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Abstract

Most injuries in American football are orthopedic, but the medical team must also be prepared to recognize and manage injuries beyond the musculoskeletal system that may result from trauma to the face, chest, abdomen, and pelvic regions. Failure to promptly identify such injuries in athletes can be life-threatening or permanently disabling. The literature on many of the nonorthopedic sports injuries is limited but can aid in understanding injury presentation, imaging modalities of choice, and initial management. Safe return-to-play decision-making requires a thoughtful approach through the use of available data and an understanding of pathophysiology and tissue healing.

Keywords

nonorthopedic trauma sports medicine football return to play

Introduction

The medical team providing sideline coverage in American football plays a vital role in recognizing and initiating management of nonorthopedic trauma. Emergency action plans can ensure appropriate, timely management for life-threatening conditions. Other important medical conditions will occur, and sideline providers should be prepared to deal with these during game conditions and beyond. They should also understand considerations for safe return to play. This article provides a guide to nonorthopedic injuries that may occur during play.

Face

Eye Trauma

Eye trauma is less common in football than it is in other sports, but it is important to recognize eye injuries and know when to refer to ophthalmology for urgent and emergent eye conditions. Early treatment can prevent permanent visual deficits [49]. To establish the severity of an injury, initial evaluation requires assessment of visual acuity and visual fields [73]. Abnormalities include diplopia, photophobia, complaints of eye pain, floaters, visual field deficits, pupil asymmetry, abnormal extraocular movements, presence of foreign body or foreign body sensation, and gross globe or periorbital abnormalities [73]. Athletes who have visual abnormalities should be removed from play and undergo further evaluation. This may include prompt ophthalmology evaluation.

While various eye injuries can occur in contact sports, one of the more common injuries is corneal abrasion–damage to the epithelium of the cornea that can occur when the eye has contact with foreign bodies, a finger, or contact lenses [49]. Common symptoms include photophobia, foreign body sensation, and tearing [49,73]. While on the sidelines, fluorescein staining can aid in diagnosis. It is important to ensure no retained foreign body is present, and a thorough examination of the eye is recommended, including eyelid eversion. Normal saline irrigation can help remove foreign bodies, and an abrasion can be further treated using lubricating ophthalmic drops and possibly antibiotics, with gram-negative coverage including Pseudomonas in contact wearers [49,73]. Anesthetic ophthalmic drops, such as tetracaine, may be cautiously used to alleviate symptoms during competition. This can allow the athlete to continue play if there are no visual abnormalities and no concern for a more significant injury. For example, complaints of “shades” or “curtains” restricting visual fields or asymmetric visual fields should raise concern for posterior vitreous detachment or possible retinal injury and detachment [73]. In fact, any new visual field deficits should prompt removal from play and urgent ophthalmology evaluation.

Other conditions include a hyphema, bleeding in the anterior chamber of the eye behind the cornea. This usually occurs as a result of a high-force mechanism [73]. This condition should be urgently referred, and the player should not return to play.

If more significant trauma to the eye results in globe injury, emergent evaluation is required, and transportation to the hospital is warranted. The globe may exhibit deformity and extrusion of intraocular contents; an eye shield should be applied to prevent further injury, taking care to avoid direct pressure on the globe [49,73].

If there is significant trauma with concern for an orbital fracture, extraocular movements should also be assessed to evaluate for muscle or nerve entrapment. Referral should be made for higher level of care and further assessment of the extent of the injury with advanced imaging [49,73].

Dental Trauma

Dental trauma can occur by direct or indirect injuries to the teeth or jaw. Mouth guards play an important role in preventing dental trauma and tooth fractures [56]. Mouth examination should focus not only on the tooth of concern but also on concomitant facial injuries [27]. Effort should be made to locate tooth fragments when fractures occur [56].

Management of tooth fracture depends on the extent of the damage. If only the enamel is involved and the injury is painless, the athlete may return to play [56]. Nonurgent referral is warranted for cosmesis. In comparison, injuries involving the dentin are typically painful. These can be covered with dental cement, and if pain is tolerable and there is no concern for increased risk to soft tissues due to sharp edges, return to play is possible. Dental care should be sought within 24 hours as these injuries may be remedied by being filed down by a dentist [56]. Fractures involving the pulp, where a redness to the tissue may be observed, should be covered with dental cement or bone wax and referred for further dental care. These injuries are painful and present an increased risk of infection [56]. If there is concern for a root fracture, referral for diagnostic radiographs is required [56].

Ideally, avulsed permanent teeth should be replaced within several minutes after rinsing with cold water, saline, or milk [37]. However, they should not be replaced when the athlete is unconscious for fear of aspiration. In such cases, the tooth can be stored in milk, saline, or Hank’s solution during transport. Care should be taken to avoid handling the root [56].

Tooth subluxation occurs after trauma, resulting in mobility without displacement; splinting can stabilize the tooth, with further referral for dental care recommended. The athlete can return to play if the tooth is stabilized to avoid the risk of aspiration [56]. Extrusion is when the tooth has been displaced out of its socket. The tooth can appear longer and should be treated by repositioning it to the anatomical position [56]. Intrusion is a serious but stable injury in which the tooth is driven into the alveolar process, causing the tooth to appear shorter. Consideration may be given to return to play, but the athlete should seek dental care for repositioning as soon as possible [56].

Chest

Commotio Cordis

Commotio cordis occurs when there is nonpenetrating, blunt trauma to the heart, specifically the precordium, during the upstroke segment of the T-wave (ventricular repolarization) resulting in ventricular fibrillation [40]. This phenomenon is more common than previously thought, having been reported as one of the top 3 leading causes of sudden cardiac death in young athletes; although a precise estimate of its incidence is not available, it is understood to be underreported [45,46]. The medical team should identify the location of a defibrillator prior to play. Suspicion should be high if an athlete has sudden collapse after trauma to the chest. Cardiopulmonary resuscitation with early defibrillation should be initiated immediately as it can significantly increase the survival rate. In fact, likely a result of these measures, survival has improved to more than 50% [47]. Given that it occurs without an underlying heart condition or associated structural changes to the heart, return-to-play decision-making requires consultation with a cardiologist and a thorough cardiac workup to rule out any underlying heart disease or arrhythmia [39]. If no predisposing cardiac abnormality is found, the athlete can return to sport without restriction. Furthermore, athletes who have experienced commotio cordis can be informed that they are at no greater risk of another event than athletes playing the same sport who have not experienced this cardiac event [39]. Although there is no clear evidence that protective equipment such as chest protectors reduces the risk of commotio cordis, these are thought to potentially offer a preventive measure [23,47].

Rib Fractures

Rib fractures are a common result of trauma to the chest wall, occurring especially at the lateral chest wall [26,57]. Rib fractures typically present with pain to palpation and pleuritic pain or pain with coughing or sneezing. Compression of the thoracic cage along a sagittal axis may reproduce pain [26,27]. If available, plain radiographs can be obtained to evaluate for rib displacement or involvement of multiple ribs. Unless multiple rib fractures have been sustained, these are stable injuries, and pain guides most return-to-play decisions. The use of sideline ultrasound may be helpful to identify occult fractures or pneumothorax [15,74]. If breathing difficulties or decreased oxygen saturation are present, it is important to further evaluate for concomitant pulmonary injuries. Managing stable injuries focuses on pain control, which may include rib binders and medication as needed. Return to play should be guided by symptoms. This can limit athletes as it may be several weeks before they are able to tolerate contact in competition [27,72]. Protective equipment can be used to further protect the injury and potentially enable earlier return to play [25]. Athletes who do not return to play can continue to be monitored for any signs of a developing pneumothorax during the initial period after injury. In addition, costochondral fractures may not be evident on radiographs, but the location of pain may prompt suspicion for this diagnosis and can be further evaluated as needed.

Flail chest occurs when 3 or more adjacent ribs are fractured in at least 3 locations [54]. It presents classically as paradoxical breathing, although this may be masked with shallow breathing [24]. Other signs of respiratory distress may also be present. Flail chest is an emergent condition necessitating transport to the emergency department and may require mechanical ventilation and surgical fixation [6,24,28,54,58].

Pulmonary Contusion

Pulmonary contusion is defined by alveolar hemorrhage and lung parenchymal damage resulting from blunt trauma to the thorax or translated forces that may present with shortness of breath and hypoxemia, pleurisy, tachypnea, chest pain, or hemoptysis [17,30,48,50]. Examination may note tachypnea or rales. If these symptoms are present during sideline evaluation, the player should be removed from play for further evaluation including a computerized tomography (CT) scan to further assess the extent of pulmonary injury [21,68]. Treatment is supportive in mild cases, including pain management [29]. Corticosteroids and antibiotics are not routinely indicated [16,53]. Although data are limited, case reports suggest that following pulmonary contusion, air travel is safe [14,55]. Guided by the resolution of symptoms, progression of activity may begin as early as 2 days after injury. For uncomplicated contusions, return to competition my occur between days 7 and 10—the period of time in which uncomplicated contusions resolve, according to the literature [3,25,31,41,48].

Pneumothorax

Pneumothorax occurs when there is air trapped between the visceral pleura and chest wall [27,59]. It can occur from blunt trauma during football competition. Presentation typically includes shortness of breath, chest pain, and pain on deep breathing [19,76]. The athlete may have decreased breath sounds in the upper lung fields or hyperresonance with percussion of lung fields [27]. Tension pneumothorax is a life-threatening condition that may distinguish itself with a more severe presentation, including respiratory distress and late hemodynamic instability with possible tracheal deviation, distended neck veins, and absent lung sounds [27,59]. Sideline management of tension pneumothorax requires immediate needle decompression with a large bore needle inserted in the second intercostal space at the midclavicular line [25]. If there is concern for a pneumothorax and the athlete is hemodynamically stable, an upright chest radiograph should be obtained during expiration to make the pneumothorax easier to identify. Management is conservative for stable patients with a small pneumothorax [69]. Serial radiographs monitor for resolution while supplemental oxygen may improve recovery [13,66]. In stable patients, the need for hospitalization is largely dependent on size, as a large pneumothorax may require chest tube placement [5,59]. For significant pneumothorax, guidelines recommend avoiding air travel within 2 weeks, although some literature suggests it may be safe to fly within 48 hours of resolution or documented stability [1,2,63]. Guided by symptoms, the athlete may return to play after complete resolution of the pneumothorax on repeat imaging, typically in 3 to 4 weeks, although return to play has occurred at 2 weeks [38,59].

Pneumomediastinum

Pneumomediastinum shares a similar pathophysiology to pneumothorax, but the air leak is into the mediastinum [59]. It may present with sharp chest pain and subcutaneous emphysema over the neck and supraclavicular region [59]. There may also be pain with swallowing or difficulty speaking [59]. A crunch may be heard with auscultation of the heart [59]. It is important to consider tracheal or esophageal injuries [25,70]. These injuries should be further evaluated with advanced imaging as return to play would depend on coexisting pathologies [20].

Hemothorax

Hemothorax is a collection of blood in the pleural cavity [25]. Bleeding into the pleural cavity with concomitant pneumothorax is termed hemopneumothorax. Symptoms can be similar to those of pneumothorax; however, upon examination, there will be decreased breath sounds in the lower lung fields and dullness rather than hyperresonance on percussion [25]. Evaluation should include advanced imaging such as a CT scan, and management will depend on the size of the hemothorax [25]. A small hemothorax can be managed conservatively with monitoring and serial imaging while large ones may require evacuation of the blood [25]. Because a hemothorax causes disruption of the pleural cavity similar to a pneumothorax, the same guidelines should be followed with regard to air travel and return to play as discussed in the previous section.

Abdomen

Blunt trauma to a football player can create a significant acceleration-deceleration mechanism that can cause severe injury to intra-abdominal organs [34,62]. Evaluating abdominal trauma on the sideline requires an awareness of the potentially serious complications that can occur, and close monitoring is prudent. When assessing abdominal injuries, the mechanism of injury, location of pain, and other associated symptoms should be elicited. Abdominal wall injury is typically localized, while more significant intra-abdominal injuries and bleeding may present as diffuse pain that persists or worsens [33,62]. Pain may also be referred to the shoulders if there is diaphragmatic irritation. Concerning signs of an acute abdomen include guarding, rebound tenderness and rigidity, peri-umbilical or lateral abdominal ecchymosis, or other signs of peritoneal irritation such as pain with jumping or coughing [22,32,62]. These findings should prompt transport to higher level of care for further evaluation and management.

Liver Injury

Liver injury in sports can result from direct contact associated with a hematoma, while the rapid deceleration mechanism of injuries more commonly results in laceration [33,61,62]. The player may present with right upper quadrant pain, at times radiating to the shoulder, or with associated nausea and vomiting [33]. If liver injury is suspected, the player should be removed and transported for advanced imaging. The gold standard for evaluating a stable patient with a liver injury is a CT scan with intravenous contrast. In hospital, management of stable patients may include observation or embolization, while unstable patients may undergo laparoscopy [18,43]. While there are limited data available to guide return to play, lower grade injuries may take 2 to 4 months to heal while more severe injuries may require up to 6 months [27,33,35,36]. Prior to return to play with full contact, the athlete should be asymptomatic, and their liver function should be normalized on laboratory evaluation [12,51]. Repeat imaging can be helpful to provide evidence of healing; however, serial imaging should be used judiciously to limit radiation exposure [35,60].

Spleen Injury

Splenic injury is the most common abdominal organ injury in sport [27,32]. Mononucleosis and hematologic abnormalities such as sickle cell disease should be considered as predisposing factors to rupture [52]. Presentation of injury may include left upper quadrant pain with possible radiation to the left shoulder and guarding [27]. Athletes who may have splenic injuries should be removed from play and undergo advanced imaging. It is important to note that the splenic capsule can contain initial bleeding, which may lead to a delayed presentation of more than 24 hours. Therefore, even no significant symptoms were present initially, continued monitoring and serial examination should be used, and imaging should be obtained. For mild splenic injuries, activity may be initially limited for 2 weeks, with return to full activity by 6 weeks. However, more severe injuries may require 6 months prior to safe return to play, similar to liver injuries [35,67,71]. Overall, return to play should be an individualized decision [35]. The player should be asymptomatic and at baseline fitness before contact. Players who require splenectomy may be able to return as early as 3 weeks postoperatively; however, this should be avoided when possible due to increased infection risk in those without a functioning spleen [71]. Again, repeat CT scans may be considered in high-level athletes to further assess healing and assist with return-to-play decision-making [35].

Renal Injury

Renal injury in sports results from direct blunt trauma [27,75]. Examination may reveal costovertebral angle tenderness to palpation, flank hematoma, gross hematuria, and concomitant injury such as rib or spine fracture [7,10,27]. Urine dipstick can be used to assess for microscopic hematuria, and if there is concern of more significant injuries, the player should be evaluated with laboratory studies as well as a triple-phase CT scan, the gold standard imaging study [4,10]. Imaging should be performed in the setting of gross hematuria, for adults with microscopic hematuria, and for children with 50 red blood cells per high-power field. However, a study of renal injury occurring through recreation found that the absence of microscopic hematuria did not exclude renal injuries, and even without this finding, nearly 25% of low-grade renal injuries can be missed [42]. Renal injuries may be present alongside other severe injuries such as rib fractures or organ injury, and clinical judgment should ultimately guide decision-making on imaging. Management of low-grade and moderate-grade injuries is mostly supportive, with surgery reserved for hemodynamic instability [7,44]. Return-to-play decisions rely on resolution of symptoms and may benefit from urology consultation. In the presence of gross hematuria, initial rest is recommended followed by progression of activity with return to play after the microscopic hematuria has resolved [11,44,65]. A study of National Football League players revealed an average of 15 days missed for renal contusion and a mean of nearly 2 months for lacerations [9]. Severe injuries may take 6 to 12 months for full return [7]. Repeat imaging is not necessary but may be used if there is clinical change or signs of complication. It can also be used to guide return-to-play decision-making for more severe injuries [75]. A solitary or abnormal kidney does not preclude participation in football as a severe injury is rare, but the player should be counseled on the risk of long-term morbidity with continued participation in the sport [7].

Genitourinary

Testicular and Scrotal Injury

Testicular and scrotal injury is most commonly attributed to blunt trauma in sports. Blunt scrotal trauma is typically unilateral [64]. Symptoms of testicular trauma may include scrotal pain and swelling, abdominal discomfort, as well as nausea and vomiting [32]. For evaluation, the physician should inspect the skin of the scrotum for lacerations, bruising, and swelling as well as the orientation of the testicle [64]. If there is significant swelling or ecchymosis and if pain is severe, the athlete should be sent for prompt imaging or evaluation in the emergency room.

For less severe testicular trauma such as contusion or mild hematoma, treatment consists of rest, ice, supportive underwear, and anti-inflammatory medications [32]. If there is concern about moderate to severe injuries such as testicular laceration, rupture, or fracture—an injury to the testicular parenchyma—an ultrasound study should be obtained. However, surgical exploration is the gold standard and should not be delayed if there is concern for a severe testicular or scrotal injury as timely intervention may salvage the injured testicle [32,64]. Although there are no published consensus guidelines on return to play after a testicular injury or in individuals with 1 testicle, decision-making should be directed by symptom resolution and improved imaging findings; urologists may be consulted for more significant injuries [32,64]. If surgery is required, the surgical wound should be healed, and all pain related to surgery should be resolved prior to return to sport [32,64]. To prevent testicular injuries, male athletes are encouraged to wear a properly fitted protective cup when participating in sports that have a significant risk of trauma [8,32,64].

Testicular torsion is a urologic emergency involving the twisting of the spermatic cord causing testicular pain and ischemia [64]. When blood flow to the testicle is compromised, infarction and atrophy of the testicle can develop within 6 hours [64]. Most cases are atraumatic, but approximately 4% to 8% of cases result from trauma [64]. Testicular torsion typically presents with an acute onset of diffuse unilateral testicular pain [64]. The testicle may feel firm and swollen and may lay more horizontal in the scrotum [64]. The most reliable examination finding is the absence of the cremasteric reflex, which is performed by stroking the superior medial thigh while observing the scrotum. The scrotum and testis should elevate if a normal reflex is present. This may also be accompanied by a negative Prehn’s sign, which is when there is no relief with elevation of the testicle. In contrast, a positive Prehn’s sign is when there is relief with elevation of the testicle, supporting the diagnosis of epididymitis. The preferred imaging modality for diagnosis is Doppler ultrasound [64]. The physician may try to manually resolve the torsion by rotating the testis laterally toward the thigh. If unsuccessful, prompt surgical exploration and correction is the treatment of choice to avoid testicular compromise [64]. Return to play relies on resolution of the torsion and wound healing, if surgery is required.

Conclusion

Providing sideline coverage for contact sports such as football requires knowledge of potential nonorthopedic injuries, so an early diagnosis can be made and appropriate management can be initiated in a timely fashion. The medical care provider must be adept at recognizing injuries to prevent significant loss of function and optimize outcomes. For many of these injuries, there is limited return-to-play data to guide decision-making. Nonetheless, it is important to implement sound clinical judgment using physical examination, diagnostic studies, an understanding of pathophysiology and tissue healing, and consultation when appropriate to provide an individualized approach.

Supplemental Material

sj-docx-1-hss-10.1177_15563316221144284 – Supplemental material for Medical Sports Injuries in American Football Players

Supplemental material, sj-docx-1-hss-10.1177_15563316221144284 for Medical Sports Injuries in American Football Players by Mark E. Matusak, Catherine C. Yau and Kenton H. Fibel in HSS Journal®: The Musculoskeletal Journal of Hospital for Special Surgery

Supplemental Material

sj-docx-2-hss-10.1177_15563316221144284 – Supplemental material for Medical Sports Injuries in American Football Players

Supplemental material, sj-docx-2-hss-10.1177_15563316221144284 for Medical Sports Injuries in American Football Players by Mark E. Matusak, Catherine C. Yau and Kenton H. Fibel in HSS Journal®: The Musculoskeletal Journal of Hospital for Special Surgery

Supplemental Material

sj-pdf-3-hss-10.1177_15563316221144284 – Supplemental material for Medical Sports Injuries in American Football Players

Supplemental material, sj-pdf-3-hss-10.1177_15563316221144284 for Medical Sports Injuries in American Football Players by Mark E. Matusak, Catherine C. Yau and Kenton H. Fibel in HSS Journal®: The Musculoskeletal Journal of Hospital for Special Surgery

Footnotes

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Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Mark E. Matusak, DO, and Catherine C. Yau, DO, report educational support from Arthrex.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was not required for this review article.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article as supplemental material.

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