603983
research-article2015
FAIXXX10.1177/1071100715603983Foot & Ankle InternationalLareau et al.
Article
Return to Play in National Football
League Players After Operative Jones
Fracture Treatment
Foot & Ankle International®
1­–9
© The Author(s) 2015
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DOI: 10.1177/1071100715603983
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Craig R. Lareau, MD1, Andrew R. Hsu, MD1, and Robert B. Anderson, MD1
Abstract
Background: Jones fractures commonly occur in professional athletes and operative treatment remains the standard of
care in this patient population. In our clinical experience, an aggressive postoperative rehabilitation protocol for National
Football League (NFL) players with an average return to play (RTP) between 8 and 10 weeks can have successful outcomes
with few complications. The purpose of this study was to quantify RTP and rate of complications, including nonunion,
refracture, and reoperation among a cohort of NFL players with operatively treated Jones fractures.
Methods: Between 2004 and 2014, 25 consecutive NFL players who underwent acute Jones fracture fixation by a
single surgeon were reviewed. Operative treatment for the majority of patients involved fixation with a Jones-specific
intramedullary screw and iliac crest bone marrow aspirate with demineralized bone matrix injected at the fracture site.
Additionally, our protocol involved the use of noninvasive bone stimulators, application of customized orthoses, and an
aggressive patient-specific rehabilitation protocol. Patient demographics were recorded along with position played, seasons
played after surgery, RTP, and complications. RTP was defined as the ability to play in a single regular-season NFL game
after surgery. At the time of surgery, average age for all patients was 24.0 years and BMI 31.0.
Results: Player positions included 8 wide receivers, 4 linebackers, 4 tight ends, 2 defensive tackles, 2 cornerbacks, 1
offensive tackle, 1 center, 1 tackle, 1 defensive end, and 1 quarterback. Seventy-six percent of players underwent operative
fixation during their first 3 seasons. Forty-eight percent were diagnosed before or during their rookie (first) season.
RTP was 100% for all players and 80% were still playing at time of publication. Three patients (12.0%) refractured
and required revision surgery. Time until RTP was influenced by other variables and difficult to measure because many
surgeries were performed early in the offseason. All 9 players who underwent surgery between July and October, and
were therefore eligible to return to play in the same season, had an average RTP of 8.7 weeks (range 5.9-13.6).
Conclusion: With an appropriately placed intramedullary screw and an aggressive rehabilitation protocol, early RTP was
achievable with a low refracture rate in professional athletes. All NFL players in this series were able to return to play after
surgery. We observed that these injuries were more likely to occur in the first 3 seasons of play and in wide receivers,
linebackers, and tight ends. This at-risk subset of players may benefit from improved preventative measures.
Level of Evidence: Level IV, retrospective case series.
Keywords: Jones fracture, fifth metatarsal, athlete, return to play, NFL, football
Introduction
Proximal fifth metatarsal metaphyseal fractures are one of
the most common foot injuries in the athletic population.26
These injuries are classified based on anatomic location as
tuberosity avulsions (zone I), true Jones (zone II), or proximal diaphyseal stress fractures (zone III).14 True Jones fractures occur at the proximal fifth metatarsal metaphysis
without extension distal to the fourth-fifth intermetatarsal
articulation.14 Delayed healing is common in the case of
zone II and III fractures because of the poor, retrograde
blood supply of this region coupled with the mechanical
forces it must withstand during activity.29,31
Athletes are especially predisposed to refracture and nonunion because of the repetitive stresses the bone must endure.
Nonoperative treatment yields unfavorable results, particularly in high-demand athletes; therefore, primary fixation
remains the standard treatment to expedite return to play and
optimize outcomes.4-7,13,25 In the past, poor operative
1
OrthoCarolina Foot & Ankle Institute, Charlotte, NC, USA
Corresponding Author:
Craig R. Lareau, MD, OrthoCarolina Foot & Ankle Institute, 2001 Vail
Avenue, Suite 200B, Charlotte, NC 28207, USA.
Email: craig.lareau@gmail.com
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Foot & Ankle International 
outcomes have been attributed to premature return to play
and inadequate screw size.26 Despite appropriate operative
treatment along with advances in technique and implants,
nonunion and refracture continue to occur in 4% to 12% of
athletes.20,28
Our protocol for National Football League (NFL) players has been to perform limited incision intramedullary
screw fixation for all proximal fifth metatarsal fractures,
regardless of chronicity, displacement, and fracture completeness. We utilize an aggressive rehabilitation protocol
with a goal of return to play (RTP) in professional competition at 8 to 10 weeks provided clinical and radiographic
examinations are satisfactory. In this case series, we report
the results of 25 consecutive NFL players who underwent
percutaneous fixation of an acute proximal fifth metatarsal
fracture with an indication-specific screw.
Methods
Prior to study initiation, this retrospective series was
approved by an Institutional Review Board. Between 2004
and 2014, 25 NFL players who underwent screw fixation of
an acute zone II or III proximal fifth metatarsal fracture by
a single foot and ankle fellowship-trained orthopedic surgeon were identified. The average age for all patients was
24.0 years (range 20-31 years), and average BMI was 31.0
(range 25.8-38.8). For all players, fixation was achieved
with a 5.5- or 6.5-mm Charlotte Carolina screw (Charlotte
Carolina Jones Fracture System, Wright Medical
Technology, Memphis, TN), ipsilateral iliac crest bone marrow aspirate (BMA), and demineralized bone matrix
(DBM). Beginning in 2008, all players received BMA and
DBM. The Charlotte Carolina screw is a partially threaded,
solid stainless steel screw designed specifically for treatment of Jones fractures. All available clinic notes, operative
reports, pre- and postoperative radiographs and computed
tomographic scans, and physical therapy evaluations were
reviewed. Patients with chronic injuries, those who had
undergone previous operative treatment, had concomitant
injuries, or had less than 6-month follow-up were excluded.
Patient demographics were recorded as well as position
played, fracture zone, fracture characteristics, time until
surgery, ability to RTP, time until RTP, seasons played after
surgery, complications, and reoperations (Table 1). RTP
was defined as the ability to play in at least 1 regular-season
NFL game after surgery, based on a previous study by
Andrews et al.1 Number of games and seasons played postinjury was determined based on data available on the NFL
website (http://www.nfl.com) and information obtained
from the players’ athletic trainers. Differences between
players who suffered refracture and those who did not were
evaluated using Student t test and repeated-measures analysis of variance (SPSS, Chicago, IL), and differences in
proportions between groups were evaluated using Fisher
exact tests, with significance set at P < .05.
Operative Technique
Under ankle Esmarch tourniquet, a 1.5-cm longitudinal
incision was made approximately 2-3 cm proximal to the
base of the fifth metatarsal (Figure 1A) and a guide wire
was inserted into the dorsal and medial aspect of the fifth
metatarsal base adjacent to the cuboid articulation (“high
and inside” starting point) (Figure 1B and C). The guide pin
was carefully advanced across the fracture site under fluoroscopy taking care not to perforate the medial cortex. Next,
a 3.2-mm cannulated drill was inserted over the guide wire
and into the canal just across the fracture site. This was then
removed and exchanged for a solid 3.2-mm drill, which was
advanced on reverse to ream the canal and minimize the
risk of cortical violation (Figure 2A and B). The canal was
then sequentially tapped over a guide wire in 1-mm increments until adequate torque was achieved such that the surgeon felt the forefoot rotate slightly and screw length was
measured radiographically (Figures 3A and 3B).
Since 2008, our protocol for NFL players has been to
harvest 30 to 40 mL of BMA from the ipsilateral iliac crest
using a standard trochar and syringe system. The BMA
was spun down over a period of 15 minutes into 4 mL of
bone marrow concentrate using a separator system
(MAGELLAN, Arteriocyte Medical Systems, Inc.,
Hopkinton, MA). This concentrate was then mixed with
an injectable scaffold in DBM (Mini Ignite, Wright
Medical Technology, Arlington, TN) which was injected
through a separate small incision at the fracture site
(Figures 4A and 4B) into the subperiosteal space within
the periosteal envelope (particularly the plantar aspect)
and within the medullary canal when possible. There is
typically only space for 1-2 mL of graft.
We utilized an aggressive rehabilitation protocol for professional athletes. Patients maintained non-weight-bearing
precautions for 2 weeks following surgery then began
weight bearing in a short controlled ankle motion (CAM)
walker boot. Bone stimulators (Ultrasound Bone Healing
System, Exogen, Durham, NC) were used (20 minutes/d)
until radiographic healing. Once the fracture site was minimally tender, the patient used an accommodative shoe.
When plain radiographs demonstrated bridging bone usually at 6 weeks (Figure 5A and B), the patient transitioned
to a running shoe and began a run progression protocol followed by sport-specific integration. A clamshell orthosis
(Figure 6) or turf toe plate was used during rehabilitation to
minimize stress on the fifth metatarsal base. When the athlete returned to play, at an average of 8 to 10 weeks following surgery, a full-length orthosis with a lateral hindfoot
post was utilized.
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Lareau et al
Table 1. Patient Demographics and Operative Details for All Jones Fractures in NFL Players.
Position Left / Days to
played
right surgery Age
WR
WR
WR
WR
WR
WR
WR
WR
LB
LB
LB
LB
TE
TE
TE
TE
CB
CB
DT
DT
C
DE
OT
QB
T
L
R
L
L
R
R
R
L
R
L
R
L
R
L
L
R
L
R
L
L
L
L
L
R
L
7
5
4
2
9
2
3
5
3
35
3
14
4
5
7
21
11
28
4
2
2
10
8
14
5
21
26
22
29
22
24
26
21
29
24
24
27
24
24
21
23
25
23
22
23
31
20
22
23
23
Height Weight
(in.)
(lb)
73
71
75
72
75
73
70
74
76
74
76
75
75
75
78
77
69
71
77
76
74
77
81
76
77
214
185
229
220
220
208
200
215
265
255
246
249
248
250
262
251
193
190
302
308
302
303
325
220
316
BMI
28.2
25.8
28.6
29.8
27.5
27.4
28.7
27.6
32.3
32.7
29.9
31.1
31.0
31.2
30.3
29.8
28.5
26.5
35.8
37.5
38.8
35.9
34.8
26.8
37.5
Screw Screw
Season Fracture
diameter length
RTP
of injury zone
Typea (mm)
(mm) Refracture (wk)
1st
3rd
1st
8th
1st
4th
4th
1st
7th
2nd
3rd
5th
2nd
1st
1st
2nd
3rd
2nd
1st
1st
8th
1st
1st
1st
1st
2
2
2
3
2
2
2
2
2
2
3
3
2
3
2
2
3
2
3
2
2
2
3
2
2
I
CN
C
C
I
C
CN
C
CN
I
C
I
I
CN
I
I
CN
I
CN
I
C
I
I
CN
CN
5.5
5.5
5.5
5.5
5.5
6.5
5.5
5.5
6.5
5.5
5.5
6.5
5.5
6.5
5.5
6.5
6.5
5.5
6.5
6.5
6.5
5.5
6.5
5.5
6.5
50
40
45
50
50
45
50
40
45
45
55
50
50
55
50
55
55
45
60
45
50
50
60
50
55
No
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
No
No
No
No
No
Yes
No
No
No
No
No
8
9.9
11.4
14.7
6
5.9
13.6
6
7
11.9
18.6
13.6
11.3
7
-
No. of
seasons
since
6
2
5
2
1
3
2
1
5
3
1
1
6
1
1
8
2
1
4
4
2
1
1
3
1
Abbreviations: WR, wide receiver; LB, linebacker; TE, tight end; CB, cornerback; DT, defensive tackle; C, center; DE, defense end; OT, offensive tackle;
QB, quarterback; T, tackle; respectively.
a
I, incomplete fracture; C, complete fracture; CN, complete, nondisplaced fracture.
Results
The most common positions played at the time of injury
were wide receiver (32%), linebacker (16%), and tight end
(16%). Player positions included 8 wide receivers, 4 linebackers, 4 tight ends, 2 defensive tackles, 2 cornerbacks, 1
center, 1 tackle, 1 quarterback, 1 defensive end, and 1 offensive tackle. Nineteen (76%) of the players underwent operative fixation during the time period between the pre-draft
NFL Scouting Combine (a week-long showcase of college
football players occurring every February) and their third
season in the league. Twelve (48%) of the players were
diagnosed before or during their rookie season.
Forty-four percent of patients had incomplete injuries
and 72% were true Jones zone 2 fractures. The average time
between injury and surgery was 8.5 days (range 2 to 35
days). The average screw length was 50 mm (range 40-60
mm). Overall RTP was 100% for all players. Eighty percent
(20 out of 25) were still playing at the end of the 2014-2015
season. Subgroup analysis of the relationships between
position played, fracture zone, refracture, and union showed
no significant differences, likely due to the small number of
patients in each subgroup. Among players who underwent
surgery between July and October and RTP during the same
season was possible, the average RTP was 8.7 weeks (range
5.9-13.6 weeks).
To date, the average number of seasons played postinjury was 2.7 (range 1-8). Two players were selected to participate in the Pro Bowl before injury and 2 different players
achieved this status postoperatively. There were 3 players
who had refractures (12%), two of which had CT confirmation of healing prior to reinjury. One occurred after more
than 2 years and another after more than 6 months. All cases
of refracture occurred in players with incomplete zone 2
fractures treated with 5.5-mm screws. All were able to
return to play after screw exchange and iliac crest bone
grafting. With regard to other complications, there were no
instances of infection, delayed wound healing, sural nerve
injury or neuritis, hardware failure, iatrogenic fracture, or
symptomatic hardware necessitating screw removal.
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Figure 1. (A) Incision marked 2 to 3 cm proximal to the base of the fifth metatarsal. (B) Ideal guide wire starting point “Inside”
(medial) and (C) “High” (dorsal).
Figure 2. (A) Intramedullary reaming with a solid 3.2-mm drill on oblique, and (B) lateral fluoroscopic views.
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Lareau et al
Figure 3. (A) Ideal screw length is assessed both clinically and (B) radiographically.
Figure 4. (A) Clinical and (B) oblique fluoroscopic views of BMA and DBM injection into and around fracture site.
Discussion
There has been ambiguity in the distinction between zone II
and III fractures, dating back to the initial description by Sir
Robert Jones in 1902 that included both fracture types.12
Because similar outcomes have been observed for these two
zones, it has been proposed that they both be referred to as
Jones fractures and treated in the same manner.3 Jones fractures are best managed in the athletic population with intramedullary screw fixation to expedite return to sport and
minimize risk of refracture.5,13,18,19 Unfortunately, nonunion
and refracture still occur in a small percentage of athletes as a
result of the repetitive stresses endured by the proximal fifth
metatarsal coupled with its tenuous blood supply. Currently,
there is limited data regarding complication rates and RTP in
professional athletes treated with modern techniques.
Our series of 25 NFL players is the largest reported series
of professional athletes with Jones fractures treated by a single
surgeon with the same technique and an accelerated rehabilitation protocol. Our data demonstrate that 100% of players
were able to return to play and 80% were most recently still in
the league. We observed a similar playing experience pre and
post-injury. This is consistent with the findings of Carreira et
al who showed no significant difference in participation following Jones fracture based on the NFL Combine database for
a single team over a 6-year period.2
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Figure 6. Clamshell orthosis used during rehabilitation to
minimize stress on the metatarsal base.
Figure 5. (A) Bridging bone across the fracture site visible on
postoperative anteroposterior (AP) and (B) lateral radiographs.
With an average return to play of less than 9 weeks, only
three patients had refracture in our series, one occurring
over 2 years postoperatively due to direct contact from
another player. These players underwent revision procedures as described by Hunt et al.11 We did not observe any
nonunions or other complications. Over half of the players
in this series were wide receivers or linebackers, highlighting the frequency of occurrence of this injury in those playing these positions. Additionally, the majority of players
had this injury during their first 3 seasons in the league and
almost half occurred during the rookie season. This underscores the importance of educating this at-risk subset of
players regarding pain that can represent impending fracture and considering preventative measures, such as clamshell orthoses and turf toe plates.
Multiple factors have been attributed to poor outcomes
after operative treatment of Jones fractures. Lee et al conducted two large series describing predictors of delayed
healing and refracture in patients treated with tension-band
wiring.15,16 In a series of 86 patients, it was demonstrated
that stress fractures with a plantar gap greater than 1 mm
take significantly longer to heal.16 Based on a series of 163
elite athletes, high BMI and radiographic protrusion of the
fifth metatarsal head have a significant association with
refracture after surgery.15 Therefore, the authors recommend that this subset of athletes should return to sport more
slowly.
There remains an ongoing debate regarding the time
until RTP and the degree of healing that is necessary. Most
believe that the fracture should be radiographically healed
prior to RTP to minimize refracture. However, despite
100% clinical and radiographic healing, Wright et al
observed 6 refractures on the day of return to full activity in
athletes treated with 4.0- and 5.0-mm cannulated intramedullary screw fixation.32 This may have been due to undersized screws and the lack of functional bracing in this
particular series. Similarly, Glasgow et al found that early
return to play was associated with delayed union and refracture in patients treated with a 4.5-mm malleolar screw, indicating that this screw diameter did not provide sufficient
support to allow healing.8 In our experience, some players
who are pain-free and able to return to play have a persistent plantar and/or lateral gap with bridging trabeculation
dorsally and medially. Breakage of 5.5- and 6.5-mm
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Lareau et al
indication-specific screws has been exceedingly rare in
patients treated at our institution because the bending rigidity of this intramedullary implant is proportional to its
radius to the 4th power. Therefore, we rely on clinical
examination and patient symptoms in addition to percentage of radiographic healing.
There exists considerable variation in screw diameter,
type, and material in different studies. We prefer stainless
steel, solid, headed, partially threaded indication-specific
large diameter (5.5 and 6.5-mm) screws for Jones fracture
fixation in athletes. Only a handful of studies provide clinical outcomes in patients treated with these modern generation implants.11,17,20 Metzl et al reported greater than 95%
union rates in patients treated with either traditional or indication-specific screws, with a higher number of adverse
events in the traditional screw group.17 Nunley et al have
performed two cadaveric studies demonstrating biomechanical superiority of an indication-specific screw over other
implants.22,24 We do not recommend cannulated screws
because of decreased fatigue strength and higher likelihood
of refracture and nonunion.27,32 Headless screws are less
likely to cause soft-tissue irritation21 but pose a challenge
when screw removal is necessary. Variable pitch screws are
inferior to partially threaded screws with respect to pull-out
strength, fracture site compression and angulation.30
At our institution, we prefer to use the largest diameter
screw that the fifth metatarsal can accommodate without
fracture malreduction or distraction. A recent radiographic
study demonstrated that the coronal diameter of the fifth
metatarsal at its isthmus is greater than 4.5 mm in 81% of
males and 74% of females.23 This confirms the need for a
5.5-mm or larger diameter screw for sufficient screw thread
purchase. The shortest length screw with all threads just distal to the fracture site is optimal. This same study recommended that screw length remain less than the straight
segment length, which is approximately 68% of the fifth
metatarsal length and averaged 52 mm.23 A screw that is too
long may abut the medial cortex as the metatarsal shaft bows
laterally, resulting in distraction and varus angulation.
Given the poor healing potential of the proximal fifth
metatarsal, adjunct treatments including autogenous bone
marrow aspirate and bone stimulation can be considered.
Clinical studies have proven the efficacy of autogenous
BMA for the treatment of nonunions.9,10 Although there is
no high-quality data to justify this added expense in the
general population, we believe that the benefits outweigh
any risk in professional athletes under tremendous pressure
to return to play as soon as possible. In our experience treating this injury, we have not observed any complications
associated with these additional measures. Promising
results have been achieved with the use of BMA and DBM
in revision procedures for Jones fracture nonunion but
future comparative studies are necessary to substantiate the
benefits of these augments.11
The limitations of this study involve those inherent to a
retrospective case series. Most studies pertaining to professional athletes are retrospective as a result of the small number of patients undergoing a specific procedure. In this
transient population, it was not always possible to obtain
radiographic images that demonstrated an exact date of fracture union because patients often followed up at other institutions. In addition, there was no control group consisting of
patients undergoing a different procedure or nonoperative
treatment. The benefit of each aspect of our treatment protocol (eg, screw type, BMA, functional bracing, and rehabilitation protocol) is not known. Lastly, no clinical outcome
measure, such as SF-36, AOFAS, Foot Function Index, or
visual analog scale, were recorded. These outcome measures
are currently a standard part of our clinical intake forms but
were not integrated during the data collection period for this
study. Formal statistical analysis was not possible based on
the small sample size and low complication rate.
This study has several strengths. First, it is the largest
study to date reporting outcomes of Jones fracture fixation
in NFL players. Second, all 25 surgeries were performed by
a single experienced surgeon based on the same treatment
algorithm, operative technique, and postoperative protocol.
Third, there were no cases of loss to follow-up. Although
clinical outcome scores were not reported, the ability of
professional athletes to return to play at their preinjury level
is indicative of a high level of function.
Although return to play data are commonly used to
assess postoperative outcomes in professional athletes,
there are a variety of factors that influence a football player’s ability to return to play. These include the occurrence of
other injuries at a separate point in time (eg, knee injury
when attempting to return to play after Jones fracture), position played, the point in a player’s career when the injury
occurs (rookie vs 11th season), the amount of playing time
received prior to injury, whether it occurred during free
agency or a contract year, etc. Our time until return to play
data is limited based on the fact that only a small subset of
players underwent surgery immediately before or during
the season. For the majority of players, surgery was performed early in the offseason. As a result, the time until
return to play in a regular season NFL game was 5 to 8
months, far longer than when the player was cleared to
return to full activity in practice and preseason games.
Conclusion
Professional American football players who undergo fixation of a Jones fracture using modern generation implants
with BMA/DBM coupled with bone stimulators, an aggressive rehabilitation protocol and custom orthoses experienced a high rate of return to play and a low rate of
refracture. This injury occurred more commonly in wide
receivers, linebackers, and tight ends within their first 3
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Foot & Ankle International 
seasons, particularly the rookie season, highlighting the
potential need for injury prevention measures in this subset
of players. Our experience suggests that physical examination and ability to return to play are as important as degree
of radiographic healing. Future prospective studies including validated clinical outcome measures are necessary to
draw more definitive conclusions.
Authors’ Note
No part of this study has been submitted or duplicated elsewhere
prior. This study has been read and approved by all authors and each
author believes that the manuscript is valid and represents honest
work.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Robert B. Anderson, MD, reports Wright Medical
Technology, Inc: paid consultant for a company or supplier, royalties from a company or supplier.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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