, including the anteroposterior size of any fascial tear and the presence of a fluid collection, are associated with longer return-to-play times after injury.

Injuries to the Collateral Ligaments of the Metacarpophalangeal Joint of the Thumb, Including Simultaneous Combined Thumb Ulnar and Radial Collateral Ligament Injuries, in National Football League Athletes.

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

Pressurized Intravenous Fluid Administration in the Professional Football Player: A Unique Setting for Venous Air Embolism.

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

Midfoot sprains in the National Football League.

Midfoot sprains in the National Football League (NFL) are uncommon. There are few studies on midfoot sprains in professional athletes, as most studies focus on severe traumatic injuries resulting in Lisfranc fracture-dislocations. We conducted a study to evaluate midfoot sprains in NFL players to allow for better identification and management of these injuries. All midfoot sprains from a single NFL team database were reviewed over a 15-year period, and 32 NFL team physicians completed a questionnaire detailing their management approach. A comparative analysis was performed analyzing several variables, including diagnosis, treatment methods, and time lost from participation. Fifteen NFL players sustained midfoot sprains. Most injuries occurred during games as opposed to practice, and the injury typically resulted from direct impact rather than torsion. Twelve players had nonoperative treatment, and 3 had operative treatment. Nonoperative management resulted in a mean of 11.7 days of time lost from participation. However, there was a significant (P=.047) difference in mean (SD) time lost between the grade 1 sprain group, 3.1 (1.9) days, and the grade 2 sprain group, 36 (26.1) days. Of the 3 operative grade 3 patients, 1 returned in 73 days, and 2 were injured late in the season and returned the next season. Eleven (92%) of the 12 players who had nonoperative treatment had a successful return to play, and 10 (83%) of the 12 played more games and seasons after their midfoot injury. Depending on the diastasis category, NFL team physicians vary treatment: no diastasis (84% cam walker), latent diastasis (47% surgery, 34% cam walker), and frank diastasis (94% surgery). In the NFL, midfoot sprains can be a source of significant disability. Successful return to play can be achieved with nonoperative management for grade 1 injuries within 1 week and grade 2 injuries within 5 weeks. However, severe injuries with frank diastasis that require operative management will necessitate a more significant delay in return to play. Either way, most NFL athletes will have a successful NFL career after their midfoot sprain injury.

Corticosteroid and Anesthetic Injections for Muscle Strains and Ligament Sprains in the NFL.

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

Syndesmosis and lateral ankle sprains in the National Football League.

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

Operative and nonoperative treatment of cervical disc herniation in National Football League athletes.

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

Epidural steroid injection for lumbar disc herniation in NFL athletes.

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

Lower cervical posterior element fractures in the National Football League: a report of 2 cases and a review of the literature.

BACKGROUND AND IMPORTANCE: Injuries in professional football players are common because of the nature of the collisions and the frequency of axial loading to the cervical spine. These injuries should be thoroughly evaluated because they can put the player at risk of future injury and even paralysis. The focus of this report is to present 2 cases of this injury and review the current body of literature. CLINICAL PRESENTATION: We present 2 cases of professional football players who experienced injuries to the lower posterior elements of their cervical spine simultaneously on a kickoff during a game. Both players described transient symptoms consistent with a "stinger," which is commonly encountered. Workup revealed fractures of the lower cervical spine in both patients. One patient was able to be managed conservatively and returned to football the following season. The second patient had an unstable fracture that ultimately required operative intervention, and the patient retired from professional football. CONCLUSION: Cervical spine injuries in football players need to be adequately evaluated, and in many cases can be career threatening. We recommend that players with persistent pain after a transient neurapraxia undergo radiography and computed tomography of the cervical spine to evaluate for a fracture.