Response to “Letter Regarding: Performance and Return to Sport After Achilles Tendon Repair in National Football League Players”

Dear Editor: Thank you for your interest in our study titled “Performance and Return to Sport After Achilles Tendon Repair in National Football League Players. ” Similar to the authors of the enclosed Letter to the Editor, we too have the research goal of ultimately improving the understanding of the impact of Achilles injuries in the National Football League (NFL). Thus, we designed, conducted, and published our paper as accurate, preserving the integrity of medical research, and best representing the injury and the operative treatment of these devastating injuries. Although no research study is perfect and without any limitation, we stand by our study as being the “most scientifically valid” of all NFL Achilles papers in the literature. Our paper was a retrospective case-control analysis (Level III evidence per the Center for Evidence-Based Medicine) with a 1-year minimum follow-up of operative treatment of 98 Achilles injuries in the NFL. Unfortunately, there is a paucity of research on the topic in the medical literature. Thus, given the injury severity, duration of either operative or nonoperative treatment, time lost from active participation in the league, and the potential impact on career longevity, we felt investigation of this injury was timely and worthwhile. We chose a 12-month follow-up because of a 2014 paper written by the Letter to the Editor’s authors’ (McCullough, Shaw, and Anderson) that showed that all athletes who were able to return to the NFL after Achilles surgery returned within the first 12 months. As the authors of the Letter to the Editor did in their Letter, we also performed a manual PubMed search for “Achilles AND national AND football AND league” on 31 October 2017 and it revealed only 5 publications on Achilles injury in the NFL. The first study identified only 31 Achilles injuries between 1997 and 2002 and was published in 2009. It used a study design of publicly available online registries very similar and analogous to our investigation. The second study, the only NFL and Achilles investigation published by the authors of the Letter to the Editor (McCullough, Shaw, and Anderson), was a singlesurgeon retrospective case series of only 9 subjects undergoing operative treatment of Achilles and return to sport in NFL with only a minimum of 9 months of follow-up. Two additional articles used the exact same methodological design as our investigation. One was published in a high-impact journal (impact factor 5.673, ranking no. 1 in Orthopedics per 2016 Journal Citation Reports) and analyzed only 32 Achilles injuries over 24 years (1989-2013) with 2-year minimum follow-up. The other investigation demonstrated epidemiologic information about Achilles injury in the NFL by the world’s leading authors on sports medicine epidemiology. The final study, also published in a high-impact journal, utilized the NFL’s Orthopaedic Surgery Outcomes Database over a 10-year eligibility period (2003-2013) with minimum 2-year follow-up. However, careful analysis of that study’s Materials and Methods section shows that they also used “player profiles, newspaper archives, press releases, and team injury reports,” just like our study did, despite claiming use of the NFL’s database. Further, for physicians attending the NFL Combine, where the database information is collected, most athletes with prior Achilles surgery do not have their medical records, operative reports, or operative photos to garner accurate history on injury type, location, operative technique, and postoperative rehabilitation. Because of the fact that this is a career-threatening injury, the accuracy of the acquired information from both the NFL’s database and the publicly-available sources used in multiple distinct investigations, and the Letter to the Editor authors’ experience in treating foot and ankle injuries in the NFL (Achilles, Lisfranc, fifth metatarsal fractures, among others), we strongly encourage the authors of the Letter to the Editor to publish their outcomes of Achilles surgery in NFL players so that we can all obtain a better understanding of the nature of the operative treatment of this injury. Interestingly and despite the “limitations” of the method of data acquisition, all of these studies, both NFL database and those using freely and publicly available Internet-based information, demonstrate similar return to sport in the NFL after operative treatment of Achilles injuries. Our study had a 72.4% return to NFL rate, similar to 72.5% by Mai et al using the NFL’s database, 66% by Trofa et al, 68% by Parekh et al, and 78% by McCullough et al. In addition to football, our study’s methods mirrored multiple prior studies in all major professional sports that have been published in a wide array of high-impact journals. Our study is unique in comparison to the above-mentioned 5 other Achilles studies, in that we also rigorously matched Achilles-injured NFL players to controls using age, position, years of NFL experience, and actual statistical performance data prior to the injury. As requested in the Letter to the Editor, we reviewed the timing of our data, since 2010 and prior to exclusion, and found 101 Achilles ruptures. Our search was likely more than 1 year prior (August 2016) to the Letter to the Editor authors’ manual search that found “over 115” total ruptures. Obviously, a more recent search would allow for the small 745266 FAIXXX10.1177/1071100717745266Foot & Ankle InternationalLetter to the Editor letter2017