Low return to play and performance in national football league athletes after Achilles tendon rupture: A systematic review

Abstract

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.

Key Words: National football league; Acute Achilles tendon rupture; Return to play; Player performance; Career longevity; Professional athletes; Athletic injuries; Tendon injury outcomes; Systematic review; American football

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.

INTRODUCTION

An acute Achilles tendon rupture (AATR) is a debilitating pathology that can have a profound effect on a patient’s quality of life, participation in sports and activities of daily living[1]. AATRs frequently occur during explosive acceleration or during a sudden change of direction with an eccentrically loaded foot, with the rupture most commonly occurring at the vascular watershed region of the tendon, roughly 2-6 cm proximal to its insertion at the calcaneus[2]. AATRs are intimately associated with the athletic population with approximately 80% of all AATRs in the United States occurring during sport and/or recreational activity[3].

In recent years, there has been a growing incidence of AATRs across various sporting disciplines, especially in the national football league (NFL)[4]. Bi et al[4] reported a 3-fold increase in the number of AATRs sustained by NFL athletes from the 2008-2009 season to the 2021-2022 season. An AATR typically results in a season-ending injury with prolonged return to play (RTP) times following operative intervention reported in the literature. Additionally, AATRs have been demonstrated to reduce player performance and negatively impact the longevity of the athlete’s career in 11 articles[5-15].

To date, no systematic review regarding AATRs sustained by athletes participating in the NFL has been conducted. Thus, the purpose of this systematic review was to evaluate outcomes following AATRs sustained by athletes participating in the NFL. This study aims to determine the RTP rate following AATR and the impact of AATR on player performance and career longevity. Additionally, we aimed to identify the impact of player position and other factors on the rate of AATR and RTP following AATR.

MATERIALS AND METHODS

Search strategy

A systematic review of the MEDLINE, EMBASE and Cochrane Library databases was performed from the January 1997 (start of literature) to May 2024 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines[16]. The following search terms were used: (1) Achilles; (2) Rupture or tear; (3) Football; and (4) American or national or professional. Table 1 displays the inclusion and exclusion criteria. After collecting the data, 2 researchers independently screened the titles, abstracts, and full-text articles according to these criteria. Any disagreements were resolved by consulting a senior author.

Table 1 Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Clinical studies reporting outcomes following Achilles tendon ruptures in athletes in the National Football League	Review articles
At least 5 patients per cohort	Case reports
Published in a peer-reviewed journal	Cadaveric studies
Article written in English	Fewer than 5 patients per cohort

Assessment of level of evidence and methodological quality

The level of evidence (LOE) was assessed using previously accepted criteria. The methodological quality of clinical evidence and risk of bias for non-randomised studies was assessed using the Risk of Bias in Non-Randomised Studies of Interventions tool by 2 independent reviewers[17]. The options for a domain-level risk-of-bias judgement are low, moderate, serious or critical risk of bias, with an additional option of no information. Discrepancies were ameliorated by a senior author who evaluated the data until a consensus was reached.

Data extraction and evaluation

Two reviewers independently extracted and assessed the data from each individual study. Data regarding the number of AATR, laterality, player position, RTP rates, timing of AATR and re-ruptures were evaluated. Values for variables that were not recorded by the authors of the individual studies were marked as “n/r” for not recorded, and were not included in the calculation of means. No imputation or statistical adjustment was performed for missing data. When specific variables or outcomes were not reported by an included study, these were excluded from pooled analysis and noted as ‘not recorded’ in summary tables. Each of the included studies, AATR was diagnosed through established surgical documentation of complete tendon rupture, through institutional coding records (current procedural terminology or International Classification of Diseases, 10^th revision codes) and diagnoses based on public reports, team press reports, and injury databases.

Statistical analysis

RStudio version (4.3.0) was used to complete statistical analyses. For all continuous and categorical variables, descriptive statistics were calculated. Continuous variables were reported as weighted mean and standard deviation, whereas categorical variables were reported as frequencies with percentages.

RESULTS

The search generated 76 studies. Of these, 12 met the inclusion and exclusion criteria (Figure 1). The 12 studies were published between 2009 and 2022.

Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Study characteristics

Study characteristics and patient demographic data are listed in Table 2[4-15]. Four studies were LOE III and 8 studies were LOE IV. Seven studies were moderate risk of bias[4,6,8,10,11,13,14], 2 studies were serious risk of bias[12,15] and 3 studies were critical risk of bias (Figure 2)[5,7,9]. The years that data was collected from ranged from 2009 to 2022.

Figure 2 Risk of Bias in Non-Randomised Studies of Interventions.

Table 2 Study characteristics and athlete demographics.

Ref.	Level of evidence	Number of players	Number of Achilles	Years data collected	Age	Body mass index (kg/m2)	Years in national football league prior to acute Achilles tendon rupture (years)
Chopra et al[14], 2023	4	5	10	2007-2021	27.8	33.4	5.8
Krill et al[9], 2017	4	44	44	2009-2016	n/r	n/r	n/r
Parekh et al[8], 2009	4	28	31	1997-2002	29	n/r	6
Yang et al[10], 2019	3	80	80	2009-2014	25.6	n/r	3
Bi et al[4], 2023	4	52	52	2019-2021	n/r	n/r	n/r
Ready et al[11], 2021	4	101	101	2009-2016	26.7	31.7	n/r
McCullough et al[7], 2014	4	9	9	2012-2013	25.6	n/r	n/r
Jack et al[6], 2017	3	95	98	1958-2016	28.2	n/r	5.5
Krill et al[15], 2018	4	98	109	2010-2016	26	n/r	n/r
Trofa et al[5], 2017	3	21	21	1988-2012	29.4	33.3	6
Mai et al[13], 2016	4	80	80	2003-2013	27.2	32	4.6
Barton et al[12], 2023	3	63	63	2009-2015	n/r	n/r	n/r

n/r: Not recorded.

Athlete demographic data

Athlete demographic data is listed in Table 2[4-15]. The weighted mean age at the time of injury was 27.3 ± 1.4 years and the weighted mean body mass index was 32.6 ± 0.9 kg/m². The weighted mean number of years of participation in the NFL prior to sustaining an AATR was 5.2 ± 1.2 years. One study found that the athletes played a mean number of 61.2 games prior to sustaining an AATR and the athletes started a mean number of 38.7 games prior to sustaining an AATR[13].

The distribution of AATRs by player position is listed in Table 3. AATRs were sustained in 257 defensive players (56.9%), 185 offensive players (40.9%) and 10 special teams players (2.2%). The playing positions that sustained the highest number of AATRs was linebackers (19.0%), wide receivers (11.9%) and running backs (9.0%). Defensive linemen sustained a higher rate of AATRs (24.4%) compared to the offensive linemen (9.4%).

Table 3 Distribution of acute Achilles tendon rupture per position, n (%).

Position
Linebacker	65 (19.0)
Wide receiver	41 (11.9)
Defensive end	35 (10.2)
Running back	31 (9.1)
Tight end	26 (7.6)
Corner back	22 (6.4)
Defensive tackle	21 (6.1)
Quarter back	12 (3.5)
Safety	9 (2.6)
Offensive tackle	7 (2.1)
Offensive guard	6 (1.8)
Kicker	5 (1.5)
Corner	4 (1.2)
Punter	3 (0.9)
Long snapper	2 (0.6)
Overall defensive linemen	83 (24.3)
Overall offensive linemen	31 (9.1)
Overall defensive players	257 (56.9)
Overall offensive players	185 (40.9)
Overall special team players	10 (2.2)

Timing of AATR and environmental factors

Details regarding timing of AATR and environmental factors are reported in Table 4[4-15]. Four studies reported the timing of the rates of AATR in relation to the season[6,8,9,11]. In total, 139 AATRs (50.4%) occurred in the pre-season, 135 AATRs (48.9%) occurred during the regular season and 2 AATRs (0.7%) occurred during a post-season game. There were 124 AATRs (44.9%) during a preseason practice session, 15 AATRs (5.4%) during a preseason game, 133 AATRs (48.2%) during a regular season game, 2 AATRs (0.7%) during a regular season practice session and 2 AATRs (0.7%) during a post-season game. Two studies recorded the quarter during which the AATR was sustained[8,9]. Twenty-three (40.4%) AATRs occurred during the 1^st quarter, 23 (40.4%) AATRs occurred during the 2^nd quarter, 6 AATRs (10.5%) occurred during the 3^rd quarter and 5 AATRs (8.8%) occurred during the 4^th quarter. One study evaluated the timing of the rates of AATR in relation to the coronavirus disease 2019 (COVID-19) pandemic[4]. The authors reported an 8.9% increase in the rates of AATR from 14.6% in 2020 to 23.5% in 2021.

Table 4 Timing of acute Achilles tendon rupture and environmental factors.

Ref.	Number of players	Number of Achilles	Preseason practice	Preseason game	Regular season	Practice session during regular season	Post-season game	Quarter	Artificial surface	Grass	Indoor/outdoor	Weather conditions
Chopra et al[14], 2023	5	10	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r
Krill et al[9], 2017	44	44	n/r	n/r	44	n/r	1	1st: 17, 2nd: 15, 3rd: 6, 4th: 5	20	24	n/r	n/r
Parekh et al[8], 2009	28	31	6	5	20	0	n/r	1st: 6, 2nd: 8	15	16	Indoor: 5, outdoor: 26	Sunny: 9, rainy: 9, cloudy: 7, average temperature: 69.7
Yang et al[10], 2019	80	80	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r
Bi et al[4], 2023	52	52	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r
Ready et al[11], 2021	101	101	55	10	34	2	1	n/r	57	44	n/r	Average temperature: 67
McCullough et al[7], 2014	9	9	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r
Jack et al[6], 2017	95	98	63	n/r	35	n/r	n/r	n/r	n/r	n/r	n/r	n/r
Krill et al[15], 2018	98	109	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r
Trofa et al[5], 2017	21	21	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r
Mai et al[13], 2016	80	80	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r
Barton et al[12], 2023	63	63	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r

n/r: Not recorded.

Three studies evaluated the impact of gameday conditions on AATR[8,9,11]. Ninety-two AATRs (52.3%) occurred on an artificial surface and 44 AATRs (47.7%) occurred on grass. One study found that 26 AATRs (83.9%) occurred on an outdoor surface and 5 AATRs (16.1%) occurred on an indoor surface[8]. One study found that the type of surface had no impact on the rate of AATR, with an injury rate ratio of 1.0 per 100 team games for AATRs sustained on grass compared to an injury rate ratio of 1.1 per 100 team games for AATRs sustained on turf[9]. One study assessed the in-game weather conditions and reported that 9 AATRs (36.0%) occurred during sunny weather, 9 AATRs (36.0%) occurred during rainy weather and 7 AATRs (28.0%) occurred during cloudy weather[8].

RTP and impact of AATR on performance

Data regarding RTP and impact of AATR on performance is listed in Table 5[4-15]. In total, 66.2% of athletes returned to play following AATR. The weighted mean RTP time was 10.9 ± 1.3 months. One study found that the mean number of games missed during rehabilitation following AATR was 9.8 games[14]. Three studies found that 89 athletes (46.8%) did not RTP in the subsequent season[7,10,11]. The weighted mean career length following AATR was 2.2 ± 0.8 seasons. One study found that the mean number of games played per season following AATR was 12.9 games and only 28.1% played in the NFL following AATR[6]. One study reported that the mean number of games played per season in the 3 seasons prior to AATR was 11.7 which subsequently deteriorated to 6.2 games played per season in the 3 seasons following AATR[8]. One study found that the mean number of games played during the course of the athlete‘s career following AATR was 27.3[13].

Table 5 Return to play and player performance following acute Achilles tendon rupture.

Ref.	Number of players	Number of Achilles	Number of RTP	Mean time RTP (months)	Participation statistics following AATR	Player performance following AATR
Chopra et al[14], 2023	5	10	5	9.3	n/r	n/r
Krill et al[9], 2017	44	44	n/r	n/r	n/r	n/r
Parekh et al[8], 2009	28	31	18	11	11.7 games/season before AATR, 6.7 games/season post AATR	Decreased Power-rankings of 83.0% for RBs, 77.0% for WRs, 73.0% for TEs and 50.0% for quarterbacks
Yang et al[10], 2019	80	80	51	11.9	10.9 games played in 1st season following AATR	n/r
Bi et al[4], 2023	52	52	n/r	n/r	n/r	n/r
Ready et al[11], 2021	101	101	59	n/r	n/r	n/r
McCullough et al[7], 2014	9	9	7	8.9	n/r	n/r
Jack et al[6], 2017	95	98	71	11.2	12.6 games/season, 2.7 seasons, 28.1% playing in national football league 3-years post AATR	n/r
Krill et al[15], 2018	98	109	n/r	n/r	n/r	n/r
Trofa et al[5], 2017	21	21	14	n/r	15 games in the season before AATR, 12.9 games in the 1st season following AATR	SAV pre-AATR: 8.7, SAV post-AATR: 5.6
Mai et al[13], 2016	80	80	58	12.3	1.6 seasons, 27.3 games played	n/r
Barton et al[12], 2023	63	63	36	12	n/r	WR/TE yards/catch pre/post AATR: 11.4/9.9, WR/TE receptions/game pre/post AATR: 2.6/2.3, WR/TE TDs/season pre/post AATR: 2.8/3.6, RB yards/rush pre/post AATR: 4.3/2.4, RB rushes/game pre/post AATR: 13/3.5, RB rushing TDs/season pre/post AATR: 3.8/1, DB/LB tackles pre/post AATR: 64.5/51.1, tackle for loss pre/post AATR: 4.8/3.3, DB/LB sacks pre/post AATR: 2/1.8, DB/LB passes defended pre/post AATR: 5/2.8, DB/LB interceptions pre/post AATR: 1.3/0.8, DB/LB fumbles pre/post AATR: 1.4/0.8, DB/LB defensive TD pre/post AATR: 0.3/0.2

AATR: Acute Achilles tendon rupture; DB: Defensive back; LB: Linebacker; n/r: Not recorded; RBs: Running backs; RTP: Return to play; SAV: Simple ankle value; TD: Touch down; TEs: Tight ends; WRs: Wide receivers.

One study evaluated the impact of AATR on power ratings calculated in subsequent seasons[8]. The authors found that the mean power ratings per game decreased significantly across multiple positions, with a reported decreased rate of 83.0% for running backs, 77.0% for wide receivers, 73.0% for tight ends and 50.0% for quarterbacks.

One study evaluated the impact of AATR on various position specific performance metrics[12]. For running backs, the mean number of yards per rush decreased from 4.3 to 2.4, the mean number of rushes per game decreased from 13.0 to 3.5 and the mean number of rushing touchdowns per season decreased from 3.8 per season to 1.0 per season. For wide receivers and tight-ends, the mean number of yards per catch decreased from 11.4 to 9.9. For running backs and linebackers, the mean number of tackles per season decreased from 64.5 to 51.1, the mean number of passes defended per game decreased from 5.0 to 2.8 and the mean number of interceptions decreased from 1.3 to 0.8.

DISCUSSION

The most important finding of this systematic review was that the proportion of athletes participating in the NFL who returned to play following AATR was 66.2%. Both the mean number of games played per season and the mean number of seasons played decreased significantly following ATR. Additionally, overall player performance deteriorated following AATR, regardless of position played. This current review reinforces the devastating sequelae of sustaining an AATR in the elite athletic population.

AATRs are commonly encountered injuries in the athletic population, with a reported prevalence rate of 11% in runners[2]. Most AATRs occur in the vascular watershed region of the mid-substance of the Achilles tendon, approximately 2-6 cm proximal to the insertion on the calcaneus[4]. These ruptures are classically produced during an initial propulsive force with the knee in full extension followed by rapid dorsiflexion of a plantarflexed ankle[2]. Furthermore, an acceleration-deceleration event has been described in approximately 90% of sports related AATRs[18]. Histological examination often reveals degenerative changes of the tendon architecture characterized by increased vascularity, increased cellularity near the rupture site and collagen disorganization[2]. These changes can result in diminished tensile strength, reduced ability to generate adequate propulsion force and an increased susceptibility to rupture[2]. Moreover, a notable decrease in the quantity and size of type I collagen fibers, which constitutes 95% of the total tendon collagen make-up of healthy Achilles tendons, has been observed[19]. These fibers are supplanted by larger type III collagen fibers which, due to their impaired resistance to tensile forces, further increases the susceptibility to rupture[19].

This current systematic review found that RTP following AATR for athletes in the NFL was 66.2% with a mean RTP time of 10.9 ± 1.3 months. Additionally, the mean career length for the athletes who returned to play in the NFL was 2.2 ± 0.8 seasons. Overall, player performance significantly decreased following AATR as evidenced by a degradation in post-AATR power ratings and individual player metrics. This current study demonstrated that individual player position had an impact on the prevalence of AATRs and RTP following. Overall, defensive players had a higher rate of AATR (56.9%) compared to offensive players (40.9%). Linebackers had the highest rate of AATRs of all positions (19.0%) which can be potentially attributed to the high velocity and high impact collisions they frequently engage in. Furthermore, defensive linemen also had a high AATR rate of 24.4%. Defensive linemen are typically the heaviest athletes on the pitch, with bodyweights often exceeding 300 Lbs. The sudden bursts of acceleration at the line of scrimmage coupled with the individual player‘s immense bodyweight places extensive load across the Achilles tendon, increasing the risk of rupture. Alternatively, offensive players such as wide receivers and running backs also had a high AATR rate (11.9% and 9.0%, respectively) which is expected given the sudden acceleration-deceleration and cutting movements performed by the athletes. The rates of RTP following AATR also varied by player position. Barton et al[12] found that offensive players such as wide receivers and running backs had the lowest rates of RTP (38.5% and 40.0%, respectively) compared to defensive players such as defensive backs and linebackers (62.5% and 70.5%, respectively).

Overall, this systematic review demonstrated that individual player performance deteriorated significantly following AATR, regardless of the individual player position. However, Parekh et al[8] found that the degree of degradation of player performance varied depending on individual player position. The authors evaluated power ratings stratified by individual player positions both before and after sustaining an AATR. It was found that linebackers and wide receivers experienced a significant degradation in power ratings over a 3 years period following AATR of 95% and 88%, respectively. Conversely, defensive tackles and defensive ends experienced a more modest decrease in power ratings over a 3 years period following AATR of 64% and 55%, respectively. Financial considerations exert a profound influence on decision-making within NFL organizations and among athletes. The intricate details of athlete contracts directly shape the team‘s flexibility in retaining or releasing individuals, particularly those with a significant injury history. In the competitive landscape for roster spots, athletes affected by AATRs may vacate their positions, creating opportunities competing athletes to step in and potentially secure permanent replacements.

Numerous extrinsic risk factors that may predispose athletes for the development of AATR in the NFL were assessed in this review. Three studies evaluated the potential role of playing surface on the rates of AATR, all of which found no statistically significant correlation between the type of the playing surface and the AATR rates[8,11,15]. Furthermore, Parekh et al[8] demonstrated that game day weather conditions had no appreciable effect on the risk of sustaining an AATR. Interestingly, prolonged periods of in-activity were found to be crucial factor in the development of AATR. Most AATRs occurred during the pre-season (50.4%) in comparison to the regular season (48.9%), despite the pre-season being considerably shorter in length in comparison to the regular in-season (approximately 3 weeks compared to 18 weeks respectively). Furthermore, Bi et al[4] found that there was a statistically significant increase in AATRs in the 2020-2021 season following the onset of the COVID-19 pandemic compared to the 2019-2020 season, prior to the onset of the COVID-19 pandemic. The high rates of AATR sustained during the pre-season in addition to the increase in incidence of AATR following the COVID-19 pandemic can be attributed to the response of the Achilles tendon to periods of inactivity. Rat models have demonstrated disorganized Achilles tendon collagen remodelling as well as a decrease in Achilles tensile strength following periods of immobilization, potentially increasing the susceptibility to tendon rupture[20]. Time spent not actively engaging and loading the Achilles tendon during both the off-season and during the COVID-19 pandemic enforced lockdowns followed by a sharp, dramatic increase in training volume during the start of the pre-season and following the resolution of the lockdown, respectively, may account for these findings. As a result, in order to reduce the risk of sustaining an AATR following a return to prior level of high impact activity, athletes should be advised to engage in prophylactic, Achilles tendon stretching, balance and proprioceptive exercises during periods of extended rest as well as be prescribed a monitored, gradual increase in training volume during the start of the pre-season. While this review provides a comprehensive synthesis of return-to-play outcomes following AATR in NFL athletes, it is important to acknowledge several methodological limitations. According to the Risk of Bias in Non-Randomised Studies of Interventions assessment, the majority of included studies demonstrated moderate to serious or critical risk of bias, largely due to retrospective design, reliance on publicly available data, and limited control for confounding variables. These factors may affect the validity and generalizability of the pooled return-to-play rates, performance metrics, and career longevity findings. Notably, a formal meta-analysis was not conducted; instead, outcomes were summarized descriptively, and weighted means were calculated using sample size as the weighting factor. As such, statistical measures of heterogeneity such as the I² statistic or Cochran’s Q test were not applicable. While the use of sample size weighting helps minimize the disproportionate influence of smaller, lower-quality studies, the overall findings should be interpreted with caution. Further prospective research with standardized methodology and reduced risk of bias is needed to confirm these results. There was overlap between studies regarding the seasons of play from which they extracted data on AATR, which may have artificially increased the number of AATRs included this study and may not have provided an accurate reflection of the RTP rate.

An important limitation of this review is the lack of data on rehabilitation protocols following AATR repair. Although surgical repair was the consistent management strategy across included studies, details regarding post-operative rehabilitation were largely absent. Given that rehabilitation is known to significantly affect recovery quality, strength restoration, and RTP timelines, variation in post-operative management likely contributed to the heterogeneity in performance and RTP outcomes. Future studies should aim to report and, when possible, standardize rehabilitation protocols to better elucidate their influence on long-term athletic recovery.

CONCLUSION

This systematic review found that only 66.2% of NFL athletes returned to play following an AATR, with significant declines observed in both the number of games played per season and overall career duration. Performance also declined across all positions. These findings highlight the substantial impact of AATR on professional football careers and may serve as a valuable resource for team physicians and athletic trainers in guiding expectations and optimizing return-to-play management following this injury.