Yeah, so to kind of set the stage, we'll start with discussing a little bit about what we commonly see in the NFL, what we need to focus on in the NFL, and then setting the stage for some of the great talks you'll see over the next three days. So usually what happens is, you know, during a busy clinic, I'll have patients come in and say, well, why are the 49ers so snakebitten with injuries? And I say, try to blow it off, move through, get home, have a barbecue with my dad, you know, that weekend. Why are you guys always so injured? Everything's fine. Then I go to the internet, and sure enough, I can't escape it. 49ers, terrible injury luck continues. And then you have other people chiming in, different physicians. The doctor explains and solves the 49ers injury problem for us, so thank you. So I kind of say, you know, what am I in this business for? And it's 16 years now. But then you step back and you realize it's really, you're not alone with that. If you've been doing this long enough, you had a year or two where you've been called snakebitten or injury problems and things. So it happens all over the league. Here's an example of the Vikings in Baltimore and in the Giants as well. So injuries are part of football. And so the whole idea of this is to, how do we get better at both prevention and treating and making better return to play decisions? I like this slide because, why is this important? Well, injuries matter. They seem to correlate with success. They do correlate with success. And this busy slide basically says all the blue teams on the top are teams that went to the NFC conference championship game. The four teams each year over the last five years. And based on this adjusted games loss, which doesn't just look at games missed, it's this football outsiders data metric that basically looks at games missed, but it weighs the starters more than the reserves. And it also gives only partial credit if somebody comes off of being questionable or doubtful because they're not seen as at full strength. So by and large, if you see this, 85 percent of the teams that make the NFC championship game are going to be in the top half of this grid here. Notice that the teams that are on the bottom in two years were anomalies, both San Francisco. So we must have really good players despite really bad medical care, but it does matter. And we've seen that if we're healthier, we do tend to be more successful. What are the biggest problems? Well, the NFL has another way to look at that, and that's injury burden. Injury burden is basically takes into account both incidence and severity. In other words, you may have something that's very common, like a hamstring strain, but may not miss as much time. But then you have something that's a little less common, like an ACL, but obviously missed that season. So what's the biggest ones on the injury burden from the data? But IQVIA is a group out of Durham that the NFL has been working with over the last seven years, originally called Quintals, that helps collect all this data for us. It's an outstanding job. And basically, these are the big four right now. The lower extremity strains, we'll call them for the lex strains for this talk, predominantly hamstring, but adductor and quad are a major component of that as well. ACL tears, no surprise there. Shoulder instability and high ankle sprains. So what can we do about these? Let's start with the soft tissue issues, the lex strains. Well, we've learned over COVID, it's kind of coming back really quickly, that there is a spike in injury rates. And we have problems with injuries in preseason with soft tissue. So in meeting with a lot of different experts, we developed this ramp up period that many teams, many sports use. Basically a gradual increase in time and reps. And the fact that we're able to get coaches and teams to buy into this was pretty amazing. So now we have a five day acclimatization phase, which we increase practice 15 minutes each day. Or you can also do an alternating high, low, really low, high, low, high intensity. And both of these have found to decrease the injury rate. In fact, this last year we found a 25 percent decrease in preseason lex strains in 2022. So that's fantastic. However, it's not solved. We still have a problem. There's a spike at day seven to eight. Why? They put the pads on. Once you put the pads on, the intensity is going to ramp up. So at some point you have to do something. So what do we do about this? Well, maybe we should just bubble wrap everybody in preseason and just say, just keep all your marquee players out and let's just wait until game one. This may not be the best idea. We found players with less than 30 preseason snaps have a greater injury rate the first three games of the season compared to those with greater than 30. Sorry, less than 30 snaps had a greater injury rate than those with greater than 30 preseason snaps. So some reps, some reps during preseason in a live format is very helpful. What about joint practices? Many of us cringe on that. The intensity goes up. You're playing another team in a practice squimmage and we worry about injuries there. But we find if we have a joint practice, there's actually less injuries in the first three weeks of the season. So getting up to game speed is important at some level. So we'll continue to research that. Also looking at evaluation and prevention. Different teams are working with the Nord Board group of collecting data for asymmetries and preseason strength of the hamstring for the eccentric exercises. We all know they're important. Looking at different ultrasound studies of ways to increase fascicle length and decrease penation angles for the hamstring. The Dari-Marcolis motion capture system is something that is collaborated with the NFL to look at ways to do kind of a quick functional movement screen. We don't have time in 73 players to put markers on everybody and do all the studies. So if we can walk them through within minutes, this is something that might be feasible to do that, to look. Second one is ACL injury. Well, why do we even need to worry about this? We've kind of got this one figured out, right? A good BTP graft is only about a 5% failure rate. NFL team doc survey in 2002 said 90% responded at 90 to 100% return to play. So I don't think this is really a problem. Maybe not. If we look deeper into this, we're not so great at this. Yes, we figured out how to put the graft in the right spot and how to do a good surgery. But as Andrews and Shaw showed in 2010, if people have an ACL reconstruction, only 63% return to play. You say, well, a lot of people weren't going to make the team maybe anyway. So they found that as well, drafted in the first four rounds, increased the likelihood of return to play. The people that are better players are going to have a higher chance of returning, but not so fast. Even this study this last year in OJSM showed that that's about that same number, 55.8% return to play. And within those players that returned, they played fewer games and there was decreased performance compared to pre-injury. So it's still an issue. GMs know it, coaches know it, management knows it, that just because they have their ACL fixed and they get back to play in a game doesn't mean they may be the same person. And then not just NFL, you look at the college and high school football levels, and only 43% in the Moon Group study got back to the same level. 30% weren't able to return, but 27% that returned, returned at a lower level of performance. So this is something that we still have to improve. How do we do that? Well, there's non-modifiable factors that we're going to hear about this week, the genetic intrinsic joint characteristics, notch width, posterior tibial slope we're looking at, what position, we're not going to really change that, whether they had a prior injury. But what about the modifiable ones? There's prevention programs and there's the shoe surface interaction. Prevention programs, you know, isn't that just a soccer thing? Football's a contact sport. It doesn't really apply, does it? Well, it does. We looked at a video analysis. We published an AJSM that looked at this, and I want to introduce this term that's important to understand, which is limited contact or perturbation injury. So if you get hit up on the shoulder or off balance and you get into a rotated position and a valgus knee, that's perturbation, that's not a true contact injury. So if you look at that and you parse them out, true direct blows to the knee aren't as common as these perturbations and complete non-contact. 72.5% are non- or limited contact. So yes, I do think it has a role for it. They're most common on punt plays, looking at that as well in the NFL, and Alan may talk more about that. 73% of these occur during the deceleration phase. So you see the issue with special teams, full sprint, going down, you're decelerating in two to three steps. If somebody's just running sprints, we're usually decelerating in about eight steps. So how can we teach that? How do we learn that? Can we improve on that? Study is ongoing. What about cleat surface interaction? Well, clearly it's important, but what's optimal? Jeff Crandall and his group out at UVA have been looking at this, working with Bob Anderson and some of the shoe companies to look at the cleat surface interaction in different shoes. We have charts within our locker rooms that talk about these different data that we found that players can look at. They use the BEAST, which is a really cool device. The BEAST is actually an acronym, some type of surface and turf interaction acronym, but it actually is a BEAST. This picture here is the actual size of it, and that little thing on the grass there is the size of a shoe. So it is a BEAST. So that's great for a lab, but you really need a mobile unit. You need to test this out at different fields. The problem is if you go to an NFL stadium or really any stadium, and you look at the field, it's not uniform throughout the entire field. There's different patches that have different data that you're going to get. So it adds to that challenge. But the bottom line is that more force is needed for lateral translation and more torque for rotation on artificial turf versus natural turf. So looking at that cleat surface interaction. What about other injuries with major impact? Well, we mentioned shoulder instability and high ankles is the other of the big four that we see in the injury burden. Shoulder instability is their role for bracing. Maybe we have a task force that Alan's put together looking at this. High ankle sprains, usually these are traumatic. There's groups looking at different tackling techniques, so-called hip drop, kind of landing on their ankle and putting it into forced external rotation, stress, and eversion. Looking at the cleat surface interaction like we just talked about, certainly would apply to high ankle sprains as well. And then taping, you know, there may be a paradigm shift in taping in the future. If taping could be contributed to high ankle sprains, maybe. Do we really need taping for prevention of low ankle sprains? Well, everybody does it because they've done it since they were youth. But that's being challenged as well. So we'll see. Meniscus and chondral injury. When I started out, we really didn't think about repairing many of these menisci. We would clean them out. And that was what the player would desire. There's been a little bit of a swing towards fixing these lately. And we'll talk more about that this week. Same with chondral injuries, the old edge stabilization or just clean it up and get you back in. Looking at different cartilage repair techniques is certainly being applied more to even in the professional ranks as well. And then MCL injury, looking at prophylactic bracing. Clearly it helps. The college literature has shown us that. But with the players' union, they just don't wear them. And so whether we can change that or look at that through other studies is going to be important. We'll talk about that this week. And Achilles ruptures. Interesting thing about Achilles ruptures is we all hear something in the news some time around May of someone tearing their Achilles. And it's a higher incidence compared to all the other injuries in the off-season program. And it seems to be that there's that time after the season. They all chill out for a while, get healthy, and then start ramping up and get right back into practice. There seems to be increased risk of Achilles rupture. And we certainly have seen that at the 49ers. So what can we do about that? I like this slide. It's basically looking at a bar graph of different surgeries. This was from AJSM in 2016, a group out of Northwestern, Wellington, Sioux, and this group. And it's looking at public Internet data, which we can argue about that later in the weekend. But it does have some truisms, I think, here, which is if we look at different surgeries that we do, certain ones are very predictable, ready to come back. So when people come to talk to us about a free agent or a player coming from college, what worries us? Well, if they had problems with core muscle injury, if they had a problem with both bone forum and everything went well, they're probably going to do pretty well. And we see that over and over again. Whereas if they had a patella tendon rupture, that's the one that's been shown that's really tough to get back from. And I would throw quad into there. They didn't look at quadriceps as well, but quad rupture. And we see that in the NFL. Those are ones that make us say, OK, let's see how this goes, even with the great surgery. So certain ones are predictable, particularly do well, and certain ones don't. Or certain ones have additional challenges. Just to summarize, we have the four big ones that we see in the injury burden that are major focus for us. The lex strains, the ACL, the shoulder instability, and the high ankle sprains. There's ongoing study for prevention and return to play guidelines. But let's not forget the importance of all these other injuries that we're going to hear about this weekend. They all have important impacts, and there's going to be some great talks coming up. We talked about the Achilles rupture and the interesting timing. We talked about the knee meniscus and chondral injuries in MCL. Patella tendon and quad rupture, how they are a concern, that even if you get a good surgery on them, that may not be that same player. You have to include core muscle injury and FAI on that, the close association with that. We often say, half-joking, if somebody comes in with a core muscle injury or FAI, just go ahead and get bow surgeries and come back with a bow on your head. Because it's that pathway that's so frustrating for the player, for the coaches, for everybody involved, to come back from a core muscle surgery and then have to have later treatment for FAI or vice versa. So really trying to ferret that out and understand it. Certainly cervical and lumbar spine are important. Recurrent stingers are a major issue if they've got significant spondylosis. Lumbar spine issues, lifting problems, a lot of our linemen. Turf toes, a bane of many our existence for some of our speed players. Over and over they'll say, I need my wheels, Doc, I need my wheels. And a simple little turf toe, not always the easiest solution, is to put a turf toe plate in and say, let's go. Jones fractures we know are so prevalent. Long bone fractures, yeah, if you fix a long bone, it's probably going to do pretty well, as we saw from that slide. But when do you return them to play? Can you push the limit a little bit and get them back at three, four weeks with some type of bracing? Elbow injuries, not just for baseball. As we saw with our 49er quarterback this year, UCL injuries occur in football as well and can be quite devastating. And hand and wrist injuries, yeah, we tend to blow off a lot of hand injuries. A lot of people have gnarled PIP joints at the end of their NFL career. But if you have an FTP, deep avulsion injury, and you're going to miss eight weeks, it's hard for people to wrap their brain around. And significant sequelae if you don't fix those. And wrist is very important. You put in a skateboard screw for somebody and say, let's go back and play. They may do well then, but we see a lot of non-unions that come back later and it affects their lifting abilities. And so even though they're just hand and wrist in football, they can have significant importance. So these are going to be exciting to look at over this weekend and thanks for having me here.

NFL injuries

prevention methods

treatment methods

lower extremity strains

ACL tears