Injuries in the NFL

Ever limped around with a sprained ankle for a couple of weeks?  Pulled a “hammy” playing softball and stayed out of the gym for a month?  Answer yes to any of these questions and you may not be cut out for a long NFL career.  While injuries are a given in the NFL, missing games with “minor injuries” is not.  Remember Jay Cutler?  Ridiculed on national television by those that thought a torn MCL was not serious enough to keep him from returning to a playoff game.

Anyone that watches football regularly is aware of the well-publicized major injuries but what is not well known are the “minor” injuries that many or all of the players deal with on a weekly basis.  Pulled or strained muscles; swollen knees and ankles; dislocated and separated shoulders; these are the injuries that many players suffer yet continue to play with during a grueling season in the NFL.

Dr. Michael Dillingham, the San Francisco 49ers team physician for 24 years, says “Playing with injury is routine.  Football is their profession and players are willing to take calculated risks to stay on the field.”   While careful not to impair a player’s ability to protect an injured area, pain-killing injections are commonplace before games to numb sore areas.  When asked about how many players are hurt during a season Dr. Dillingham articulates that “during the season virtually every player on an NFL team experiences an injury that the average person would consider a substantial injury.”

Even when players require surgery or significant rehabilitation after more serious injury, the time frame for recovery is accelerated when compared to the “normal” patient.  In his groundbreaking return from ACL surgery and rehabilitation, Jerry Rice was able to return to the NFL less than four months after his surgery by Dr. Dilllingham.  Active Care physical therapist and owner Lisa Giannone guided the rehab process, covered by Sports Illustrated.  Normal recovery after ACL surgery would require at least 7-9 months of rehabilitation prior to returning to sports.

After spending a season consulting inside the 49ers facility, Lisa and other Active Care therapists and trainers were accustomed to dealing with the accelerated pace of recovery.  As Lisa relates it was not uncommon to see players practicing with post-knee surgery sutures.

Public awareness of the risk of injury and the long-term health risks associated with professional football continues to increase.  In a report entitled “The Dangers of the Game”, released during the recent NFL lockout, research by the NFL Player’s Association revealed that major injuries have continued to increase with 352 players sustaining injuries that required missing at least half of the 2010 season, an all-time high.  The NFLPA released the report in response to the owner’s push for an expansion of the regular season to 18 games.  Not surprisingly, the research showed that the risk of injury increased through the season.

In wake of injuries to high profile players such as Robert Griffin III, debate will continue to rage about the wisdom of playing with injury.  But the question will be, how much will the heightened awareness about injury change the future of football?

Hip Joint Injuries

When the New York Yankees recently announced the news that Alex Rodriguez, All-Star third baseman and owner of the largest yearly salary in all of baseball, would undergo hip surgery for the second time in 5 years, it highlighted the evolving awareness and concern over injuries involving the hip joint.  The surgery, performed in January, will likely keep Rodriguez out of baseball for at least six months.

The sharp rise in the number of hip injuries and surgeries in professional baseball has been cause for increasing alarm among Major League Baseball teams.   As sports medicine professionals scramble to determine the cause for the increase in hip injuries, it is evident that no singular reason can explain the epidemic.  While media attention has focused on Alex Rodriguez and baseball’s stars, athletes of all ages, skill levels and sports have experienced the disturbing development of hip joint injury.

While arthroscopy, or the use of a less invasive camera guided device for joint surgery, has long been used for knee, ankle and shoulder surgery, it is only in the past decade that it has been utilized for hip surgeries.  During that period, the options available for the treatment of hip joint injuries have increased, most notably with the condition for which Alex Rodriguez had his surgery, FAI or femoro-acetabular-impingement.

The condition, in which a bump on the femur or leg bone collides with the soft-tissue structures of the hip joint, causes a characteristic pain in the front or groin area of the hip.  These repeated collisions can lead to tearing of the hip labrum and cartilage.  While it is commonly found in runners, cyclists, ballet dancers and baseball players, many are predisposed to the condition because of an anatomical difference in the structure of the hip.  It is the belief of many surgeons and sports medicine researchers that FAI is a leading cause of hip arthritis when left untreated.  However, as the sports medicine community has only been aware of the condition for the past 15 years it is difficult to conclusively connect FAI with any long term connection to hip arthritis.

Non-surgical treatment of the condition is often the best initial course of action.  Physical therapy treatment should focus on regaining hip and leg strength with an emphasis on the hip abductors or outer hip muscles.  The exercise program should be individualized based on activity level, sport, joint mobility and relative muscle strength.  Anti-inflammatories are often part of the initial treatment to reduce the bony or soft-tissue inflammation associated with the condition.

If a more conservative treatment plan is unsuccessful in returning an individual to a prior level of athletic activity or pain-free daily life, surgery is likely the next course of action.  If the FAI has not led to any cartilage damage, the surgery can be performed arthroscopically and focus on restoring normal mechanics by shaving down the bony bump on the femur.  Involvement of the hip labrum or cartilage of the hip joint usually requires a more significant surgery and rehabilitation.  It is possible that a more extensive surgery will not be performed arthroscopically but rather will require an open procedure.

Overuse Injuries Are Not Just For Adults

Overuse injuries are not just for adults.  With 30 million kids participating in organized youth sports every year, athletics have become the number one cause of injury among adolescents.  Those that participate in organized sports frequently play in a year-round format that allows little time for recovery and may encourage the development of overuse or repetitive stress injuries.

During periods of rapid growth, the areas in which tendons connect to bones are vulnerable sites of injury as these growth centers are subjected to the high demands of athletic activity.  Two common injuries of this type are Osgood-Schlatter’s Disease of the knee and Sever’s Disease of the heel.  As both are caused by the repetitive stress of athletics, a pause in sports activity may play a role in recovery from these conditions.  However, with the increasing seriousness and organization of youth sports, the traditional approach of extended rest and activity modification may not sit well with eager young athletes anxious to return to a favorite sport.

Those children with Sever’s Disease are typically between the ages of 7-10 and are usually very active.  Pain or soreness is usually located at the back of the heel where the Achilles’ tendon meets the bone with many experiencing symptoms on both sides.  Like overuse injuries in adults, early diagnosis and treatment are important in a quick resolution of the problem.  Not surprisingly, weakness and a lack of flexibility of the calf and lower leg are associated with the condition and should be addressed as part of any treatment program.  Physical therapy aimed at strengthening and stretching of the calf and leg is recommended by nearly all sports medicine clinicians and researchers.  Although relative rest from sport may be important, young athletes can still remain active through cross-training on a stationary bike or in the pool.

Osgood-Schlatter’s is usually found in 11-15 year old adolescents, especially in those playing basketball, volleyball and soccer.  Pain is present below the kneecap at the bony bump at the top of the lower leg bone.  This bump, called the tibial tubercle, usually swells and remains more prominent, even after the condition resolves.  Like Sever’s, many experience the condition on both sides.  For Osgood-Schlatter’s, strengthening the quad, hamstring and hip is of primary importance in treating the condition.

As kids increasingly begin to suffer from sports-related overuse injuries it is important to take an active, exercise focused approach to treatment.  As many young athletes are dedicated to a year-long sport, rehabilitation can no longer consist of long periods of complete rest and a recovery based on “just go play.”

Quite Simply a Pain in the Rear

It’s quite simply a pain in the rear.  While it goes by the technical name, high hamstring tendinopathy, the condition can strike runners and triathletes with a vengeance.  With a training program that features miles of running combined with the uncountable hills that litter the Bay Area landscape, the hamstring muscles and their tendons can become overworked and overloaded.  The first inkling of this is usually soreness after a run in the upper portion of the back of the leg and may progress to pain during exercise and difficulty with simple daily tasks like sitting and walking.  Despite the fact that high hamstring pain is common in those that exercise it is underreported in the medical literature and can often be misdiagnosed.

Trying to ignore the soreness and “run through” high hamstring tendinopathy frequently leads to a worsening of the condition and possible prolonging of the recovery.  Making matters worse, high hamstring tendon pain is frequently associated with back conditions as the hamstring muscles can be weakened with back-related nerve irritation.  If this is the case, treatment of the high hamstring tendinitis must first begin by addressing the lower back condition.

In the early phases of recovery running should be halted and cross training on a stationary bike used to maintain cardiovascular fitness.  Safe yet vigorous reconditioning of the hamstring and leg are the focus of the initial exercise program.  After the hamstring tendon irritation has subsided and leg strength improved, more advanced cardiovascular training can be combined with functional pre-running exercises.

Runners

Preventing Winter Sports Injuries

For Bay Area skiers and snowboarders, the recent stormy weather means one thing-snow is on the way.  Soon the roads up to Tahoe will be clogged with anxious snow lovers on their way to ski favorite runs at Squaw, Heavenly and Sugar Bowl.  While it is extremely popular, Alpine skiing and snowboarding are sports that come with a risk of knee injury.  However no injury is inevitable and several techniques can be taken to minimize the risk and stay on the slopes.

The most important step in a pre-season skiing program is a comprehensive leg strengthening program.  The sports medicine literature is full of research validating the effectiveness of leg strengthening and coordination training in minimizing the risk of injury with sports, especially in women.  As researchers also point to a lack of core stability and coordination as an independent risk for injury, core stability training should also be included in a comprehensive program.

Another related cause is stopping skiing before fatigue becomes a limiting factor as an all too common refrain is the “last run of the day” injury.  Interestingly a study in the Journal of Sports Science and Medicine found that recreational skiers, when fatigued, changed their technique to a more “uncontrolled” style rather than properly using tired muscles.  Unfortunately uncontrolled skiing frequently means injury-prone skiing.

Other important factors include using a multi-directional release binding as well as a proper binding setup.  Not surprisingly, first time skiers and snowboarders are at increased risk of injury for a variety of factors.  In addition to improper equipment and setup, the authors of this study also implicate insufficient conditioning as a reason for the greater threat.

So use the rain as an excuse to hit the gym before you hit the mountain.  The following exercises will get your legs tuned up so you can ski or snowboard longer and hopefully avoid injury.

Squat

Side Plank

Pseudo-hop 1

Pseudo-hop 2

Hamstring Bridge 1

Hamstring Bridge 2