Without a doubt, football remains the national pastime of the U.S. football is a contact sport. In combat sports such as boxing, where the goal is to win by causing a knockout (e.g. a concussive head injury), in football, helmet-to-helmet and helmet-to-turf contacts are not intentional. Yet, due to the nature of the sport, head impact exposures (HIEs) leading to concussions and at times a more severe grade of traumatic brain injuries (TBIs) unfortunately do occur. Traumatic subdural hematoma is a well-recognized cause of mortality in combat and contact sports.
Separate from acute neurological injuries reported in the game, the burden of chronic neurological injuries — such as chronic post-concussion symptoms, post-traumatic Parkinsonism, post-traumatic cognitive deficits, changes in mood and behavior, and chronic traumatic encephalopathy (CTE) — are gaining increased attention from the sports medicine community. The burden is likely higher than known as it remains hidden for years or even decades — it comes to attention long after the player has stopped playing, typically when they are in their late 40s or 50s.
But what about when these chronic injuries begin in childhood? Given football’s popularity, youth are often exposed to the game at an early age. In America, the age at which children start playing football varies. In high school, tackle football is the norm and kids may start playing around age 14-15. However, some middle schools offer tackle football too. Others stick to flag football.
High school football remains exceedingly competitive. Getting dinged is common. Unfortunately, there have been a number of fatalities reported recently among youth and high school football players, which has raised renewed concern about the health hazards of concussive head injuries on the pediatric brain. Age susceptibility to concussive head injuries is well recognized: young (pediatric) brains are more susceptible to the adverse effects of HIEs as compared to adult brains.
While contact sports such as football cannot be made completely safe, they can be made safer — especially for the youth. This goal will require collective effort on the part of all concerned parties.
While an outright ban on youth tackle football is neither a practical nor viable solution, I believe it would be prudent for every school or youth football program to consider and implement the following where any or all of these rules are not already in place:
Tackle football should be restricted by age: Children should play flag football until at least age 14-15.
It makes no sense to get dinged in practice: All youth football and high school practice sessions should be restricted to flag football. As the athlete matures both in age and football skills, tackle football should be introduced with emphasis on learning the correct techniques to defend oneself from an accidental hit.
Adequate medical supervision: The NFL has instituted strict concussion protocols. These include the presence of the team physician and athletic trainers on the sidelines. The athletic trainers undergo formal concussion recognition and management training. In addition, at every game, there are at least three unaffiliated neurotrauma consultants (UNC). These UNCs are either neurologists, neurosurgeons, or emergency medicine physicians highly skilled in concussion recognition and management.
There is one UNC stationed at the 25-yard line of both the home and visitor sides. The third UNC is stationed up in the booth alongside the athletic trainer spotter (ATC). An ATC spotter is a certified athletic trainer who monitors the game closely to identify injuries and communicates the same with the referee or medical staff. While this level of medical supervision may not be logistically feasible at every youth and high school football game, all games should have, at minimum, one physician on the sideline.
It should be mandatory for all coaches to be certified in concussion recognition and management. In addition, every game should always have at least one ambulance present along with emergency medical service (EMS) personnel. Minimum equipment that should be available on the sidelines includes a backboard, cervical collar, splints, oxygen, endotracheal intubation equipment, and an automatic external defibrillator.
Protective headgear: It should be mandatory for all players to wear a superior quality certified helmet along with a well-fitting mouthpiece. The use of Guardian Caps should be encouraged.
Stringent enforcement of concussion protocols after HIE: After a player suffers a HIE and displays concussion symptoms and signs — such as headache, subjective feeling of dizziness, light sensitivity, sound sensitivity, confusion, or gross motor instability — he should be immediately pulled out of the game and be administered a concussion evaluation either on the sideline or in the locker room. A concussed athlete should enter the concussion protocol. While the player is undergoing the concussion “return to play” protocol, he should remain under the close observation of the athletic trainers and coaches. He should be evaluated by a neurologist or a sports medicine physician skilled in concussion recognition and management before clearance to return to the game.
Education remains key: All concerned parties should be educated about concussion recognition and management. This includes the young players, coaches, athletic trainers, and parents.
Culture shift: The culture of youth and high school football needs to change from one of “you shake it off and continue to play” to one of, “if you feel something, say something and sit it out.”
Monitoring: There should be more stringent monitoring of brain health of these young athletes. Serial neuroimaging and neurocognitive evaluations can help achieve this. If any worrisome changes are seen on neuroimaging or a decline in neurocognitive scores, the player should be counseled to stop playing.
Rule changes: Changing the rules of the game to avoid dangerous tackles should be considered. This would require involvement of all concerned parties including the sport governing bodies.
Making youth football safer requires a collective effort of all concerned parties. In no sport should an athlete die — particularly not kids and especially not regularly. Football should be no different.
Nitin K Sethi, MD, MBBS, is an associate professor of neurology at New York-Presbyterian Hospital/Weill Cornell Medical Center. He now serves as voluntary faculty.
Disclosures
Sethi serves as the chief medical officer of the New York State Athletic Commission. Sethi has, in the past, served as an NFL unaffiliated neurotrauma consultant and independent neurotrauma consultant. The views expressed by the author are his own and do not necessarily reflect the views of the institutions and organizations that the author serves.
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