General Principles
Overview
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Approximately 1.5 million athletes participate in American football in the United States.
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It has been competitively played at the college level for over 100 years. The “flying wedge” was a V -shaped formation used by Harvard in a game against Yale in 1892 and was thought to be associated with significant brutality and injuries; therefore, it was banned in 1894. Concerns regarding the safety issues of “flying wedge” led to the formation of the National Collegiate Athletic Association (NCAA).
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A total of 725 schools sponsor varsity college football, representing approximately 70,000 student-athletes playing college football.
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American football involves discontinuous sprint activity and requires strength; sport-specific skills vary depending on the position played.
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Various schemes and options are used to advance the team’s objective: moving the ball down the field. There are four “downs” per possession, each with the goal of moving the ball forward by 10 yards, at which point four additional possessions are acquired. Teams score either by touchdown (6 points) or by kicking a field goal (3 points). Following a touchdown, the scoring team has the option of kicking for 1 point or attempting a play for 2 points. The team with the most points at the end of the game wins. Different rules regarding length of game, overtime, out of bounds, and possession are based on the level of play (high school, college, and professional).
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Football is a high-velocity contact/collision sport with an increased risk of injury. Physician coverage for games is optimal and often required, depending on the level played and the league and/or state regulations.
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Various medical as well as musculoskeletal issues must be considered in treating football players at all competitive levels.
Injury Statistics
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At the college level, in a report reviewing sport-related injuries from 2009 to 2010 through 2013–2014, men’s football accounted for the largest annual estimated number of injuries (47.2), the highest competition injury rate (30.0 per 1000 athlete-exposures [AEs]), and the third highest overall injury rate (9.2 per 1000 AEs) ( Table 66.1 ). Football also accounts for the largest percentage of AEs, with 14.6% of all AEs and 31.2% of all male AEs. Football accounts for the largest proportion of injuries requiring >1 week before full participation (26.2%), surgery (40%), and emergency transport (31.9%).
TABLE 66.1
INJURY RATES (PER 1000 ATHLETIC EXPOSURES)
Sport
Practice
Game
Football
5.8
39.9
Wrestling
9.0
38.5
Men’s Ice Hockey
3.2
26.3
Men’s Soccer
5.2
17.9
Women’s Soccer
5.3
17.2
Men’s Basketball
5.8
15.0
Men’s Lacrosse
4.9
13.7
Women’s Gymnastics
2.9
13.2
Women’s Ice Hockey
3.2
11.2
Women’s Field Hockey
5.1
10.5
Women’s Basketball
4.9
10.4
Men’s Tennis
2.9
10.0
Women’s Lacrosse
4.2
9.7
Women’s Cross Country
3.4
7.7
Women’s Tennis
3.1
7.6
Men’s Baseball
3.0
6.8
Men’s Indoor Track
3.1
6.5
Women’s Softball
3.5
5.9
Women’s Volleyball
5.6
5.9
Men’s Outdoor Track
2.3
5.4
Men’s Cross Country
3.2
5.2
Women’s Outdoor Track
2.7
5.1
Women’s Indoor Track
3.8
4.4
Men’s Swimming and Diving
2.1
2.0
Women’s Swimming and Diving
2.1
1.9
Modified from NCAA Handbook 2014-2015. National Collegiate Athletics Association. 25 th ed. Indianapolis, IN: August 2014; Kerr ZY, Marshall SW, Dompier TP, Corlette J, Klossner DA, Gilchrist J. College Sports-Related Injuries–United States, 2009-2010 through 2013-2014 Academic Years. MMWR Morb Mortal Wkly Rep. 2015;64(48):1330-1336.
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Between 1988–1989 and 2003–2004, the preseason injury rate was higher than both the regular season and postseason injury rates (7.05 vs. 2.02 and 7.05 vs. 1.70 per 1000 AEs, respectively). Preseason is a critical time to stress appropriate stretching, warm-up, fluid and nutritional replacements, recovery, technique, and supervision.
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For games, knee internal derangements, ankle ligament sprains, and concussions account for a majority of injuries (17.8%, 15.6%, and 6.8%, respectively). For fall practices, knee internal derangements, ankle ligament sprains, and upper leg muscle–tendon injuries account for a majority of injuries (12%, 11.8%, and 10.7%, respectively). Heat illness accounts for 3.9% of fall season injuries. Spring practice injuries are similar to those seen in the fall with regard to the most common body parts injured. Cervical spine injuries can have a catastrophic potential but fortunately have declined since rule modifications were made about tackling and blocking techniques, improved fitness, coaching, and equipment.
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Ankle sprains account for 13.6% of all injuries (0.83 injuries per 1000 AEs), anterior cruciate ligament (ACL) injuries for 3% of all injuries (0.18 injuries per 1000 AEs), and concussions for 6% (0.37 injuries per 1000 AEs). At the NCAA level, spring football ankle sprains account for 13.9% of all injuries (1.34 injuries per 1000 AEs), ACL injuries for 3.5% (0.33 injuries per 1000 AEs), and concussions for 5.6% of all injuries (0.54 per 1000 AEs).
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Player contact is the most common mechanism of injuries in football, and this is true for games as well as fall and spring practices.
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Player position plays a factor in the likelihood of injury, with game injuries by position being most common in a running back (19.6%), followed by quarterback (17.5%), linebacker (15.5%), flanker/wide receiver (14.4%), defensive back (11.7%), defensive lineman (11.3%), and offensive lineman (9.9%).
Medical Problems
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Fatalities have been reported in both high school and collegiate football players, and from 1990 to 2010, 243 fatalities were reported to the National Center for Catastrophic Sports Injury Research, resulting in an average of 12.2 per year or 1 per 100,000 participants.
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Of these, 164 were indirect (0.7 per 100,000 participants) and 79 direct (0.3 per 100,000 participants).
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The most common causes of fatalities in this review were cardiac failure (41.2%), brain injury (25.5%), heat illness (15.6%), sickle cell trait (4.5%), asthma and commotio cordis (2.9%), embolism/blood clot (2.1%), cervical fracture (1.7%), and intra-abdominal injury, infection, and lightning (each 1.2%).
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The risk of fatality was similar at high school and college levels for all causes with the exception of brain injuries, which were slightly more common at the college level.
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Preparticipation Physical Examination
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Preparticipation physical examination is an important part of the initial evaluation of any athlete. The evaluation should be performed before the competitive season and with sport-specific objectives. Additional testing, such as the addition of electrocardiogram or sickle cell testing, has recently been debated (see Chapter 3 , The Preparticipation Physical Evaluation).
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Three areas of importance in the preparticipation physical examination are cardiac, musculoskeletal, and neurologic. They are stressed not only in history but also on physical examination.
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Family history of sudden cardiac death (SCD), including myocardial infarction before age of 50 years, Marfan syndrome, hypertrophic cardiomyopathy, and other abnormalities known to cause SCD
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History of exertional syncope, chest pain, dizziness
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History of prior injury or incomplete rehabilitation
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History of previous head or neck injury, concussions, stingers or burners, as well as any work-up, in the past is important.
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Other areas of importance include exercise-induced asthma, single organs, heat intolerance, appliances (e.g., dental plates), medications, allergies, medical conditions, sickle cell disease, and immunizations.
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Historical questions to assess the risk of SCD, preexisting musculoskeletal injuries, or anatomic conditions that put athletes at risk of injury. Thorough history is essential.
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Physical examination
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Emphasize cardiac, musculoskeletal, and neurologic systems.
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Ensure adequate cervical spine protection, joint stability, absence of cardiac abnormalities, and neurologic integrity.
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Screen for inflexibility, muscle imbalances, and inappropriate rehabilitation.
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Nutrition issues: Need for strength gaining often puts an athlete at risk of abuse of performance-enhancing drugs. Use of protein supplementation should be discussed. The athlete should understand basics about good nutritional balance and risks of excessive protein load as well as additional costs of protein supplements. A healthy, natural, and well-balanced diet (see Chapter 5 , Sports Nutrition) should be emphasized. The use of unsupervised nutraceuticals should be discouraged.
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Fluids: A study in high school football players in 50-play scrimmage simulation demonstrated no difference in anaerobic performance with a 7% glucose polymer beverage containing electrolytes compared with water, but the beverage had a positive effect on maintaining plasma volume during recovery from anaerobic exercise.
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In 2003, as a response to heat-related deaths in preseason football, the NCAA instituted rules that addressed heat illness by requiring a 5-day acclimatization period during which the practice time is limited. American College of Sports Medicine published expert roundtable recommendations, “Youth Football: Heat Stress and Injury Risk,” which expounded on these risks of youth football.
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Given the risk of heat-related illness with sickle cell disease, role of screening for all African-American athletes should be considered and counseling and modification of training regimens at altitude occur as needed.
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Renal injuries: A retrospective review of professional football players demonstrated 52 cases between 1986 and 2004, representing an average of 2.7 cases of renal injuries per season. Kidney injury rate was 10 times greater during games (0.55 per 10,000 exposure) than during practice (0.05 per 10,000 exposure), with the most common injury being renal contusion, followed by renal laceration and renal stones. In fact, 49 of 52 injuries were related to contact, and none required surgery. Renal laceration and renal contusion was associated with mean time loss of 59.8 and 15.1 days, respectively, and all athletes returned to play.
Strength and Conditioning
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Important aspect at all levels of football
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Stress maintenance of good flexibility program in conjunction with core and overall strengthening
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Sport specificity in training; endurance work as baseline
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Interval training, stadium stair running, and hill training for explosive speed
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Supervision and appropriate technique in strengthening program, particularly if free weights are used
Infections
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General guideline is to avoid exercise during acute infection; avoid participation if fever is >100° F. Avoid common-source water outbreaks. To avoid spread of infection, athletes should not share water bottles.
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Myocarditis reported as cause of SCD in athletes
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Skin infections (herpes gladiatorum, ringworm) often spread from person-to-person contact. Antiviral, antifungal, and antibacterial treatment necessary with protective covering to avoid transmission. Risk of methicillin-resistant Staphylococcus aureus (MRSA) of significant concern because of number of athletes participating. Important to avoid sharing towels, razors, toothbrushes, as well as ensuring appropriate hygiene. Rigorous cleaning of shared athletic training facilities and daily skin checks by athletic medicine staff to evaluate any suspicious skin lesions.
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Infectious mononucleosis is additional consideration for splenic rupture. Caused by Epstein–Barr virus (EBV). No activity for initial 3–4 weeks of symptoms, then dependent on athlete’s clinical condition and presence or absence of splenomegaly, which is present acutely in a majority of cases of EBV. Abdominal ultrasound useful for accurate assessment but not generally useful unless serial assessments are performed. Position stand regarding mononucleosis in the athlete was written for the American Medical Society for Sports Medicine (AMSSM) and published in 2008. Recent systematic review of 81 cases of splenic rupture due to mononucleosis between 1984 and 2014 found that 84% occurred within 4 weeks of symptom onset, but cases reported up to 8 weeks
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Human immunodeficiency virus (HIV)
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No reason to disallow competition. Study in professional football players found 3.7 bleeding injuries per game for each team involving 3.5 players and found that 88% of bleeding injuries were abrasions, with remainder lacerations. Risk of HIV transmission estimated to be <1 per 85 million game contacts.
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Universal precautions should be used for all body fluids. More important to consider activities off field than on field regarding risk factors.
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A more substantial risk of hepatitis ; same precautions apply; hepatitis vaccination series recommended
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Head Injuries
Statistics
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The CDC estimates 2.6 million children aged <19 years, between 2001 and 2009 treated for sports-related injuries, and 6.5% or 173,285 of these were traumatic brain injuries (TBIs).
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Concussion, the most common type of TBI, is also the most common head injury occurring in sport, accounting for 8.9% and 5.8% of injuries at the high school and college level, respectively (see Chapter 45 , Head Injuries).
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Team Physician Consensus Statement, AMSSM Statement, American Academy of Neurology Statement and National Athletic Trainers Association statements have all been updated; represent most recent consensus documents to address mild traumatic head injury (concussion) in athletes. Upcoming Fifth International Consensus Conference in Berlin Germany will provide additional update on evolving literature.
NCAA Data on Head and Neck Injury
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Football has a high rate of head injury of sports monitored at the collegiate level ( Table 66.2 ).
TABLE 66.2
NCAA DATA ON CONCUSSION INJURIES: 2009-2010 THROUGH 2013-2014
Concussion *
Game
Practice
Overall
Sports With No Head Protection
Field hockey
11.10
1.77
4.02
Women’s lacrosse
13.08
3.30
5.21
Men’s soccer
9.69
1.75
3.44
Women’s soccer
19.38
2.14
6.31
Women’s basketball
10.92
4.43
5.95
Men’s basketball
5.6
3.42
3.89
Wrestling
55.46
5.68
10.92
Sports With Head Protection
Men’s ice hockey
24.89
2.51
7.91
Football
30.07
4.20
6.71
Women’s ice hockey
20.10
3.00
7.50
Men’s lacrosse
9.31
1.95
3.18
Women’s softball
5.61
1.75
3.28
Baseball
1.20
0.72
0.90
From Zuckerman SL, Kerr ZY, Yengo-Kahn A, et al. Epidemiology of Sports-Related Concussion in NCAA Athletes from 2009-2010 to 2013-2014: Incidence, Recurrence and Mechanisms. Am J Sports Med. 2016;43(11):2654-2662.
* Concussion as a subset of all head injuries; rates are per 10,000 athlete-exposures
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Injury rates in sports with no head protection, such as men’s soccer, women’s soccer, and field hockey, are comparable to helmeted sports of ice hockey, football, and men’s lacrosse (see Table 66.2 ). Helmets do not prevent concussion.
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Player contact is primary injury mechanism in football.
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In football, spearing technique is associated with significant cervical injuries and head-to-head contact is associated with a significant risk of head injury. Rules to prevent these mechanisms of injury exist, although enforcement is often difficult; point of emphasis for officials in 2008 to call head-to-head contact fouls.
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Efforts to decrease head and neck injuries in football have come from the NCAA (Safety in in College Football Summit, 2014) as well as USA Football (HeadsUpFootball) and include having a concussion plan in place, decreasing contact exposures, education regarding appropriate tackling techniques, and signs and symptoms of head injury.
Cervical Injuries
Neck pain, radiating arm pain, paresthesias, weakness, and loss of cervical motion are criteria for removal from the game and further work-up.
Myofascial Sprains
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Muscular or ligamentous injury to neck (most common form of neck injury)
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Presents with paravertebral spasm, decreased range of motion, usually without radicular or neurologic symptoms
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Radiographs to rule out fracture or ligamentous instability
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Treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs), rest, and physical therapy.
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Return to sport when full active range of motion with little or no pain, absence of neurologic findings, and negative work-up for more severe injuries.
Brachial Plexus Injuries (“Burner” or “Stinger”)
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Usually occur with compression of vertebral foramina or distraction of neck and shoulder, causing pinching or stretching of brachial plexus
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Initial symptoms include one of knife-like searing pain radiating down from neck into arm. Typically, there is transient numbness or paralysis in the involved upper extremity; beware of bilateral symptoms, which may represent transient quadriparesis or spinal cord involvement.
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With first occurrence, consider cervical spine films to evaluate for congenital anomalies or spinal stenosis.
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Treatment includes NSAIDs, rest, and physical therapy.
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Return to sport with full clinical strength and resolution of neurologic symptoms, particularly in vertebrae C5 or C6 nerve distribution, on sidelines, check supraspinatus strength as this is often the last area of strength to return. Use protective equipment, including neck roll or a collar, which can help prevent some of the extension of the neck. These must be well fitted to tightly secured shoulder pads. Loose shoulder pads eliminate beneficial effect of neck roll. Be aware of delayed weakness. The athlete should be re-examined 24 hours later.
Fractures and Dislocations
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Less frequent after installation of rules banning “spearing” and use of top of helmet to strike another player; injury still occurs with inadvertent hitting of crown of helmet on another player as players aggressively move to ball after initial contact is made.
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If neurologic injury present or fracture or dislocation suspected, spine must be immobilized until appropriately assessed, including radiographs
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Never remove helmet or shoulder pads until the spine is appropriately immobilized and protected; cut or remove face guard for airway management when transporting the athlete. If removal of shoulder pads and helmet are necessary, remove both at same time to maintain neutral alignment of cervical vertebrae.
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Be aware of emergency personnel guidelines that may advocate helmet removal—protect your players! Pediatric head size is relatively larger than the shoulders—take this into consideration with young athletes.
Return-to-Play Criteria After Cervical Injury
Absolute Contraindications to Return to Collision Sports
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Congenital: Odontoid hypoplasia, atlanto-occipital fusion, Klippel–Feil anomaly with occipital–cervical involvement or mass fusion
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Developmental
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Spinal stenosis with episode of cervical cord neurapraxia and ligamentous instability or cord edema by magnetic resonance imaging (MRI) or more than one recurrence
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“Spear tackler’s spine” (stenosis with persistent straightening of cervical spine, often rigid in flexion and extension)
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Traumatic conditions
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Any C1–C2 injury with ligamentous laxity or C1–C2 fusion
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Unstable ligamentous injuries of C2–C7
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Vertebral body fractures with sagittal component of displacement into the canal
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Healed fractures with residual instability, neurologic finding, limitation of motion
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Disk herniation with neurologic findings or limited motion
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Status postfusion of more than three levels
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Relative Contraindications
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Developmental: Episode of central cord neurapraxia (with resolution) and vertebral body-to-canal ratio of ≤0.8
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Traumatic: Full pain-free range of motion and neurologically intact with healed displaced body compression fracture or neural ring fracture; two- or three-level fusion
No Contraindication
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Congenital: Klippel–Feil anomaly with stable one- to two-level fusion below C2 and full range of motion
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Developmental: Stenosis ratio of ≤0.8 in otherwise asymptomatic patients
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Traumatic: Full, pain-free range of motion and neurologically intact with healed stable compression fracture or healed spinous process fracture; solid one-level fusion after disk excision at ≤C3
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Study of collegiate football players found that players with a Torg ratio <0.8 had three times the risk of incurring stingers.
Upper Extremity
Shoulder Girdle (Clavicle Fractures)
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Mechanism or injury: direct blow (most common) or impact onto point of shoulder
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Faster healing and return to sport with surgical fixation; however, conservative treatment still usually successful but with longer healing time and higher refracture rate. Surgery recommended if overlapping fragments of 1.5–2 cm
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Return to sport with resumption of strength and healed fracture
Acromioclavicular Joint
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Incomplete acromioclavicular separations (coracoclavicular ligaments intact, grade I and II acromioclavicular sprains) (see Chapter 49 , Shoulder Injuries)
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Acromioclavicular injuries most commonly result from fall onto point of shoulder ( Fig. 66.1 ).
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