Football Injuries: Slideshow

American football is one of the most popular sports in the United States and the one with the most potential for serious injury. Players of all ages and skill levels are at substantial risk. There has been growing concern regarding the long-term risks of repetitive head injuries. A small but persistent number of direct and indirect deaths from football occur every year, and players are at risk for significant neurologic and musculoskeletal morbidity. The spectrum of injuries is diverse and is related to both the impact and the playing conditions. Clinicians must be aware of the diverse presentations of football injuries because the potential complications of returning to play before appropriate recovery can be devastating.

Image courtesy of Wikimedia Commons.

From 1931 to 2012, the National Center for Catastrophic Sport Injury Research reported 1,027 direct and 750 indirect fatalities resulting from participation in organized football (sandlot, high school, college, and professional) in the United States.^[1] Data from the report since 2000 is shown, which demonstrates no significant improvement in mortality despite increased awareness of football injuries. Although sports injury–related deaths are rare, injury to the head or neck is the most common cause of death, followed by heatstroke.

Data from the National Center for Catastrophic Sport Injury Research.

A concussion or mild traumatic brain injury (TBI) is a transient alteration of mental status induced by traumatic biomechanical force, with or without loss of consciousness. There are over 40,000 concussions suffered every year among high school football players. Diagnosis is primarily clinical; routine imaging studies of the brain are often normal. A traumatic hemorrhagic contusion of the brain is a more serious injury that occurs when the brain impacts the adjacent skull, with resultant bruising and bleeding within the affected portion of the brain. Hemorrhagic contusions of the brain are readily apparent on noncontrast computed tomography (CT) scans (arrows). They are most commonly found in the inferior frontal and temporal lobes.

Significant efforts have been made to improve the equipment worn by football players. The Head Impact Telemetry (HIT) system is a system that measures helmet impacts and sends them to a sideline computer that stores and analyzes the data in real time during games and practices. The HIT system measures impact force, location, and direction, which may be invaluable in the early detection of brain injuries. Athletes who have signs or symptoms of a concussion should return to play only after a medical evaluation has been done and a doctor has determined that recovery is complete.

In 1994, the National Football League (NFL) initiated a comprehensive clinical and biomechanical research study of mild TBI, a study that is ongoing. In 2009, the NFL commission reported that memory-related diseases, like Alzheimer disease, occurred in former NFL players at 19 times the normal rate in men ages 30-49. There is a growing controversy about whether football players are adequately protected from the long-term complications that develop years after they retire. Pathology studies show diffuse brain parenchymal atrophy with advanced Alzheimer disease. Other studies have shown that players who suffered concussions were also more likely to suffer from depression.

Cervical spine injuries are estimated to occur in 10-15% of football players. A neck sprain commonly occurs as the result of a hyperextension or hyperflexion injury. The result may be injury to cervical muscles, ligaments, facet joints, cervical discs, or nerve roots. Pain may be present immediately after the injury or be delayed in onset up to several days. Other symptoms may include shoulder and back pain, numbness or tingling in the upper extremities, headache, and dizziness. Players should not tackle with their head down, because this increases the risk for spine injuries. Straightening of the normal lordotic curvature of the cervical spine is commonly found after whiplash injuries, most likely related to muscle spasm or guarding (as shown in the upper cervical spine on this lateral x-ray).

Cervical subluxation, dislocation, or fracture occurs when significant axial loading forces are applied to the cervical spine. Spearing is when a football player uses his helmet as the first point of contact with another player and is a significant cause of cervical spine injuries and quadriplegia. Patients must be assessed anatomically, radiographically, neurologically, and physiologically. The most important initial consideration in a suspected cervical spine injury is maintaining immobilization to avoid further injury, regardless of current neurologic symptoms. Until stability can be established, all players must have their cervical spine immobilized. Lateral x-ray of the cervical spine demonstrates bilateral C4-C5 facet dislocation (a potential complication of axial loading while tackling) with associated anterior displacement (anterolisthesis) of the C4 vertebral body with respect to the C5 vertebral body.

Acute disc herniations are rare in football but must be considered in a player with acute onset of transient neurologic deficits and normal cervical x-rays. The symptoms may range from radiculopathy to anterior cord syndrome. Anterior cord syndrome presents as paralysis of upper, lower, or all four extremities, as well as loss of pain and temperature sensation. If suspected, the diagnosis is best made with magnetic resonance imaging (MRI), though CT myelography can be used in patients who cannot undergo MRI. Sagittal T2-weighted MRI demonstrates a central disc herniation (protrusion) at C5-C6 (arrow). Chronic disc-related degenerative changes are very common among football players.

Image courtesy of Roger J Bartolotta, MD.

Heatstroke occurs with elevated body temperature, usually in excess of 41°C, and anhidrosis with altered sensorium. It is a major concern in college and high school football, with 27 reported deaths in the past 10 years. Risk factors for heatstroke are dehydration, fatigue, poor fitness, and lack of acclimatization. Water should always be available to replace evaporative losses. Much effort has been expended on educating coaches about the proper procedures and precautions for practicing or playing in the heat. Immediate cooling is needed. The equipment needed for noninvasive cooling includes ice water, cooling blanket, Foley catheter, and intravenous fluids (shown). More invasive cooling options include nasogastric and peritoneal lavage.

Musculoskeletal injuries are common in football and range from minor aches and pains to serious traumatic injuries. Almost all football injuries result from contact between players or between a player and the ground. The most common type of injuries in football are contusions, sprains, and strains. Close to one third of all injuries during childhood are sports-related, and contact sports such as football account for the majority. An x-ray of a left femur fracture is shown.

The majority of football injuries occur in the lower extremities. Football cleats and rapid changes in momentum place substantial forces on the knee. The knee is a hinge joint, where the femur meets the tibia. Most knee injuries are ligamentous. The four main knee ligaments are as follows:

• The medial collateral ligament (MCL), which runs along the medial knee and prevents valgus deformity
• The lateral collateral ligament (LCL), which runs along the lateral knee and prevents varus deformity
• The anterior cruciate ligament (ACL), which lies within the knee joint and prevents anterior translation of the tibia as well as provides rotational stability
• The posterior cruciate ligament (PCL), which lies within the knee joint and prevents posterior translation of the tibia

On sagittal fat-saturated proton-density MRI (shown), the normal ACL (yellow arrow) and normal PCL (white arrow) are demonstrated.

Image courtesy of Roger J Bartolotta, MD.

The ACL is the most important ligamentous knee stabilizer with torsion but is also the ligament most commonly injured. Injury is usually due to a sudden stop and twisting motion of the knee, trauma to the front of the knee, or hyperextension of the knee joint. Patients often describe an audible "pop" at the time of injury. The knee may feel unstable and develop significant swelling. The ACL is often torn at the same time as both the MCL and the medial meniscus. The classic finding on physical examination is anterior displacement of the tibia with the anterior drawer test. On this sagittal fat-saturated proton-density MRI, there is bright fluid in the expected course of the ACL (yellow arrow) without any discernible ligament remaining. Note that this sagittal image includes a portion of the distal aspect of the PCL (white arrow), which was intact on the remainder of the MRIs. Treatment of complete ACL tear involves surgical reconstruction.

Image courtesy of Roger J Bartolotta, MD.

The MCL is usually injured by excessive valgus stresses to a slightly bent knee. MCL tears are rarely isolated and are often associated with ACL and medial meniscus tears (the "unhappy triad"). Coronal fat-saturated proton-density MRI demonstrates an acute tear (arrow) of the MCL near its proximal (femoral) attachment with surrounding edema. Treatment for isolated MCL injuries is usually conservative. With combination injuries, treatment of an ACL tear may be sufficient to maintain joint stability.

Image courtesy of Roger J Bartolotta, MD.

Tears to the LCL often occur from varus trauma to the knee. Both the MCL and the LCL can also be injured by repeated stress that causes them to lose their normal elasticity. Most patients are still able to ambulate after an acute LCL injury. This proton-density MRI demonstrates a proximal LCL tear (yellow arrow). LCL tears do not heal as well as MCL tears do, because of their differences in collagen density. As a result, LCL ligament tears are more likely to require surgery.

The PCL is the strongest ligament in the knee. It is usually injured secondary to a hyperextension injury or from a direct blow to a flexed knee. Many PCL injuries occur with other ligament injuries and severe knee trauma. Isolated PCL injuries may manifest as swelling in the knee that subsides over a few days or weeks. Unlike ACL injuries, isolated PCL injuries may not initially limit knee function. The classic physical examination finding is the posterior tibia sag sign, in which the tibia is posteriorly displaced (shown). Treatment of a PCL injury depends on the extent of the injury, the patient's age, and the patient's desired level of activity.

The menisci are two small C-shaped structures that act as cushions in the medial and lateral compartments of the knee. Meniscal tears usually occur with movements that forcefully rotate the knee during weightbearing, often when an athlete quickly twists or rotates the upper leg while the foot is firmly planted. An injured or torn meniscus may cause pain and swelling. Frequently, an injury to the meniscus causes an audible click, and the knee may lock or feel weak. Coronal fat-saturated proton-density MRI demonstrates linear bright signal (arrows) in the body and posterior horn of the medial meniscus, compatible with horizontal cleavage tear. If the meniscal injury is small, these symptoms may resolve over time; more serious meniscal injuries may require surgical repair.

Image courtesy of Roger J Bartolotta, MD.

Traumatic football injuries to the shoulder may develop despite upper body padding. Clavicle fractures may occur from a fall onto the shoulder or an outstretched hand. Diagnosis can usually be made with a x-rays (shown), and the majority of clavicular fractures can be treated nonoperatively. Clavicle fractures should prompt consideration of additional injuries, including traction injury to the brachial plexus (nerves that run from the cervical spinal cord through the upper shoulder and into the axilla). Damage to the brachial plexus may result in loss of sensation or muscle control in the arm, wrist, hand, or fingers. The majority of brachial plexus injuries resolve with conservative therapy.

Image courtesy of Roger J Bartolotta, MD.

The rotator cuff is a group of muscles and tendons that stabilize and support the shoulder. A rotator cuff injury involves a disruption of the rotator cuff tendons, usually the humeral attachments. Tears can occur from falling on an outstretched arm. Tears are classified as full-thickness or partial-thickness. Diagnosis can be confirmed with MRI or arthroscopy. Sagittal fat-saturated proton-density MRI of the left shoulder demonstrates a full-thickness supraspinatus tear with associated retraction of the torn tendon (arrow). Note that the humeral head is "high-riding" because of the absence of supraspinatus between the humeral head and acromion. Although many rotator cuff tears improve with rehabilitation and rest, arthroscopic repair is appropriate for more advanced tears or for high-performance athletes.

Image courtesy of Roger J Bartolotta, MD.

The iliotibial band (ITB) is a tendinous band that runs along the outside of the thigh from the iliac crest to the lateral tibia and helps to stabilize the knee and hip during running. ITB syndrome occurs when the iliotibial band rubs over the bones on the outside of the knee and becomes irritated, causing pain. ITB syndrome may be secondary to blunt trauma but is usually caused by overuse in sports training, specifically with running. ITB syndrome can cause localized pain at the lateral aspect of the knee or may radiate up the side of the thigh. ITB syndrome may resolve with reduced activity and stretching followed by muscle-strengthening exercises. The image illustrates the location of the ITB.

The hamstrings are a group of muscles (semimembranosus, semitendinosus, biceps femoris) that run along the back of the thigh from the ischial tuberosity to the tibia. This muscle group allows leg extension and knee flexion. The hamstring muscles are very susceptible to tears and strains from excessive stretch. Athletes particularly at risk for hamstring injuries are competitors participating in sports that require a high degree of speed, power, and agility and involve sprinting with sudden stops and starts. A consistent program of stretching and strengthening exercises can help prevent hamstring injuries. The image shows ecchymosis due to a hamstring tear.

The Achilles tendon is the strongest tendon in the body but also the most commonly injured. It connects the calf muscles to the calcaneus. The Achilles tendon raises the heel and transfers weight to the toes. It can be subject to forces equivalent to 3-12 times body weight during a sprint or pushoff. Achilles tendinosis (tendinitis) reflects repetitive or overuse injury of the Achilles tendon and typically presents with pain and swelling. It usually improves with ice and rest. Excessive force may cause a partial tear or complete rupture. Treatment of an Achilles tendon rupture requires complete immobilization and often surgery (shown).

Turf toe is a sprain of the ligaments around the metatarsophalangeal (MTP) joint of the big toe. The injury usually results when an axial load is delivered to a foot flexed in equinus, often from repeatedly pushing off in football players. The most common symptoms are pain and swelling. The name turf toe comes from the fact that the injury is common among athletes who play on artificial turf; specialized turf shoes have more flexibility, and this places increased strain on the MTP joint. Conservative therapy works in the majority of cases, but for those with persistent symptoms or gross deformity, surgical repair is needed. Protection of the MTP joint after surgery can be achieved with specialized footwear (shown) that forces weightbearing to the hindfoot.