There is an elephant in the room, and some football evangelists are willing to back right up to it as long as they don’t have to acknowledge it. There are even staunch defenders of the game who want to ride that elephant all the way over the cliff.
Before anyone decides this article is yet another panicked and cherry-picking attack on football, you should know that simply isn’t the case. I played football from junior high into college, have coached at the high school level, and supported a staff for a Division I Power-5 football team. For the past 13 years, I have worked for athletes and teams of this sport as my central focus and chief passion. While I have participated in other sports—outdoor soccer, indoor soccer, basketball, hockey, and track and field—football is by far my favorite and has made the greatest impact on my life. It’s a terrific team sport that is in a dire position.
Football is dying, and there are proud football evangelists tightening the noose on their own sport.
While high school sports participation is now at an all-time high and showing continued, steady growth, football participation is shrinking. Football still led the pack of all high school sports in the 2016-2017 school year, but has lost some 25,503 participants since 2015-2016. The numbers show that schools are not dropping football programs; students are simply electing to participate in other sports. For schools that offer 11-man football, this decrease means that about two kids per school are electing not to come back out for football. These aren’t drastic decreases, but with the current issues surrounding the sport, it begs the question: What is driving students away from the game, and what can we do to stop it?
The Elephant in the Room…
Player safety in football has been a hot topic for the past several years. All levels of football have implemented rule changes to try to make the game safer. Thanks to the high-profile nature of the NFL, these changes have been publicized and widely debated. Since 2011, the NFL has instituted 22 rule changes aimed specifically at enhancing player safety. Also during that period, the NFL announced a donation of $30 million to the National Institute of Health (NIH) to research “serious medical conditions prominent in athletes.” The press release from the NIH in September 2012 listed the first medical condition they would investigate: chronic traumatic encephalopathy (CTE).
CTE is a degenerative brain disease found in patients with a history of repetitive brain trauma. While military veterans have it, it is prominent in those who compete or have competed in athletics as well, and football appears at the top of this list. Thanks to the 2015 film, “Concussion,” starring Will Smith, the connection between football, concussions, and CTE has become a hot topic of discussion. This article will not focus on the controversy surrounding suppression of facts, money influencing research, or other back-door dealings and mischief. There is a central issue to discuss: Concussions in American football are indeed a problem and we, as members of the football and sport community, must do a better job representing our game and field.
CTE Findings: Facts, Fiction, and Fallout
There have been recent research findings showing a high prevalence of CTE among former football players of all levels. The survey findings, published in 2017, showed that 177 of 202 former players who had recently passed away and donated their brains for research had a CTE diagnosis. Of this sample, 111 players competed in the NFL, and 110 of them had received a CTE diagnosis. Those who played past the high school level were also diagnosed at a higher prevalence: college (48 of 53 had CTE), semi-professional (9 of 14 had CTE), and Canadian Football League (7 of 8 had CTE). The summary of findings was that CTE may correlate to prior participation in football.
Is it nail-in-the-coffin evidence? Not exactly. Objectively speaking, this study used a convenience sample. This means that researchers only examined the brains of men of an older age who agreed to participate in this study upon their death. Additionally, these older men may have had more confounding factors contributing to their CTE diagnosis, such as military service and other head injuries not related to football. While this study isn’t permanent proof, it certainly isn’t flattering for football. It also highlights the importance of understanding how the media presents research findings.
In an article appearing on FootballScoop, a popular site for football coaches to get insight on coaching changes and all-around football talk, content manager Doug Samuels proclaimed that a recent study proved that “playing HS football is just as safe as band, glee club, or choir.” In fact, this was the headline he chose when describing the findings of a study assessing the risk of developing neurodegeneration from playing high school football. Pro-football evangelists shared the headline and subsequent article from Mr. Samuels on Twitter and social media hundreds of times. But what did the study actually find?
The study examined medical records from a group of men from one town, in one county, in one state, who played high school football between 1946 and 1956. See where there might already be some issues in making an inference from football in small town America at the dawn of the Cold War to football played around the country in 2017? This comparison is like making a statement that driving in the front seat of a 1956 Chevy on a back-country gravel road without a seatbelt is no different than racing down the freeway during rush hour in a 2017 Camaro without a seatbelt while on your cell phone. It seriously lacks validity to make any inference from this study and apply it to football in 2017 and beyond. In fact, the very authors of the study urge caution in making any inference from this study in the complete study’s conclusion:
“These data should be interpreted in light of the many differences between today’s high school football players and those of the distant past. Although today’s players have better equipment, trainers and physicians who are more knowledgeable about concussions, and rules against spearing, they also tend to be larger and quicker than athletes in the prior era, increasing the force of impact. Moreover, although dramatically different from the marginally protective headgear of this earlier era, current helmets certainly do not eliminate concussions and may provide players with a false sense of protection. Although these results should be somewhat reassuring to high school players from 50 years ago, they should give no reassurance to today’s players.”
Pro-football evangelists who want to refute any science suggesting that the current way athletes play football may be dangerous conveniently ignore this section of the study, as well as the concept that football may be unnecessarily unsafe at times. Yet, at the same time, there are those from this same population willing to cherry-pick arguments despite the prevalence of evidence.When we cherry-pick arguments, it confuses athletes and their perception of safety in the game, says @MdHCSCS. Click To Tweet
Whether the research findings are more favorable to one side of the argument or another, there is an unknown fallout from cherry-picking arguments and click-baiting headlines. This discussion both directly and indirectly influences athletes and their perception of safety within the game. Within the last five years, I’ve witnessed firsthand the interaction of high school, collegiate, and professional football players and talk surrounding player safety, concussions, and CTE. There are high school students who legitimately believe that any head-to-head contact, at any speed or force, will result in a concussion. Teenagers are self-diagnosing themselves with concussions, and are genuinely afraid of returning to play following their self-assessment.
I’ve also witnessed players at the college level take pride in the deliberate destruction of their helmet in practice. Imagine a helmet that has incurred so many head-to-head collisions on its crown that it cracks within an eight-month span covering spring football, fall camp, and the first several weeks of the season. These players were of a high caliber at their position, and were adamant that concussions were only for the weak and timid.
Failure on the Front Line?
There is good news for the sport, as governing agencies within youth and high school football have adopted modernized techniques for blocking and tackling. USA Football’s campaign for Heads Up Football prioritizes a new approach to positioning the athlete to execute contact in the game or practice while almost completely removing the head from the trajectory of contact. Traditional cues for tackling specifically use the head, helmet, and face mask as a reference when blocking and tackling.
The old mindset was that the player needed to secure the tackle first and foremost, and protecting the neck was a secondary benefit from this technique. The modernized Heads Up protocol, as used by the NFL’s Seattle Seahawks, emphasizes local positioning, leverage, and body contact similar to techniques used in rugby and Australian Rules Football. The theory behind the methodology is that taking the head out of the play will lead to reduced exposure to head impacts and thus, fewer concussions.
Many state high school organizations now mandate that football coaches must be Heads Up certified in order to coach. This process must occur in the weeks leading up to the pre-season camp period, and done in partnership with the National Federation of State High School Associations (NFHS). The NFHS also offers continuing education and certification on athlete safety, health, coaching, and administration.
Has the Heads Up program been effective in reducing injuries and concussion? Preliminary findings showed that the program was making great strides forward, but a more in-depth review showed that the overall rate of concussions in youth and high school football has not significantly changed. Does this mean football is doomed, regardless of the techniques? The issue at hand here more likely has to do with the fact that certification in Heads Up techniques does not necessarily result in strict enforcement of these traits.
As football coaches, we are responsible for the health and safety of our athletes, regardless of our own preconceived beliefs or opinions. In the past several years, I have witnessed firsthand tackling drills from peewee leagues up through the college level around the country. Not all coaches with certification requirements are universally accepting or enforcing the progressive techniques of Heads Up football. Instead, they continue to utilize more traditional tackling and blocking techniques that explicitly involve the helmet and face mask as a landmark reference. Coaches still heavily use cues like “get your eyes to the football” or “put your helmet in his chest,” even at the youngest levels of the game.As football coaches, we are responsible for our athletes’ safety, regardless of our own opinions, says @MdHCSCS. Click To Tweet
The issue here is clear: There are some football coaches failing their players and the sport as a whole, with their deliberate rejection of player safety and insistence that safety equates to weakness. This is the same type of coach who once believed that taking water breaks during practice made you weak, or that face masks, gloves, and forearm pads meant you were a lesser player who lacked toughness. These coaches are not in the majority, but enough of them exist and employ their beliefs to make them a threat to the longevity of football.
How Technology Transforms Player Safety
Along with improvements to the techniques of blocking and tackling, there are also advancements to the equipment that players use. Many helmet manufacturers have changed their designs in the past decade to produce lighter helmets that improve safety. One helmet company, VICIS of Seattle, Washington, has taken the traditional physics of football helmet design and turned it upside down, almost literally. VICIS reports that their ZERO1’s RFLXTM layer is a “sophisticated construction of columns that bend and flex in response to linear and rotational impacts.”
They designed the ZERO1 ARCHTM shell of the helmet to spread out forces from contact to the head over a broad area to help reduce the risk of injury to the head. This is similar in concept to the old junior-high science experiment of dropping an egg from a rooftop in a cushioned box: The central idea here is to distribute impact forces and absorb them more optimally. The traditional hard-shell design of helmets can act in the opposite way, localizing forces to the area of contact.
While VICIS offers a new generation of helmets, there are also independent studies on individual helmet model safety levels available for reference when buying helmets. Additionally, the NFL-backed Play Smart Play Safe initiative offers further resources for parents, athletes, and coaches on the safety rating of helmets available for purchase.A helmet must fit properly as more movement of the helmet leads to a greater risk of #concussion, says @MdHCSCS. Click To Tweet
Improvements in helmet technology go hand in hand with progress being made on the front lines of football: properly fitting equipment. The most advanced helmet technology’s limiting factor is undoubtedly how coaches, athletes, and parents ensure the proper fitting assignment of each helmet. While USA Football offers a guideline on how the helmet should fit, there is still a great margin for error due to the simple fact that not all heads have the exact same proportions. What is the danger of a helmet not fitting properly? It is simple: More movement of the helmet leads to a greater risk of concussion.
Existing fitting procedures involve taking one manual measurement of the circumference of the head just above the eyebrow and adjusting the padding and chinstrap accordingly to meet subjective fit and feel markers. This procedure is quick and manageable, and a realistic task for almost every coach to accommodate. The problem is that it neglects the fact that human skulls are three-dimensional entities where specific length, width, and height measurements can vary just enough to make a significant difference in fit and feel. Beyond fit and feel, there are safety implications, as recent research highlighted an increased risk of concussion severity due to poorly fitting helmets. As it turns out, fitting helmets should focus more on the shape of the head rather than simply fitting within an acceptable range of the one circumference measurement taken.
Three-dimensional modeling is a potential solution to maximizing helmet fit. Imaging procedures, such as the methodology developed by Falcon Pursuit of Portland, Oregon, take only a few seconds and provide a hyper-accurate 3-D map of the athlete’s head with millimeter precision. Finding the exact dimensions of the athlete’s head is critical information for the equipment manager or coach trying to find the best fit for the athlete. This also applies to the equipment manufacturers who want better insight into designing size ranges for various levels and positions of football players. While coaches must continue to work on blocking and tackling technique to help further protect athletes, providing them with better-fitting and more advanced helmet technology is also a step in the right direction.
Beyond helmet technology, there are companies such as Q30 Innovations taking the conversation around concussion prevention by the neck…literally. Their technology, called the Q-Collar, focuses on mildly increasing blood volume in the brains of athletes with an apparatus worn around the back of the neck. Initial research into the effectiveness of this method is promising, as exploratory research shows a potential positive effect of reducing brain slosh from contact sports resulting from the use of this neck-collar technology.
Further analysis also shows the technology potentially reduces white matter diffusion alteration when wearing this type of neck-collar technology during football. While initial research investigation shows potential for helping reduce the risk of brain injury, further research should continue to help the football community understand the size of the potential benefit, as well as identify any potential limitations in the application of the technology.
Detection as the Best Defense
With concussions still present in the sport, the assessment, diagnosis, and subsequent treatment have all greatly improved in recent years. According to the American Academy of Pediatrics, high school athletic programs that have a certified athletic trainer present incur fewer overall injuries. Additionally, these schools tend to be able to diagnose more concussions than schools that lack an athletic trainer. The reasoning centers on the fact that athletic trainers have much more training to detect and diagnose concussions. This highlights a critical element of the issue of concussions in football: the need for objective assessment of the incidence of head trauma by knowledgeable, certified individuals.Football needs an objective assessment of head trauma incidence by knowledgeable certified trainers, says @MdHCSCS. Click To Tweet
While football coaches are obliged to make a good-faith effort in the detection of concussion-like symptoms in their athletes, they are limited by the scope of their training and assessment, and lack of diagnosis capability. In some instances, football coaches face a real conflict of interest when it comes to concussion-like symptom identification, as any detection of these symptoms would necessitate the athlete’s removal from activities for further assessment. Some coaches see this as holding out their best players merely on the chance they have a concussion.
In recognition of the need at the high school level, Providence Sports Medicine, a branch of the regional Providence Health & Services hospital network, is teaming up with high schools across the Northwest. They help place certified athletic trainers at the schools, and the trainers are available for practices and home games, and many away games as well. One of the many services these athletic trainers offer is the ImPACT® concussion management protocol, as part of the Providence Primary Care Concussion Treatment Pathway. This pathway consists of a battery of tests that better assess brain function beyond simple memory and recognition exercises. Balance, memory, eye function, neuromuscular function, musculoskeletal symptoms, and the ImPACT® protocol are all part of their assessment process.
In addition to better detection of concussion-like symptoms, the pathway developed by Providence Sports Medicine helps give athletes access to more complete treatment options depending upon the severity of the injury. Rather than simply improving their ability to detect head trauma, Providence Sports Medicine can offer athletes more specific rehabilitation and treatment options based upon the type of concussion symptoms displayed. Beginning with a physician’s thorough evaluation, these symptom-based treatment recommendations are designed to meet the specific needs of the patient, rather than subject them to a “cookie-cutter” approach to rehab.
As soon as the physician finds the athlete is asymptomatic, the athletic trainer assists them in a modernized approach to return-to-activity protocols. More recent findings, as documented in the Berlin Consensus of 2017, show that there is insufficient evidence to continue complete rest in the days and weeks following a suspected concussion. After an initial rest period in the acute stage of the suspected injury (the first 24-48 hours), the latest evidence suggests that:
“…patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds (ie, activity level should not bring on or worsen their symptoms). It is reasonable for athletes to avoid vigorous exertion while they are recovering. The exact amount and duration of rest is not yet well defined in the literature and requires further study.”
What is the aim of the pathway from Providence Sports Medicine? It is to identify more specific treatment pathways that match patient symptoms, identify those at risk who display lingering symptoms, improve the rehabilitation process for patients who become asymptomatic, and maximize the return-to-play process. This coordinated, individualized approach can help athletes who are ready to return to sport do so safely. The role of the ATC working with a well-designed medical team is critical to the success of the program and reduces the liability for the coaching staff.
Saving Football’s Future: Look Within the Sport
Early in this piece, I stated that this article is not an attack on football, but rather a call to action for helping preserve the game. As I mentioned, I played football from junior high through college, and have spent most of my professional career working within the sport. I, too, experienced diagnosed concussions, and like many players I also wonder how many concussions I experienced that went undiagnosed. But, like many things, as time passes we learn more and should focus our efforts on maximizing player safety by any means possible.
The sport itself is a terrific vessel for teaching life lessons, perhaps unlike any other sport. The issues hotly debated by the media have shown an uglier side of the game in the form of the willingly ignorant football evangelists refuting science, facts, and common sense. This is the worst approach imaginable to helping the game of football survive into the 21st century.
We should call out the portion of football coaches and fans who refute the facts and research surrounding head injuries to the point of bullying athletes, fellow coaches, and media outlets.We need to call out the football coaches and fans who refute the facts surrounding head injuries, says @MdHCSCS. Click To Tweet
These willfully ignorant bullies will destroy the game by disrespecting the very real and rational fears of past, present, and future players, their families, and the fans who express concerns over the status quo of football. Concussions, CTE, and head trauma have nothing to do with lacking “mental toughness,” not being disciplined, or being a “wimp.” As coaches of the game, we must grow a spine and halt these types of behaviors among our fellow coaches, athletes, and fans.
This past fall, I had the privilege of returning to the sidelines of my alma mater to coach defensive backs for Head Coach Aaron Hazel of La Salle Prep. Coach Hazel has seen the game change in his nearly 20 years of playing and coaching, including many positive steps in tackling and blocking techniques. “Since I took over the program four years ago, we’ve completely done away with live tackling at practice. That being said, we work on tackling every day by focusing on technique, angles, and leverage over the old mantra of ‘whatever it takes.’ We have found over this time utilizing the techniques taught through USA Football that our tackling has improved significantly now that our kids have a plan for almost every scenario they will see.”
The issue at hand is not that the tactics of football and the game are dangerous, but rather that different schools don’t uniformly enforce more progressive and safer techniques. In his years of experience with football at the high school and college level across the Pacific Northwest and West Coast, Coach Hazel has seen positive signs from many areas. “Talking with coaches in our region, most programs are implementing these techniques. Some are not going to the non-tackling depths that we are, but everyone I communicate with understands that we owe it to the game to continually adapt.”
The idea of adapting is not lost on football coaches either, but there are some coaches from the “old school” that just want to hold onto the game of football that they know. As Coach Hazel points out, “It is cyclical. Thirty years ago, everyone was running the wing-t, 20 years ago everyone was running the wishbone, 10 years ago everyone was single-back and nobody was running the wing-t. Now the wing-t is growing again; we played three wing-t teams this fall! In the late ‘90s when I played, all the talk was on neck injuries, now the focus is on head injuries. What we have to look forward to is that we made a lot of changes in how the game was taught and what rules needed to be added to reduce the risk of neck injuries. We are now doing the same for head injuries, and it is only going to make our game safer and better.”
La Salle Prep is also one of schools working with an athletic trainer from Providence Sports Medicine. While this service has greatly helped the school, Coach Hazel sees hope for even more progress with player safety, equipment, and the future of football. “Right now, the best equipment is extremely expensive and is not financially feasible for a lot of schools. We are very fortunate to have a handful of kids purchase their own top of the line helmets, reducing our costs, but other places are not as lucky. I would love to see the NFL subsidize the cost of top-end equipment so that youth and high school programs have the ability to put every kid in the best gear.”
A To-Do List for Every Football Program in America
Instead of simply crying wolf, there needs to be action taken to help preserve the game across all levels. These are first steps I believe each football coach and program should seriously consider in the coming offseason:
Implement and Enforce Better Blocking and Tackling Techniques
The Heads Up football initiative is a terrific first step to help limit unnecessary head contact from blocking and tackling, but certification should become mandatory and oversight on tackling and blocking techniques should come from state high school associations. Additionally, state referee and official associations can offer feedback to high school associations, leagues, and individual teams regarding the quality of their tackling and blocking techniques, and whether they are within the rules. If there are teams incurring more illegal helmet-to-helmet hits or blindside blocks, this system would help hold coaches accountable for implementing safer techniques. Sharing game film of these incidences in widely used video systems such as Hudl will improve transparency in the detection and assessment of poor tackling and blocking techniques.
Invest in and Research Equipment Technology
There are companies such as Falcon Pursuit, VICIS, and Q30 Innovations willing to produce cutting-edge technology when it comes to equipment and apparel in sport. The NFL, NCAA, and any entity that profits from the sport of football would be wise to invest in companies that can help preserve the longevity of football in an ethical, optimal, and sustainable manner. This has nothing to do with spending money to prevent the publication of research, or paying entities to skew or withhold information. Instead, this has everything to do with pursuing innovation and advancements in equipment and player safety.
The potential is there, as fine-tuning the helmet to best fit the shape of each athlete’s head, improving the materials of the helmet, and utilizing supplemental equipment like the Q-collar all show great promise in reducing the risk of severe head trauma. None of these will happen without continued investment and research in these areas. Implementing gear-exchange programs funded by the NFL and their major sponsors for youth, high school, and under-funded teams will help expand access to better equipment.
Embrace the Medical Community and Work Alongside Them
This is going to be tough for some coaches to hear, but unless you are a medical doctor or a certified and licensed sports medicine practitioner, you are not qualified to diagnose and treat concussions or other injuries. Having certified athletic trainers present for both practices and competitions will help ensure that knowledgeable and certified individuals deal with any potential injuries—particularly head injuries. Having your starting running back, stud linebacker, or all-conference quarterback take a few minutes to make sure they are not putting themselves, or their teammates, in danger by playing with a head injury is a worthy investment of time. He won’t suffer from missing five minutes of everyday cone drills!This is an opportunity for the broader football community to preserve our sport for the future, says @MdHCSCS. Click To Tweet
Initiatives such as those from Providence Sports Medicine are growing in popularity, and should be taken up in conjunction with state athletic associations for youth and high school sports. Additionally, state athletic associations must increase educational opportunities for coaches by supplying specific guides for athlete health, wellness, safety, and performance. They can do this online, or in quarterly, regional seminars.
The Time Is Now
While not every team can accomplish all the elements to help improve player safety, the overall football community needs to step up and realize this is our opportunity to preserve our sport for the future. Doing nothing, protecting the status quo of football under the guise of being “tough,” and speaking out against player safety because of your fear of watering down the sport are all irresponsible and cowardly. If we want football to survive, the time to act is now.
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