A new study published by the CDC on January 6, 2017, reported that from 2005 through 2014, a total of 28 traumatic brain and spinal cord injury deaths in high school and college football were identified. The most common playing positions of those fatally injured were running back and linebacker. Approximately 18% of identified high school brain injury deaths were preceded by an earlier concussion, which might have led to second impact syndrome.
An estimated 1.1 million high school and 75,000 college athletes participate in tackle football annually in the United States. Football is a collision sport; traumatic injuries are frequent and can be fatal. This report updated the incidence and characteristics of deaths caused by traumatic brain injury and spinal cord injury in high school and college football and presented illustrative case descriptions. Information was analyzed from the National Center for Catastrophic Sport Injury Research (NCCSIR).
From 2005 through 2014, 2.8 deaths per year from traumatic brain and spinal cord injuries occurred among high school (24 deaths) and college football players (four deaths) combined. Most deaths occurred during competitions and resulted from tackling or being tackled. All four of the college deaths and 14 (58%) of the 24 high school deaths occurred during the last 5 years (2010–2014) of the 10-year study period.
Among the 24 high school fatalities, 22 (92%) involved head/brain injuries. All four college fatalities involved a brain injury. Subdural hematoma was the most common diagnosis for both high school and college fatalities (46% overall). Four (18%) of the 22 high school players who died from brain injuries had sustained a concussion within 4 weeks of the event, and second impact syndrome (in which a second concussion occurs before a first concussion has properly healed, causing rapid and severe brain swelling) was implicated in three of these four events.
Among the 24 high school fatalities, 20 (83%) occurred during a regular season game; 17 (71%) involved tackling or being tackled. Among the four college fatalities, two occurred during a regular season game, and two occurred during spring football. The most common player positions among those fatally injured were running back (32% of players overall) and linebacker (21%). Of the 28 deaths, head first/head down contact was identified in eight deaths.
The average number of high school deaths per year was 2.4 (standard deviation [SD] = 2.2) and ranged from zero to seven deaths annually. The average number of deaths among college players per year was 0.4 (SD = 0.7) and ranged from zero to two deaths annually. For 2 years (2007 and 2012) of the 10-year study period, no traumatic brain or spinal cord injury deaths were reported among either high school or college football players. Fatality rates over the study period were 5.96 fatalities per 1 million college football players (95% confidence interval [CI] = 0.12–11.81) and 2.18 fatalities per 1 million high school football players (CI = 1.31–3.06) (Figure).
The finding of an annual average of 2.8 brain and spinal cord injury deaths for high school and college football combined is consistent with a previous report of 3.1 brain injury fatalities annually between 1990 and 2010. Also consistent with previous studies, most brain and spinal cord injury deaths occurred during competition, among players at running back and linebacker positions, and as a result of tackling or being tackled.
The finding that 18% of high school players with fatal traumatic brain injuries had a concussion less than 4 weeks earlier is consistent with a previous study that found 16% of football players who died from traumatic brain injuries over a 20-year period had a previous concussion within 30 days of death. This finding supports the importance of recognition, reporting, management, and adherence to recommended return-to-play protocols after a concussion. All 50 states and the District of Columbia currently have concussion education and safety laws in place that include appropriate medical evaluation by a trained medical professional, no same-day return to play, and return to play only after medical clearance. All laws include education for various stakeholders about concussion symptoms and management. However, for the laws to be effective, athletes must report their concussion symptoms, and medical professionals must be able to accurately assess symptom resolution and full recovery from the concussion before allowing an athlete to resume contact. The implementation and impact of these laws are an important area for future inquiry.
Head first/head down contact was identified as contributing to eight of the 28 deaths. This emphasizes the importance of instruction in proper tackling techniques (both delivery and receipt of tackles) for all players, but particularly for running backs, linebackers, and defensive backs. A previous evaluation of football tackling programs among youth league football players indicated a reduction in concussions in practice and games when education of coaches was combined with practice contact restrictions, providing evidence that these programs might have a positive impact on reducing nonfatal head injuries among youth league players. However, it is unclear whether older players who learned high risk methods can be retrained in new techniques. Football is a collision sport played at high velocity, and players must act and react quickly. In such situations, new techniques might be difficult to deploy, resulting in players possibly reverting to past behaviors and reactions unless coaches routinely intervene to correct their technique.
The cases described in this report illustrate the importance of emergency preparedness, recognition, and access to medical services. All schools should have written emergency action plans specific to their school and venue that are rehearsed annually by coaches and staff. The availability of medical professionals onsite who are trained to recognize and act in emergency situations is critical in catastrophic football injury events. Many schools employ certified athletic trainers, and for competitions, have emergency medical services onsite. However, nationally, 30% of public high schools do not have access to an athletic trainer, and 50% do not have athletic trainers present at practices. One of the deaths in this report occurred during a junior varsity football scrimmage when emergency medical services were not onsite and arrival of emergency medical services took 15 minutes because of traffic. Current best practices include access to athletic trainers for practices and competition and maintaining emergency medical services onsite during competitions.
NCCSIR has been conducting catastrophic injury surveillance at the national level for high school and collegiate football since 1965 and for all sports since 1982. Deaths were identified through ongoing and systematic monitoring of public media sources (e.g., online search engines and news search engines) and individual reports from national and state-level organizations, clinicians, school authorities, and researchers. Once a death was identified, NCCSIR researchers contacted family members or school staff members to gather additional details. When possible, NCCSIR obtained medical examiner reports. Information was collected about the athlete’s age and level of play; player position and activity; and injury type, medical care, and cause of death.
The events included in this study were defined as fatal traumatic brain and spinal cord injuries that occurred during a scheduled team activity (game, practice, or conditioning session) and were directly related to football-specific activities (e.g., tackling or being tackled). Each fatality report was manually reviewed for inclusion and classification. Fatality rates per 1 million players were calculated using National Federation of State High School Associations and National Collegiate Athletic Association participation statistics as the denominators. The causes and potential strategies to prevent these injuries were described in association with the 10 Haddon energy damage countermeasures.
The findings in this report are subject to at least four limitations. First, most events were captured through publicly available media sources, and it is possible that some football deaths were missed. Second, football participation numbers are representative of National Federation of State High School Associations and National Collegiate Athletic Association-affiliated schools and likely underestimate the actual number of football participants. Third, whenever possible, medical diagnoses and medical examiner report causes of death were used, however, the exact diagnosis was unknown for seven of the traumatic brain injury deaths. Information availability might be hampered by the sensitivity surrounding a fatal event, potential litigation, and inability to talk with persons involved. Finally, public interest and media attention about sport-related deaths and traumatic brain injuries increased during the study period, and it is unknown how this might have affected the identification of fatal injuries over time.
These findings support continued surveillance and safety efforts to ensure proper tackling techniques, emergency planning, and medical care, particularly during competition, and adherence to protocols for safe return-to-play after a concussion. These measures will also reduce the risk for concussion and improve treatment and management after a concussion is sustained. The CDC provides emergency action plan templates and guidance and information about concussions through the CDC HEADS UP program. Information on state laws related to concussions is available. Catastrophic sport injuries can be reported to the National Center for Catastrophic Sport Injury Research.
See also the CDC Report
See also Medical Law Perspectives, May 2012 Report: Repeat Brain Trauma That Is More Than a Bump on the Head: Multiple Concussion Injury and Second Impact Syndrome