What I ve Learned from the NFL. Momma don t let your babies grow up to be Football Players Willie Nelson 3/11/16

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1 What I ve Learned from the NFL Patrick Birmingham M.D. NorthShore University Health Sys Momma don t let your babies grow up to be Football Players Willie Nelson 1 2 Financial Disclosure First Day With The Bears Dr. Birmingham is a paid Orthopedic Consultant for the Chicago Bears Football Club I don t know why we have Coaches, we ll just let the F.*:.g Doctors decide who will play Da Coach, Chicago Bears Chicago Bears Valued at 2.4 Billion in million revenue last year Started as the Decatur Staley s in 1919 Bought for $100 by PAPA BEAR George Halas in 1920 Have more player s in the Hall of Fame (27) than any other team 13 number s retired Have won more games than any other franchise 700+ Nine world titles One of two original franchises in NFL, the other the Chicago Cardinals (Arizona) 5 6 1

2 There Soon May Be More Doctors On the Field than Players! 7 8 THE SPORTS MEDICINE TEAM Athletic Trainer Doctor Athlete Athletic Trainer Coach,GM Therapist Counselor Friend and Confidant Every High School and College should have a Certified Athletic Trainer Can t survive without an Athletic Trainer you trust! 9 10 George Koonce, Doctoral Dissertation Through my personal experience and the experiences of those whom I have interviewed for this study, I conclude that playing in the NFL is detrimental to one s life and well being, especially for the players who are engulfed in the role of a professional athlete Handed in same day Jr. Seau committed suicide George Koonce Player s not prepared for Life after Football Emotional aspects of life during and after game as important as Physical Money Defer Player s salary till more mature? 78% broke 2 yrs. after?

3 I ve been big ever since I was Little Refrigerator Perry Player Size and Speed First 300 lb. NFL Lineman players players players players, 532 players in training camp First 400 lb lineman Premium on Weight in NFL Started in 1980 s with the Washington Redskins The Hogs Where will it end? lbs. The House 16 Risks High Blood Pressure Sleep Apnea Heart Disease Stroke D.M N.I.O.S.H. 52% higher rate of Death from Cardiovascular DIZ U.N.C. 25% of Players Class 2 Obesity Sleep Apnea League Funded Study 2009 JAMA 33% of Linemen have Sleep Apnea Overall 14% 4 times Higher than Population at Large Risk of Heart Diz., Hypertension, Stroke 504 active players Players not at greater risk of Heart Diz. Higher Likelihood of Borderline Hypertension

4 Head Injury Lawsuit against NFL The Risk of Concussion Will and Is Changing This Game! Suit alleges that the NFL and the Helmet Maker Riddell deliberately concealed information about the Neurologic effects of repeated hits to the Head About 5000 players Involved Head Injury Lawsuit The Concern - Chronic Traumatic Encephalopathy Settled for $765 Million initially $675 Million compensation $75 Million for Medical Exams $10 Million for Research Player s with confirmed CTE or Lou Gehrig s disease can collect up to 5 Million Rejected by Federal Judge in January Now player s can receive up to 5 million, no cap on settlement Chronic Traumatic Encephalopathy Concussion May begin Months, Years or Decades after last trauma Symptoms Memory Loss Confusion Impaired Judgment Impulse control Problems Aggression Depression Progressive Dementia Reggie Fleming

5 Football Attributes Head Games Intelligence Power Grace Speed Collisions Pure unadulterated Violence Head Games Chris Nowinski 3 Concussions per season Rest entire season 25% of players may suffer 3 concussions per season ¼ the Team might be out each season, would necessitate enlarged Roster s Concussion Symptoms Second Impact Syndrome Time of Injury Headache - 92% Dizziness 72% Blurred Vision - 67% Disorientation 58% Confusion 56% Disequilibrium 44% Nausea/ Vomiting 31% Antegrade Amnesia 31% Neck Pain 31% Photophobia 31% Sleepiness 28% Fatigue 25% Loss of Consciousness 19% Retrograde Amnesia 19% Irritability 17% 3 days later 45% 12% 17% 0% 10% 0% 14% 18% 64% 36% 60% 33% N/A 14% 50% Brain Swells Rapidly and Catastrophically after a person suffers a 2 nd Concussion before Symptoms from an Earlier one have subsided Age most vulnerable deaths from SIS NFL Players 37% Greater Risk of Alzheimer s NFL - Concussions Number of Concussions Self Reported Memory Problems Relative Reported Memory Problems None 5.2 % 8.0% Number of Concussions Zero 6.6% % Current or Former Bouts of Depression 1-2 Concussions 3 Concussions 8.8% 11.0% 17.4% 25.0% %

6 MADDEN RULE If a player is evaluated to have a concussion and removed from the game he must taken to the locker room accompanied by Medical Staff and not to return to field under any Circumstance Helmets Helmet protects Skull not Brain Helmet protects Direct Line Impact but cannot prevent injuries to the Brain that result from Rotational Acceleration Concussion National Operating Committee on Standards for Athletic Equipment League allows wearing helmet certified by NOCSAE Certification based on Preventing Catastrophic Injury like Skull Fracture not Concussion If 90% of team uses helmet - Free Helmets Player and League commissioned studies 3 helmet models Revolution Revolution Speed DNA Pro by Shutt Players still use helmet based on how it looks Remove Face Mask? Remove Helmet? NFL Definition of Concussion A traumatically induced alteration in Brain Function Manifested by an alteration of awareness or consciousness, including but not limited to - Observable Loss of Consciousness Seizure Not Observable Ding Dazed Wooziness Fogginess Amnesic Period NFL Definition of Concussion And By symptoms commonly associate with Post- Concussive Syndrome Observable Loss of Balance Syncope Near - Syncope Not Observable Headache Vertigo Light Headed Unsteadiness Cognitive Dysfunction Memory Disturbance Hearing Loss

7 NFL Definition Of Concussion And by Symptoms commonly associated with Post Concussion Syndrome - Observable Not Observable Tinnitus Blurred Vision Diplopia Visual Loss Personality Change 1-10% of Concussions Reported by Players Reasons Did not think Serious enough % Did not Want to Leave Game - 41% Did Not Know it was a Concussion 36.1% Did Not Want to Let Teammates Down Drowsiness Lethargy Fatigues 37 Inability to perform Daily 38 Activities Concussion Return to Play Guidelines -Concussion American Academy of Neurology Guidelines Grade 1 Confusion, Symptoms last < 15 min., No LOC Grade 2 Symptoms last > 15 min., No LOC Grade 3 LOC A Lasts Seconds B Lasts Minutes Grade 1 Return same day if clinically Normal within 20 minutes at rest and exertion, may return in 7 days if asymptomatic at rest and with exertion Grade 2 Return in 2 weeks if asymptomatic at rest and with exertion for 7 days Grade 3 Return in 1 month if asymptomatic at rest and exertion Depression Center for the Study of Retired Athletes 3000 former players 14% of Players yrs. 8% of same age group University of Michigan 1617 retired Players 14.7% of Players moderate to severe Depression The NFL Has The Best Pre-Participation Exam The NFL Combine!

8 Pre-Participation Evaluation N.F.L. Combine Indianapolis, Indiana February after Pro- Bowl 320 College Seniors 4 day period Multiple Radiographs Over 300 M.R.I. And C.A.T. scans Pre-participation Exam Primary Goal to help maintain the health and safety of the athlete Detect conditions that might limit competition Detect conditions that might Predispose the athlete to Injury Availability to Play Impacts-Athlete Education Social Economic Rewards Completeness of Exam-Level of Play Congenital Problems Multi-station Environment Advantages Specialists in Sports Medicine Can Handle large No. of Athletes Performance Testing Available Immediate communication with coaches etc Multi-station Environment Disadvantages Noisy environment, quick exams Impossible to counsel athlete Follow-up Spotty Recheck Combine Chicago Bears Before N.F.L. draft all players are graded and discussed with coaches, player personnel director and scouts Medical grade (fail) Players with a Medical Grade of 3.5 or worse are given particular attention as to draft status Decision Can Participate Fully Needs Rehab Can t Participate

9 Pre-participation Exam Mini-Camp Prevalence of Musculoskeletal Disorders at NFL Combine 87-00, Brophy et al. Med S.Sports Ex. 07 Orthopaedic Surgeons Internists Ophthalmologists Dentists Neuro Psychiatric Testing Dental Technicians Nurse Practioners Nutritionist Athletic Trainers Drug Testing Lab Technicians Radiologists Avg. Number of Dx./ Player 2.15 Avg. Number of Procedures 0.53 Most common Procedures Menisectomy ACL Reconstruction Shoulder Stabilization ORIF Ankle Fx. 5.6% failed, but dropped during study period Top 10 Procedures NFL Combine Per 100 Players Menisectomy 10.3 Knee Arthroscopy 8.2 ACL Reconstruction 5.9 Shoulder Stab. 4.7 ORIF Ankle FX. 1.8 ORIF MCP/Phalanges 1.5 ORIF Carpal 1.1 Meniscal Repair 1.0 ORIF 5 th MT 0.9 ORIF Rdius/Ulna 0.6 Top 15 Diagnosis NFL Combine Incidence per 100 players Ankle Sprain 29.1 Burner 16.7 Wrist Hand Injury 16.7 MCL 16.2 AC Injury 15.7 Meniscal Tears 12.4 Hamstring 12.2 Other Knee Injuries 11.1 Shoulder Instability 9.7 Fx. MCP 9.2 Other U.E. Injury 9.1 Low Back 8.3 Concusion 8.1 Turf Toe 7.9 ACL Prevalence and Variance of Shoulder Injuries in Elite Collegiate Football Players, Kaplan et al. AJSM 05 Shoulder Injuries at Combine 336 Players NFL Combine 226 Injuries of Shoulder A/C Separations 41% Anterior Instability 20% Rotator Cuff 12% Posterior Instability 4% Injuries Most common in QB, DB Anterior Instability most common in Defensive Players 76% require Surgery Offensive Linemen had Rotator Cuff Injuries and Posterior Instability more than other players

10 3/11/16 Kaplan et al. AJSM 05 Injuries Really Determine Who Wins! Surgeries Most Common Anterior Instability 48% Weaver Dunn/ Mumford 15% Posterior Instability 10% Rotator Cuff Surgery 10% Surgery Most common in LB, OL Star Tribune Sept. 14, 03 Moe Williams, Vikings Running Back There s a difference between being injured and hurt. When you re injured, you can t play. When you re hurt, you suck it up and do what you can do That s part of this game. It s like going to work with a headache or a migraine. You really don t want to go but you have to do it anyway NFL Injury Surveillance System Injury Surveillance System Currently the best in Pro-Sports Existence since 1980 Each Injury that leads to lost practice or game is reported to the NFLISS Records kept through Quintiles, Data Base Repository and Analysis System 59 Reportable Injury Head Athletic Trainer Any Injury from which player is Removed from session or missed 1 day after injury Any Fracture Regardless of time missed Any Concussion Any Dental Injury Any Heat Related Problem 60 10

11 Chicago Bears Sources of Injury - Football record Games missed 60 Injured reserve record Games missed 136 Injured reserve - 14 Over 30 players on 53 man roster have surgery Player to Player Contact Player to Ground contact Overuse Injury Non-Contact, High force ligament tear or muscle strain Epidemiology of Training Camp Injuries Feeley et al. AJSM, Injuries per yr. during Training Camp Most common Weeks 1-2 Game Injury Rate /1000 Athletic Exposures Practice 12.7/1000 Athletic Exposures Season ending Injuries 5.4/1000 games Season ending Injuries 0.4/1000 practice Most Common Injuries Feeley et al. Knee Sprain Hamstring Strains Contusions Ankle Sprain Lumbar Sprain Shoulder Sprain Fx. - dislocation Groin Strain Foot Sprain Cervical Strain Hip Flexor Strain Quadriceps Strain Injury Rates per Position Offense Injuries/ Athletic Exposure Total Injuries Quarterback Running Back Wide Receiver Tight End Offensive Line Defense Defensive Line Linebacker Defensive Back Kicker Effect of ACL Reconstruction and Menisectomy on Length of Career in NFL Athletes, Brophy et al., AJSM 09 NFL Combine Athletes with Menisectomy 29 ACL Reconstructions 11 with Both

12 Menisectomy Vs. ACL Reconstruction Combined ACL and Menisectomy Menisectomy Reduced length of Career 5.6 vs. 7.0 years 65 vs. 85 games ACL did not reduce length of career Shorter Career in Games Started 7.9 vs Shorter career in Games Played - 41 vs. 63 Shorter career in years 4.0 vs Bears Quotes I wouldn t set out to hurt anybody deliberately unless it was important like a league game or something Dick Butkus Shoulder Injuries to Quarterbacks in the NFL , Kelly et al. AJSM games 13,002 QB exposures 1534 QB Injuries Mean 18.8 Median 6 days playing time lost 83.8% occur during games AC Joint Injuries 40% 14% overuse Rotator Cuff tendinitis 6.1% Biceps tendinitis 3.5% Quarterback Injuries Football Vs. Baseball Throw Head 15.4% Shoulder 15.2% Knee 14.2% Hip, Thigh, Groin 9.8% Hand 9.3% Ankle 6.2% Chest 5.7% Elbow 4.1% Foot 4.0% Back 3.7% Leg/Calf 3.0% Face 2.4% Forearm/Wrist 2.0% Other 1.9% Neck 1.7% Abdomen 1.4% Slower Rotational Velocities Decreased Extremes of Motion Decreased Electrical Activity from the Rotator Cuff and Shoulder Musculature

13 Football Vs. Baseball Throw Shoulder Internal Rotation Velocities times faster with baseball Elbow extension Velocities 2-3 times faster with baseball Is It Safer on Grass Or Artificial Surfaces? Safer on Grass than Artificial Surface? NFL Injury Surveillance System First artificial turf Astrodome 1966 First INFILL surface 1990 Long Polyethylene Fibers Spaces filled between with rubber particle and sand 2005 All Grass or Infill /32 surfaces Grass in NFL, 14 Infill Includes data Date of Injury Weather Conditions Date of Return to Play after Injury Type of Injury Rate of Injury Related to Type of Playing Surface Rate of Injury Related to Type of Playing Surface Hershman et al, AJSM 12 Years Team Games played on Field Turf 4004 Teams games played on Grass 1528 Knee Sprains 1503 Ankle Sprains Knee sprains MCL Sprain ACL Sprains Ankle Sprains Eversion Ankle Sprains Inversion Ankle Sprains

14 Incidence Density Ratio s Da Bears Incidence Rate 22% Higher for Knee Sprains on FieldTurf Incidence Rate 22% higher on FieldTurf for Ankle Sprains ACL 67% Higher than Grass p<.001 Eversion Ankle Sprains 31% Higher than Grass p<.001 Tell the Commish that this game is not good for your health, If he does too much research he will research himself right out of business! This sport is not good for the human body. Fred Caito, 92 Head Athletic Trainer Pain Management- Perception of Being Shot Up! Pain Management Consideration for Pain Relief Specific Injury Ease of Use Provide effective Pain Relief Toradol? Minimal Adverse Effects Mind Body Interaction Goals for Pain Relief Attain comfort to Return to play at high level of function Facilitate not hinder healing Accommodate the demands of the sport without compromising safety Rules for Analgesic Use In Sports Medicine Do No Harm The Treatment of Overuse is Underuse Make a specific Diagnosis Be Cautious with NSAID s when bone or collagen healing needed Biologic Healing does not Equal Functional healing

15 Rules for Analgesic Use in Sports Medicine Toradol Pain Relief can be Integral to Recovery Consider the Ease of Use and Potential Adverse Effects of Medication in Addition to Pain Relief Efficacy Don t Ignore the Placebo Effect Athletes come in all sizes and shapes Think Accordingly Remember the Perception of Injectable Medications Non-Steroidal Antiinflammatory Drugs (NSAID) 29% of Collegiate Athletes use as preventive measure on day of a game Ketorolac Tromethamine (Toradol) Potent analgesic and anti-inflammatory Oral IV IM Nasal Toradol Tokish et al., 2002 Toradol 28 of 30 teams responding to Survey used IM Toradol NFL Game day usage 93% Pain Relief 1-2 days in 50-75% of players Six adverse Reactions 4 muscle 1 GI complaint 1 Post injection soreness Getting A Shot More Powerful Medication? Mechanism of Action Inhibition of cyclooxegenase (COX) Responsible for conversion of Arachidonic Acid to Prostaglandins and Thromboxane By Decreasing Prostaglandin levels, decreases the sensitivity of afferent nerve receptors and ameliorating pain Peak Plasma level 20 minutes Oral 45 minutes IM 6.5 hour half life Toradol NFL Task force Recommendations Indication Short term management of moderately severe acute pain that requires analgesic use at the opioid level Side efects GI Renal Hemostasis Cardiovascular Toxicity Ketorolac Only administered by Team Physician Not used Prophylactically Only use on Players with Diagnosed Injury Use lowest effective dose Use Oral Preparation Faster Onset than IM or IV Duration equivalent to IM & IV Do not take with other NSAID s

16 Is it Cutting Edge Science or Voodoo? Biologic Medicine Person s own tissue is collected processed in a particular way and then placed back in the body Body s own healing power to cure Regenokine, PRP, Activegin, Stem Cell Injection Platelet Rich Plasma (PRP) Are they the latest overhyped medical treatment for desperate athletes? Volume of Plasma that has a platelet count above the baseline of whole blood Platelet Rich Plasma Autologous Blood Increased Concentration of Growth Factors Hoped to Enhance Recruitment, Proliferation and Differentiation of Cells involved in Tissue Regeneration Collagen Synthesis Vascularization Platelet Rich Plasma Vary by The amount of blood used and the efficacy of platelet recovery The presence of absence of white or red blood cells Platelet activation with thrombin The level of fibrin production

17 Platelet Rich Plasma Platelet Rich Plasma Used in Sports Muscle injuries Tendonitis DJD Pain Limited research as to it s efficacy and use Things to be worked out Optimal Activation of PRP Timing of Injection Optimal Growth Factor, Platelet and Leukocyte Concentration Possible Acute Inflammatory Response Following Injection PRP Injection in Athletes and Doping Regulation He s got a Hammy! I Want a Second Opinion! Not For Long? Length of Player career NFLPA 3.5 years NFL 6.0 years Average length of career that makes opening day roster 6.0 years Average Length for Player with 3 pension credited seasons 7.1 years Length of Career Career Length Pension credit for each season a player spends at least 3 games on Active roster/ Inactive roster or IR Average Career Length 1 st Round Pick 9.3 yrs. Average Career Length for a player selected to a Pro Bowl 11.7 years 288 Players who Began Career were on a club roster in

18 NFL Retirement NFL Retirement Severance Pay Plan 2 credited NFL Seasons 12,500 for every year from 2000 Player Annuity Program A Player with 4 credited NFL Seasons receives an Annuity $65,000 at age 35 or 5 years after last credited season 401 K - Player with 2 credited season will receive a $2 match for every $1 contributed up to club Maximum of $26,000 Player with at least 3 credited season earns a benefit credit for every season he plays pension begins at Age NFL Retirement 10 year NFL Veteran who retired in $51,000 per year 10 year MLB Veteran eligible for $175,000 at Age 62 Length of Career Round 2 nd Contract % % % % % % Medical Legal Responsibilities Liability Is Higher For Physicians Covering NFL! NFL players do not have No-Cut Contracts Player may sign a multiple year contract but in reality it is a series of single year contracts Up front bonus money is the only money that is guaranteed Agents are generally attorneys Higher liability risk with NFL than other sports

19 Da Bears What do the Chicago Bears and Billy Graham have in Common, They Both can make 70,000 People Stand and yell Jesus Christ! Conclusions This is the most exciting sport played today! Important as a Team Physician to surround yourself with the most capable people These players are getting bigger and faster What is the limit? - What are the Risks? Winning is often dictated by Injury Those who play HURT get rewarded Have a game plan for Pain Management NFL stands for Not For Long Liability is Significant The Mother s in this country will change this game! Life is Great, Football is Better! Steve Sabol NFL Films Thank You! Dr. Robert Kerlan Rotator Cuff Contusions in Professional Football Players, Cohen it al. AJSM, Started his Private Practice 1958 Brooklyn Dodger s move to Los Angeles Becomes Team Physician 1965 Dr. Frank W. Jobe joins Southwestern Orthopedic Medical Group, Inglewood Orthopedic Sports Medicine Fellowship 1985 Kerlan Jobe Orthopedic Clinic Acute direct or indirect Shoulder Injury in an Athlete with prior normal RC function that caused an acute loss of RC function followed by Rapid Recovery

20 Rotator Cuff Contusions Rotator Cuff Contusions Years Steelers 26 players 5.5 Players per Season Direct Blow 70.3% MRI Peritendon Edema Critical Zone Tendon Edema (5-15mm from footprint) Subenthesal Bone Bruise Treatment Cuff Rehab 6 Cortisone Injections 3 Required Surgery Avg. number of Shoulder Injuries per year 11.7% 5.5/season RCC (47%) 3.8 days missed 2.0 practices 0.35 games/season Utilize your Subspecialists! Communication with Medical Staff Communication Other Physicians Athletic Trainers Physical Therapists Paramedical Personnel Radiology Technician Relationship of Team Physician to Administration School League Team-Coach Ditka, Wannstadt, Jauron, Smith Owner-Institution Physician Remuneration Physician pays Team? Contract Liability AC Joint Injuries Kelly et al., AJSM 04 40% of shoulder injuries to QB s Most occur during games Direct trauma 44% Type I, 20% Type 2 Mean time lost 22 days

21 Injury Statistics - NFL How Big Can They Get? Body Part Type of Injury Frequen cy Rank Total Frequen cy Rank Games Lost Total Practice s Lost Average Practice s Lost Knee Sprain Thigh Strain Ankle Sprain Meniscus Musulosk eletal Groin Strain Boxers Length of Boxing Less than 5 years 1% Chronic Traumatic Brain Injury Injuries Really Determine Who Wins! 6-10 years 14% Greater than 10 Years 25% Kaplan et al., AJSM NFL Combine 336 College Athletes 41% of all shoulder Injuries Second most common shoulder surgery 12% Medical-Legal Responsibilities Physician Employed by Team Good Samaritan Laws-If volunteer Negligence Fail to Diagnose Traveling Team Physician out of state, out of country

22 Informed Consent Assumption of Risk Workers compensation Full disclosure of information is a key factor in defending cases involving professional athletes Description of athletes medical condition Proposed treatment Alternative treatments Potential for further injury and adverse longterm health effects Is team physician a co-employee or independent contractor Work compensation bars claims against a co-employee Claims against independent contractors not covered by workers compensation Salary Time spent with team vs. private practice Where players are seen Potential Conflicts of Interest Effect of Shoulder Stabilization on Career Length in NFL Athletes Team Physicians/Players Athletes want to return to play despite their injuries or health risks Team Physicians/Teams Management wants players back in the game. Some have recommended that Doctor hired by player union Team Physicians/themselves Doctor considers himself part of the team and compromise their medical judgment for the good of the team Physician pays to be the team doctor Official health carrier Athletes - Shoulder Stabilization 56+/-53 games played with surgery 77+/-50 games played without surgery Linemen, Linebacker significantly shorter career, 51 vs. 81 games Effect of Shoulder Stabilization on Career Length in NFL Athletes, Brophy et al. AJSM, Athletes Shoulder Stabilization 5.2+/- 3.9 yrs with surgery 6.9+/- 3.6 yrs without surgery Shoulder Stabilization Most Treated with Open Stabilization 91% Football players 15 times more likely than Non-Football Players to have Posterior Labral Tear No Significant Diff. Career length in Non- Lineman and Non- Linebackers

23 NFL Experience Survey Full Thickness Rotator Cuff Tears Off. Line 37 Linebackers 20 Defensive Back - 8 Defensive Line 9 Receiver 4 Q.B. 2 Running Back 1 Unknown 3 Foulk : 2002 Mechanism of Injury 45/50 Players - Traumatic Fall onto shoulder with player on top - 14 Unknown 11 Attrition 8 Fall on outstretched arm 6 Abd vs. Resistance 5 Direct Blow 3 Abducted Extension - 2 Blocking Non-Operative Tx. - Foulk Operative Tx. In NFL 41 continued to play after diagnosis 22 without restrictions in performance Non-Operative Treatment 4 players RTP at 4.2 weeks ¾ had full use no pain acute repair may not be needed in athletes with preservation of function 46 repaired, 1 debrided 41 returned to play at 20.8 wks 41 who returned had full use in sport 39 reported normal use 31 some residual discomfort 3 retired ( no surgery) AC Joint Injuries in the NFL T.S. Lynch et al. AJSM, 13 Injury recorded Player removed from a practice, game or training session Or caused loss of one practice, gaming or training session. NFLISS shoulder injuries reported 795 (30%) involved the AC Joint 341 unspecified 234 Type 1 83 Type 2 39 Type

24 AC Joint Injuries in the NFL AC Joint Injuries in the NFL 393 Offensive Players 293 Defensive Players 104 Special teams 506 Injuries occurred on Natural surfaces 64% 276 on Artificial Surfaces 34.7% Pass plays accounted for slightly more injuries AC Joint Injuries in the NFL AC Joint Injuries in the NFL 20 players had Surgery (2.5%) Offensive line most common for DJD AC Joint Quarterback second most common - 3 Injuries by Position Defensive Secondary Wide Receivers Special Teams Offensive Line Defensive Line Linebacker Running Back Quarterback Tight End