Management of thoracic spinal cord injury in a professional American football athlete: illustrative case.

BACKGROUND: A case of catastrophic thoracic spinal cord injury (SCI) sustained by a professional American football player with severe scoliosis is presented. OBSERVATIONS: A 25-year-old professional football player sustained an axial loading injury while tackling. Examination revealed a T8 American Spinal Injury Association Impairment Scale grade A complete SCI. Methylprednisolone and hypothermia protocols were initiated. Computed tomography scan of the thoracic spine demonstrated T8 and T9 facet fractures on the left at the apex of a 42° idiopathic scoliotic deformity. Magnetic resonance imaging (MRI) demonstrated T2 spinal cord hyperintensity at T9. He regained trace movement of his right lower extremity over 12 hours, which was absent on posttrauma day 2. Repeat MRI revealed interval cord compression and worsening of T2 signal change at T7-T8 secondary to hematoma. Urgent decompression and fusion from T8 to T10 were performed. Additional treatment included high-dose omega-3 fatty acids and hyperbaric oxygen therapy. A 2-month inpatient spinal cord rehabilitation program was followed by prolonged outpatient physical therapy. He currently can run and jump with minimal residual distal left lower limb spasticity. LESSONS: This is the first known football-related thoracic SCI with idiopathic scoliosis. Aggressive medical and surgical intervention with intensive rehabilitation formed the treatment protocol, with a favorable outcome achieved.

If You're Not Measuring, You're Guessing: The Advent of Objective Concussion Assessments.

Sport-related concussion remains one of the most complex injuries presented to sports medicine professionals. Although the injury has been recognized since ancient times, the concussion-assessment process has seen significant advances over the last 30 years. This review outlines the addition of objective measures to the clinical evaluation of the concussed athlete, beginning in the 1980s and continuing through the modern age. International and domestic organizations now describe standardized symptom reports, neurostatus and neurocognitive-function evaluations, and postural-control measures as standards of medical care, a significant shift from a short time ago. Despite this progression, much about the injury remains unknown, including new clinical and research-based assessment techniques and how the injury may influence the athlete's cognitive health over the long term.

Significance of T2 Hyperintensity on Magnetic Resonance Imaging After Cervical Cord Injury and Return to Play in Professional Athletes.

BACKGROUND: Cervical cord magnetic resonance imaging (MRI) T2 hyperintensity is used as evidence of cord trauma in the evaluation and management of athletes in contact sports. The long-term pathophysiologic and prognostic value of this finding is poorly understood, especially in return to play (RTP). OBJECTIVE: To examine the significance of T2 hyperintensity in the cervical spinal cord of professional athletes. METHODS: Retrospective review of MRI T2 hyperintensity findings between 2007 and 2014 in 5 professional athletes. Pertinent examination and demographics, including mechanism of injury, surgical intervention, radiographs, MRI studies, long-term outcomes, and RTP recommendations were collected. RESULTS: Four National Football League players and 1 professional wrestler had prior traumatic neurapraxia that at the time of initial consultation had resolved. MRIs showed congenitally small cervical canal (1) and multilevel spondylosis/stenosis/disc herniation (4) along with focal cord T2 hyperintensity (5). The signal abnormalities were at C3/C4 (3), C4 mid-vertebral body (1), and C5/C6 (1). Four athletes had single-level anterior cervical discectomy and fusion, and 1 was nonoperative. Serial MRI imaging at 3 months after surgery showed hyperintensity partially resolved (4) and unchanged (1), and at 9-months 3 of the 5 completely resolved. Based on the author's RTP criteria, 4 of 5 were released to return to their sport. Clearance for RTP preceded complete resolution of MRI T2 hyperintensity in 3 of 4 athletes. The 2 athletes that have returned to profession sport have not had any additional episodes of neurapraxia or any cervical spine-related complications. CONCLUSION: MRI T2 hyperintensity in contact sport athletes who are symptom-free with normal examination and no evidence of spinal instability may not be a contraindication to RTP. Additional observations are needed to confirm this observation.

Vitamin D profile in National Football League players.

BACKGROUND: By maintaining phosphate and calcium homeostasis, vitamin D is critical for bone health and possibly physical performance. Hence, vitamin D is important to athletes. Few studies have investigated vitamin D levels in relation to fractures and performance in athletes, and no published study has included a multiracial sample of professional American football players. PURPOSE: To assess vitamin D levels, including the prevalence of vitamin D deficiency/insufficiency, in professional American football players and to evaluate the association of vitamin D levels with race, fracture history, and the ability to obtain a contract position, which may be a marker for athletic performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Serum vitamin D levels of 80 professional football players from a single team in the National Football League were obtained during the 2011 off-season (mean age, 26.5±3.7 years; black, n=67 [84%]). These levels were used to compare injury reports from the 2011-2012 and 2012-2013 seasons. Statistical analyses were performed to test if vitamin D levels were related to race, fracture history, and the ability to obtain a contract position. RESULTS: Mean vitamin D level was 27.4±11.7 ng/mL, with significantly lower levels for black players (25.6±11.3 ng/mL) versus white players (37.4±8.6 ng/mL; F 1,78=13.00, P=.001). All athletes who were vitamin D deficient were black. When controlling for number of professional years played, vitamin D levels were significantly lower in players with at least 1 bone fracture when compared with no fractures. Players who were released during the preseason because of either injury or poor performance had significantly lower vitamin D levels than did players who played in the regular season. CONCLUSION: Black professional football players have a higher rate of vitamin D deficiency than do white players. Furthermore, professional football players with higher vitamin D levels were more likely to obtain a contract position in the National Football League. Professional football players deficient in vitamin D levels may be at greater risk of bone fractures.

Outcomes after anterior cervical discectomy and fusion in professional athletes.

BACKGROUND: Significant controversy exists regarding when an athlete may return to contact sports after anterior cervical discectomy and fusion (ACDF). Return-to-play (RTP) recommendations are complicated due to a mix of medical factors, social pressures, and limited outcome data. OBJECTIVE: The aim of this study was to characterize our diagnostic and surgical criteria, intervention, postoperative imaging results, and rehabilitation and report RTP decisions and outcomes for professional athletes with cervical spine injuries. METHODS: Fifteen professional athletes who had undergone a 1-level ACDF by a single neurosurgeon were identified after a retrospective chart and radiographic review from 2003 to 2012. Patient records and imaging studies were recorded. RESULTS: Seven of the 15 athletes presented with neurapraxia, 8 with cervical radiculopathy, and 2 with hyperintensity of the spinal cord. Cervical stenosis with effacement of the cerebrospinal fluid signal was noted in 14 subjects. The operative level included C3-4 (4 patients), C4-5 (1 patient), C5-6 (8 patients), and C6-7 (2 patients). All athletes were cleared for RTP after a neurological examination with normal findings, and radiographic criteria for early fusion were confirmed. Thirteen of the 15 players returned to their sport between 2 and 12 months postoperatively (mean, 6 months), with 8 still participating. The RTP duration of the 5 who retired after full participation ranged from 1 to 3 years. All athletes remain asymptomatic for radicular or myelopathic symptoms or signs. CONCLUSION: After a single-level ACDF, an athlete may return to contact sports if there are normal findings on a neurological examination, full range of neck movement, and solid arthrodesis. There may be an increased risk of the development of adjacent segment disease above or below the level of fusion. Cord hyperintensity may not necessarily preclude RTP.

Incidence and variance of foot and ankle injuries in elite college football players.

We conducted a study on the risk for foot and ankle injuries in college football players on the basis of injury type and player position. In February 2006, we evaluated 320 intercollegiate football players at the National Football League Combine. All pathologic conditions and surgical procedures of the foot and ankle were recorded, and data were analyzed by player position to detect any trends. Seventy-two percent (n = 231) of the players had a history of foot and ankle injuries, with a total of 287 foot and ankle injuries (1.24 injuries/player injured). The most common injuries were lateral ankle sprain (n = 115), syndesmotic sprain (50), metatarsophalangeal dislocation/turf toe (36), and fibular fracture (25). Foot and ankle injuries were most common in kickers/punters (100% incidence), special teams (100%), running backs (83%), wide receivers (83%), and offensive linemen (80%). Lateral ankle sprains, the most common injuries, were treated surgically only 2.6% of the time. Offensive linemen were most likely to have had syndesmotic sprains (32%), and quarterbacks had the highest incidence of fibular fractures (16%). Foot and ankle injuries are common in collegiate football players, affecting 72% of players. Thirteen percent underwent surgical treatment. Trends are seen in the types of injuries for the different player positions.

Evaluation of lipid profiles and the use of omega-3 essential Fatty Acid in professional football players.

BACKGROUND: Recent research showed 82% of 233 retired National Football League players under age 50 had abnormal narrowing and blockages in arteries compared to the general population of the same age. It has been suggested that early screening and intervention in this at-risk population be a priority. HYPOTHESIS: Omega-3 essential fatty acid has been shown to improve cardiovascular lipid risk factors and should improve lipid profiles in professional football players to help reduce their recently shown accelerated risk of developing cardiovascular disease. METHODS: A total of 36 active national football players were randomly assigned to 2 groups: the first group (n = 20) was provided fish oil capsules (2200 mg of mixed docosahexaenoic acid and eicosapentaenoic acid and 360 mg of other omega-3s), and the second group (n = 16) served as controls during a 60-day trial. Vertical Auto Profile cholesterol tests directly measuring serum low-density lipoprotein, high-density lipoprotein, and other subfractions were performed. Compliance, side effects, and seafood consumption data were also collected. Baseline, midpoint, and poststudy blood work measured plasma docosahexaenoic acid and eicosapentaenoic acid. RESULTS: Treatment increased high-density lipoprotein (average percent change: +25.96, control +14.16), decreased triglycerides treatment (-8.06, control +43.98), very low-density lipoprotein treatment (-13.98, control +23.18), intermediate density lipoprotein (-27.58, control +12.07), remnant lipoproteins (-23.86, control +8.33), and very low-density lipoprotein-3 (-17.10, control +7.77). An average increase of 106.67% for docosahexaenoic acid and 365.82% for eicosapentaenoic acid compared to control was also shown. CONCLUSION: Omega-3 supplementation significantly improved the lipid profile of active players randomized to treatment. These results suggest that fish oil supplementation is an effective way to increase eicosapentaenoic acid and docosahexaenoic acid levels in plasma and should be considered as a method to improve modifiable cardiovascular risk lipid factors in professional football players. CLINICAL RELEVANCE: A prospective study examining the effects of 60 days of a highly purified fish oil supplementation in professional football players.

Incidence and variance of knee injuries in elite college football players.

Knee injuries are among the most common musculoskeletal injuries in US football players. The literature includes little information about the role of player position and risk for knee injury. We hypothesized that the incidence of knee injury in elite collegiate US football players is high and that type of injury varies by player position. We evaluated 332 elite collegiate US football players at the 2005 National Football League Combine. All players underwent radiographic examinations, including plain x-rays and/or magnetic resonance imaging when necessary. All knee pathologic conditions and surgical procedures were recorded. Data were analyzed by player position to detect any trends. Fifty-four percent (179) of the 332 players had a history of knee injury; knee injuries totaled 233 (1.3/player injured). Eighty-six players (25.9%) had a total of 114 surgeries. The most common injuries were medial collateral ligament injury (n = 79), meniscal injury (n = 51), and anterior cruciate ligament (ACL) injury (n = 40). The most common surgeries were arthroscopic meniscectomy (n = 39), ACL reconstruction (n = 35), and arthroscopic meniscal repair (n = 13). A history of knee injury was most common in defensive linemen (68% of players), tight ends (57%), and offensive linemen (57%). Knee surgery was more commonly performed on running backs (36%) and linebackers (34%). There were no significant associations between type or frequency of specific injuries with regard to player position. Knee injuries are common injuries in elite collegiate football players, and one fourth of these players undergo surgical procedures. However, there were no statistically significant differences in type or frequency of injuries by player position.

Cervical neurapraxia in elite athletes: evaluation and surgical treatment. Report of five cases.

OBJECT: Neurapraxia, transient posttraumatic paralysis of the motor and/or sensory tracts in the spinal cord, may be a career-ending event in an athlete. Management, rehabilitation, and return-to-play decisions remain controversial. METHODS: Five elite football players were evaluated after experiencing episodes of neurapraxia. All patients experienced bilateral paresthesias--three in all four extremities and two in the upper extremities--lasting a few minutes to more than 24 hours. Transient motor deficits occurred in two individuals but caused no permanent sequelae. Neuroimaging confirmed the presence of herniated discs, focal cord compression, and no parenchymal changes in all cases. All patients underwent anterior cervical microdiscectomy and fusion, and cervical plates were placed in four. After aggressive rehabilitation and confirmation of fusion ranging from 9 weeks to 8 months postoperatively, the players were allowed to return to active play. Two of the players developed recurrent career-ending disc herniations, one above and the other below the fusion level. One player required repeated spinal cord decompression. CONCLUSIONS: Neurologically intact athletes with focal cord compression due to a single-level herniated disc may safely return to football after undergoing decompressive surgery and confirmation of fusion. It appears, however, that there may be an increased chance of repeated herniation above or below a fused level.

Sideline and ringside evaluation for brain and spinal injuries.

Participation in contact and collision sports carries an inherent risk of injury to the athlete, with damage to the nervous system producing the most potential for significant morbidity and death. Neurological injuries suffered during athletic competition must be treated promptly and correctly to optimize outcome, and differentiation between minor and serious damage is the foundation of sideline/ringside management of the injury. In this article the authors present a guide to the sideline or ringside identification and management of head and spinal injuries.

Measurement of symptoms following sports-related concussion: reliability and normative data for the post-concussion scale.

It is important to carefully evaluate self-reported symptoms in athletes with known or suspected concussions. This article presents data on the psychometric and clinical properties of a commonly used concussion symptom inventory-the Post-Concussion Scale. Normative and psychometric data are presented for large samples of young men (N = 1,391) and young women (N = 355). In addition, data gathered from a concussed sample of athletes (N = 260) seen within 5 days of injury are presented. These groups represent samples of both high school and collegiate athletes. Data from a subsample of 52 concussed athletes seen 3 times post-injury are presented to illustrate symptom reporting patterns during the initial recovery period. General guidelines for the clinical use of the scale are provided.

Prevalence and variance of shoulder injuries in elite collegiate football players.

BACKGROUND: Shoulder injuries are the fourth most common musculoskeletal injury encountered in American football players. There is little information in the literature on the role of playing position in the type of shoulder injuries seen. HYPOTHESIS: There is a high prevalence of shoulder injuries in elite collegiate American football players, with type of injury varying by playing position. STUDY DESIGN: Cohort study (prevalence); Level of evidence, 3. METHODS: A total of 336 elite collegiate American football players were invited to the National Football League Combine for physical testing and medical evaluation. Current and historical data were evaluated for the purpose of this study, and all players underwent radiographic examinations, including plain radiographs and/or magnetic resonance imaging when necessary. All shoulder pathological conditions and shoulder surgical procedures were recorded. Players were categorized by position for the analysis of position-specific trends. RESULTS: Of the players, 50% had a history of shoulder injuries, with a total of 226 shoulder injuries (1.3 injuries per player injured); 56 players (34%) had a total of 73 surgeries. The most common injuries were acromioclavicular separation (41%), anterior instability (20%), rotator cuff injury (12%), clavicle fracture (4%), and posterior instability (4%). The most common surgeries performed were anterior instability reconstruction (48%), Mumford/Weaver-Dunn surgery (15%), posterior instability surgery (10%), and rotator cuff surgery (10%). Shoulder injuries were more common in quarterbacks and defensive backs. Surgery was more common in linebackers or linemen. A history of anterior instability was more common in defensive players, with surgery required 76% of the time. Linemen had more rotator cuff injuries and posterior instability than players in other positions. CONCLUSION: Shoulder injuries are common injuries in elite collegiate football players, with one-third undergoing surgical procedures. There are definitive trends in the types of injuries per player position.

On-field predictors of neuropsychological and symptom deficit following sports-related concussion.

OBJECTIVE: Investigate the relationship between on-field markers of concussion severity and postinjury neuropsychological and symptom presentation in an athlete-specific population. DESIGN: Case control study. SETTING: Multicenter analysis of high school and college athletes. PARTICIPANTS: A total of 78 athletes sustaining sports-related concussion were selected from a larger sample of 139 concussed athletes. ASSESSMENT OF PREDICTOR VARIABLES: On-field presence of disorientation, posttraumatic amnesia, retrograde amnesia, and loss of consciousness. MAIN OUTCOME MEASURES: ImPACT, a computerized neuropsychological test battery, was administered pre-season and, on average, 2 days postinjury. Good postinjury presentation (n = 44) was defined as no measurable change, relative to baseline, in terms of both ImPACT memory and symptom composite scores. Poor presentation (n = 34) was defined as a 10-point increase in symptom reporting and 10-point decrease in memory functioning (exceeding the 80% confidence interval for measurement error on ImPACT). Athletes failing to meet good or poor selection criteria (n = 61) were not included in the analysis. RESULTS: Odds ratios revealed that athletes demonstrating poor presentation at 2 days postinjury were over 10 times more likely (P < 0.001) to have exhibited retrograde amnesia following concussive injury when compared with athletes exhibiting good presentation. Similarly, athletes with poor presentation were over 4 times more likely (P < 0.013) to have exhibited posttraumatic amnesia and at least 5 minutes of mental status change. There were no differences between good and poor presentation groups in terms of on-field loss of consciousness. CONCLUSIONS: The presence of amnesia, not loss of consciousness, appears predictive of symptom and neurocognitive deficits following concussion in athletes. Athletes presenting with on-field amnesia should undergo comprehensive and individualized assessment prior to returning to sport participation. Continued refinement of sports concussion grading scales is warranted in lieu of consistent findings that brief loss of consciousness is not predictive of concussion injury severity.