Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.
Low return to play and performance in national football league athletes after Achilles tendon rupture: A systematic review
James J Butler, Davis Hedbany, Charles C Lin, Luilly Vargas, Matthew T Kingery, Nathaniel P Mercer, Bradley A Lezak, Alexander Tham, Jared Rubin, John G Kennedy
James J Butler, Department of Orthopedic Surgery, Royal College Surgeons in Ireland, Dublin 18, Ireland
Davis Hedbany, Department of Orthopedic Surgery, Suny Upstate Medical University, New York, NY 13210, United States
Charles C Lin, Luilly Vargas, Nathaniel P Mercer, Bradley A Lezak, Alexander Tham, Jared Rubin, John G Kennedy, Department of Orthopedic Surgery, NYU Langone Health, New York, NY 10002, United States
Matthew T Kingery, Department of Foot and Ankle, NYU Langone Health, New York, NY 10002, United States
Author contributions: Butler JJ was responsible for conceptualization, methodology, data curation, formal analysis, writing original draft; Hedbany D was responsible for data curation, investigation, writing review and editing; Lin CC was responsible for data curation, validation, visualization, writing review and editing; Vargas L was responsible for investigation, resources, writing review and editing; Kingery MT was responsible for methodology, supervision, writing review and editing; Mercer NP was responsible for formal analysis, validation, writing review and editing; Lezak BA was responsible for resources, project administration, writing review and editing; Tham A was responsible for investigation, writing review and editing; Rubin J was responsible for supervision, writing review and editing; Kennedy JG was responsible for conceptualization, supervision, project administration, writing review and editing; all of the authors read and approved the final version of the manuscript to be published.
Conflict-of-interest statement: Kennedy JG is a consultant for Arthrex and In2Bones; Kennedy JG receives financial support from Mr Winston Fisher, the Ohnell Family Foundation, and Ms Tatiana Rybak. Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/Licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. The authors report no other conflict of interests.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Corresponding author: James J Butler, Research Fellow, Department of Orthopedic Surgery, Royal College Surgeons in Ireland, 123 St Stephen‘s Green, Dublin 18, Ireland.
jamesjbutler@rcsi.ie
Received: June 23, 2025
Revised: September 26, 2025
Accepted: December 29, 2025
Published online: March 18, 2026
Processing time: 260 Days and 6.5 Hours
BACKGROUND
Acute Achilles tendon rupture (AATR) is a debilitating injury that significantly impacts elite athletes, particularly those in the national football league (NFL). While return to play (RTP) and performance outcomes are critical to career longevity, these outcomes may be influenced by factors such as injury timing, player position, and unreported rehabilitation variation. Prior literature lacks a comprehensive synthesis of these outcomes in NFL athletes.
AIM
To systematically evaluate return-to-play rates, performance outcomes, and career longevity following AATR among NFL athletes, while considering the methodological quality of available evidence.
METHODS
A systematic review was conducted in May 2024 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, EMBASE, and Cochrane Library databases. Studies reporting outcomes following AATR in NFL players were included. Data were extracted on demographics, timing of injury, RTP, games played, and performance metrics. Pooled rates and weighted means were calculated based on sample size. Risk of bias was assessed using the Risk of Bias in Non-Randomised Studies of Interventions tool. No meta-analysis or statistical heterogeneity testing (e.g., I²) was performed due to the descriptive nature of the analysis.
RESULTS
Twelve studies including 676 NFL athletes met inclusion criteria. The weighted mean age at injury was 27.3 ± 1.4 years, with a mean of 5.2 ± 1.2 years in the NFL prior to injury. Linebackers (19.0%), wide receivers (11.9%), and running backs (9.0%) were most affected. AATRs occurred most often during the preseason (50.4%). The overall RTP rate was 66.2%, with a weighted mean time of 10.9 ± 1.3 months. Post-injury, players averaged 12.9 games/season and played for 2.2 ± 0.8 additional seasons. Performance significantly declined regardless of position. Most studies lacked data on rehabilitation protocols and exhibited moderate to critical risk of bias.
CONCLUSION
NFL athletes experience a relatively low return-to-play rate and substantial decline in performance following AATR. These outcomes are further influenced by high heterogeneity in study quality and the unreported variability in post-operative rehabilitation. These findings underscore the need for prospective, standardized research and may inform team physicians and athletic trainers in developing evidence-based RTP strategies.
Core Tip: This systematic review investigates outcomes following acute Achilles tendon rupture (AATR) in national football league athletes. AATR is a serious injury associated with a 66.2% return-to-play rate and significant post-injury performance decline, regardless of player position. The review highlights decreased career longevity, positional variability in outcomes, and the potential impact of inactivity periods – such as during the coronavirus disease 2019 pandemic – on injury risk. These findings underscore the career-threatening nature of AATR in elite-level athletes.
