tackling in youth football

POLICY STATEMENT Organizational Principles to Guide and Define the Child HealthCare System and/or Improve the Health of all Children

Tackling in Youth FootballCOUNCIL ON SPORTS MEDICINE AND FITNESS

abstractAmerican football remains one of the most popular sports for young athletes.The injuries sustained during football, especially those to the head and neck,have been a topic of intense interest recently in both the public media andmedical literature. The recognition of these injuries and the potential for long-term sequelae have led some physicians to call for a reduction in the numberof contact practices, a postponement of tackling until a certain age, and evena ban on high school football. This statement reviews the literature regardinginjuries in football, particularly those of the head and neck, the relationshipbetween tackling and football-related injuries, and the potential effects oflimiting or delaying tackling on injury risk.

INTRODUCTION

With more than 1.1 million players, American football remains one of themost popular sports for male high school athletes.1 In addition, there areapproximately 250 000 youth football players 5 to 15 years of age in PopWarner leagues alone, making football one of the most popular sports foryounger athletes as well.2 The injuries sustained during football, especiallythose to the head and neck, have been a topic of intense interest recentlyin both the public media and the medical literature. Concerns about thenumber of head and neck injuries, especially concussions and catastrophicinjuries, have led some athletes to stop playing football.3 More recently,the cumulative effects of concussions and the potential for a cumulativeeffect of subconcussive blows to the head, defined as those that do notcause symptoms of concussion, have been hypothesized as a causative riskfactor for chronic traumatic encephalopathy (CTE). The recognition ofthese injuries and the potential for long-term sequelae have led somephysicians to call for a reduction in the number of contact practices,a postponement of tackling until a certain age, and even a ban on highschool football.4–6

Others, however, have argued that football is a generally safe sport thatcarries with it the substantial benefits of regular exercise on health7,8 aswell as social and academic outcomes9–11 that outweigh the risks involved,pointing out that the risk of catastrophic injury is low, that mostconcussions resolve within a few days or weeks, and that there are

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, policy statements from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive courseof treatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2015-3282

DOI: 10.1542/peds.2015-3282

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: Dr. Meehan participates in research funded, inpart, by the National Football League Players Association and receivescompensation from ABC-Clio Publishing, Wolters Kluwer, and SpringerInternational Publishing for his authored works. Dr. Landry hasindicated he does not have a financial relationship relevant to thisarticle to disclose.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated theyhave no potential conflicts of interest to disclose.

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substantial limitations to the currentunderstanding of CTE. Some haveexpressed concerns about limitingcontact practices or delaying the ageat which tackling is introduced forfear that inadequate training maylead to unintended consequencesonce contact is allowed, such asincreased forces of impact and moreconcussions.

The purpose of this statement is toreview the literature regardinginjuries in football, particularly thoseof the head and neck, the relationshipbetween tackling and football-relatedinjuries, and the potential effects oflimiting or delaying tackling on injuryrisk. For purposes of this statement,unless otherwise defined, an athleticexposure (AE) refers to 1 athleteparticipating in 1 game or 1 practice.

INCIDENCE OF INJURIES IN YOUTHFOOTBALL

The most commonly injured bodyparts in football at all ages are theknee,12–20 ankle,12–21 hand,21 andback.12–16 The head and neck sustaina relatively small proportion ofoverall injuries, ranging from 5% to13%.12–18 Fortunately, most injuriesare contusions, musculotendinousstrains, and ligamentoussprains.12,13,15,17,18

Available data suggest that both theoverall incidence and the severity ofinjuries sustained by younger footballplayers are lower than thosesustained by olderplayers,12–16,18,19,21–25 although thisfinding is not universallyconsistent.21 Some studies suggestthat the incidence of overall injuriesin football is similar to othersports,19,21 although the incidence ofserious injuries appears to be greaterfor football than many other teamsports.21,26 Although data regardingthe most common injuries sustainedby football players at the professional,collegiate, and high school level aremore readily available, data regardingyounger players is limited. Theoverall incidence of injury varies

between studies, depending on howan injury was defined and how datawere gathered (Table 1).

Cumulative and Catastrophic Headand Neck Injuries in Football

Although the risk of catastrophicinjuries to the head and neck infootball is low, with yearly estimatesbetween 0.19 and 1.78 for every100 000 participants,27–29 it appearshigher in football than most otherteam sports.28 The risk ofcatastrophic injury duringparticipation in football is, however,comparable to the risk in gymnasticsand lower than the risk in icehockey.28 The risk appears lower foryouth players than for high schoolplayers and lower for high schoolplayers than for college players.27,29

The annual risk of quadriplegia isapproximately 0.52 per 100 000football participants and, again,appears lower for high school footballplayers (0.50/100 000 participants)than collegiate players (0.82/100 000participants). Spear tackling, orleading with the crown of thehelmeted head while tackling bydefensive players, continues to be thepredominant mechanism of injurycausing quadriplegia.29

The cumulative effects of concussionhave been documented both inathletes and those outside the realmof organized sports.30–34 Someformer athletes who participated insports that involve purposefulcollisions and repetitive blows to thehead have suffered from mooddisorders, behavior problems,cognitive difficulties, gaitabnormalities, headaches, andParkinsonism later in life. At autopsy,these athletes had pathologic changesto the brain, includingventriculomegaly, cerebral atrophy,b-amyloid deposits, andphosphorylated t deposits, an entitynow commonly known as CTE.35–49

These case reports and case serieshave led to the hypothesis thatrepetitive blows to the head, whetherconcussive or subconcussive, result in

the pathologic changes noted aboveand that these pathologic changes areassociated with certainneurobehavioral characteristics.Whether the pathologic findings aresolely attributable to the blows to thehead and whether the pathologicchanges are significantly associatedwith the neurobehavioral correlates isdebated because these hypothesesremain to be tested by case-controland cohort studies.50–54 Some haveargued that these effects may beattributable to confounding variables,such the use of drugs, alcohol, orperformance-enhancing substances. Itshould be noted, however, that animalmodels of repetitive concussive braininjury have shown a decrease incognitive function in the absence ofsuch potential confoundingvariables.55–57

“Second impact syndrome” is a termused to describe a devastating braininjury associated with cerebral edemathat occurs after an often minor blowto the head is sustained before fullrecovery from a concussion.58–61

Although second impact syndrome isoften associated with football, it hasbeen observed in other sports, suchas ice hockey, boxing, and skiing.58

Nearly all athletes with this diagnosisin the literature are younger than 20years old. Given the rarity of thisinjury, its incidence in football isunknown. Furthermore, whethersecond impact syndrome is a uniqueentity, as opposed to cerebral edemaattributable to a solitary blow to thehead, remains debated.62–65

INJURIES ASSOCIATED WITH TACKLING

Injuries are common during contactand tackling in particular.14,16–18 Ahigher proportion of injuries resultfrom contact than noncontactmechanisms.14,16,17,23,66 Tackling,specifically, is the most commonplayer activity at the time of injury20

and at the time of severe injury.26

Being tackled and tackling accountfor about half of high school andcollege football-related injuries.17,18

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TABLE1

Summaryof

StudiesDescribing

Incidenceof

Injuries

inAm

erican

Football

Study

Population

Definitionof

Injury

Methods

Results

Shankaret

al200718

High

school

(and

college)football

playersfrom

100high

schools

Occurred

during

organizedpracticeor

game

Prospectivecohort

study

Overallinjury

incidence4.4/1000

AEs

(higherrate

observed

for

college

players;8.6/1000

AEs)

Required

medical

attentionfrom

athletictrainer

orteam

physician

Injuries

reported

byathletic

trainers

Gametim

eincidencehigher

than

practice

(12.0vs

2.6/1000

AEs)

Resultedin

$1dof

restrictionbeyond

dayof

injury

Badgeley

etal

201317

High

school

footballplayers

from

100high

schools

Occurred

during

organizedpracticeor

game

Prospectivecohort

study

Overallinjury

incidence4.08/1000AEs

Required

medical

attentionfrom

athletictraineror

team

physician

Injuries

reported

byathletic

trainers

Gametim

eincidencehigher

than

practice

(12.61

vs2.35/1000AEs)

Resultedin

$1dof

restrictionbeyond

dayof

injury

Included

allfractures,concussions,anddental

injuries

Know

leset

al2006114

High

school

athletes

from

100high

schools

Resultedfrom

participationin

high

school

sport

Prospectivecohort

study

Overallinjury

incidencerate

of2.08/1000AEs

Limitedfullparticipationdayfollowinginjury

orrequired

medical

attention

Injuries

reported

byathletic

trainers

orathleticdirectors

Footballhadthehighestincidenceof

injury

Included

allconcussions,fractures,andeyeinjuries

Turbevilleet

al200314

Middleschool

footballplayers,

grades

6–8,aged

10-15y,

N=646

Resultedin

aplayer

missing

$1

practices/gam

esProspectivecohort

study

Gametim

eincidenceof

overallinjuries

higher

than

practice(8.84vs

0.97/1000AEs)

Included

allhead

injuries

resulting

inalterationof

consciousnessrequiringtheplayer

toleavepractice/game

Footballcoachor

athletictrainer

reported

injuries

Head

was

site

ofinjury

for2%

ofallinjuries

Neck/spine

was

site

ofinjury

for3%

ofallinjuries

Concussion

accountedfor12.5%

ofallinjuries

Dompier

etal

200715

Youthfootballplayers

aged

9–14

y;N=779

Non–tim

e-loss

injuries

didnotrequireremoval

from

participation

Prospectivecohort

study

Overallinjury

incidenceof

17.8/1000AEs

Time-loss

injuries

required

removal

from

session

orsubsequent

session

Athletictrainers

presentfor

practices

andgames,reportedinjuries

Time-loss

injury

onlyincidence7.4/1000

AEs

Included

allfractures,dental

injuries,concussions,

andinjuries

requiringreferral

Injury

rate

increasedwith

gradein

school

(4.3/1000AEsforfourth/fifth

graders,

14.4/1000AEsforeighth

graders)

Neck

andhead

weresitesof

injury

for4.6%

and6.5%

ofinjuries,respectively)

Malinaet

al200622

Youthfootballplayers

Caused

cessationof

participationandprevented

return

tothat

session

Prospectivecohort

study

Overallinjury

incidence10.4/1000AEs

Aged

9–14

y;N=678

Included

allfractures,dental

injuries,

andconcussions

Athletictrainers

reported

injuries

Nosignificant

associationbetweenincidence

ofinjury

andheight,w

eight,BM

I,or

estim

ated

maturity

status

Incidenceof

injury

increasedwith

gradein

school

Stuart

etal

200213

Youthfootballplayers,

aged

9–13

y;N=915

Occurred

during

agame,kept

the

player

outforremainder

ofgame,and

required

attentionof

aphysician

Injuries

reported

byorthopedistin

medical

tent

adjacent

tothe

playingfield

Gametim

eincidence8.47/1000AEs

(onlyassessed

gametim

eAEs)

Included

allconcussions,dental

injuries,eye

injuries,and

nerveinjuries

Olderplayersin

thehigher

grades

more

susceptibleto

injuries

Runningbacksat

highestrisk

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The majority of concussions resultfrom tackling or being tackled.17

Head-to-head contact is one of theleading causes of concussionssustained by youth footballplayers.18,23

Badgeley et al studied themechanisms leading to injury ina cohort of high school studentsplaying football.17 Players in the olderdivision had higher overall rates ofinjury than players in youngerdivisions. The leading mechanism ofinjury was player-to-player contact,with tackling/being tackledaccounting for nearly half (46.2%) ofall injuries. Similar findings have beenreported in studies of youth football.In an observational cohort study of208 Pop Warner football teams fromNew England, Goldberg et al reportedon injuries sustained by playersbetween the ages of 5 and 15 yearsthat required restricted participationfor more than 1 week.16 The vastmajority (88%) of injuries occurredduring contact with another player;41% resulted directly from tackling.Players in the older division (Bantam)had higher overall rates of injury thanplayers in younger divisions.

In a community survey by Radeletet al, the incidence of injuriessustained by children ages 7 to 13years playing football (0.15 per 1000AEs) was similar to, and in factslightly lower than, that of baseball(0.17 per 1000 AEs) and boys’ soccer(0.17 per 1000 AEs).21 This findingwas unexpected, but the authorsnoted that the results may have beenaffected by underreporting anddifferences in the interpretation ofthe definition of injury. Thepercentage of injuries that weredefined as serious (fractures,dislocations, and concussions) washigher in football (13%) than othersports (0%–3%). Furthermore, thefrequency of injury per team perseason was 5 to 7 times higher infootball than in baseball, soccer, orsoftball. The most common method ofinjury was contact with anotherTA

BLE1

Continued

Study

Population

Definitionof

Injury

Methods

Results

Radeletet

al200221

Youthathletes

inseveral

sports,aged7–13

y;N=1659

Broughtcoachon

thefieldto

checkcondition

ofaplayer,requiredremoval

from

play,orrequired

firstaid

Coacheskept

records,contacted

weeklyby

researchers

Overallinjury

incidencein

football

was

15/1000AEs

Overallinjury

incidencecomparableto

baseball

andboys’soccer,but

lower

than

girls’soccer

Authorsnote,how

ever,the

reportingof

injuries

may

have

differedby

sport,possibly

underreportedin

football

8-to

10-y-old

playersinjuredmorefrequently

than

5-to

7-y-oldand11-to

13-y-old

players

Kontos

etal

201323

Youthfootball

playersaged

8–12

y,N=468

Concussion

definedas

anymild

closed

head

injury

involvingalteredcognitive

functioning

orsignsor

symptom

sor

briefloss

ofconsciousness

afterablow

tothehead

Prospectivecohort

study

Concussion

incidencewas

1.8/1000

AEs

Coachesreferred

suspected

concussionsto

medical

professional

fordiagnosis

Gametim

eincidencehigher

than

practices

(6.2vs

0.24/1000AEs)

Concussion

incidencerate

lower

forthe

8-to

10-y-old

playersthan

11-to

12-y-old

players(0.93vs

2.53/1000AEs)

Linder

etal

199524

High

school

football

players,aged

11–15

y;N=340

“Any

sports-related

mishap”

occurringduring

practiceor

games,resultingin

removal

from

practiceor

gameand/or

missing

subsequent

practiceor

game

Injuries

recorded

bycoaches;

data

collected

weekly

byauthors

16%

ofparticipants

wereinjured

Proportionof

participants

injured

increasedwith

Tanner

stage



player, although the authors did notreport the nature of contact;therefore, the proportion of injuriesattributable to tackling as opposed toblocking or incidental person-to-person contact is unknown. As withmany other studies,17,18,67 theirresults showed a higher rate ofinjuries during football games (0.43per 1000 AEs) than practices (0.07per 1000 AEs).21

Head Injuries and ImpactsAssociated With Tackling

The study by Badgeley et al suggeststhat during high school football, themajority (64.3%) of concussionsoccur when an athlete is tackling orbeing tackled,17 a finding consistentwith previous work performed bysome of the same investigatorsshowing that tackling/being tackledaccounted for half of all high schoolfootball injuries.18 During footballplayed by younger athletes, Kontoset al showed that head-to-headcontact was the most commonmechanism of concussion, butwhether head-to-head contactoccurred during tackling, as opposedto blocking or incidental contact, isnot discussed.23

In a study of 42 varsity high schoolfootball players, Broglio et al usedaccelerometers to record headimpacts resulting .14.4 g of linearacceleration and found a mean of 774impacts per player during a singleseason. The mean number of impactsvaried by player position, withlinemen sustaining a higher numberof impacts. Games were associatedwith a higher incidence of impactsthan practices. Contact practices wereassociated with a higher incidence ofimpacts than noncontact practices.68

In a single-season study of 7 footballplayers aged 7 and 8 years, Danielet al used accelerometers to recordthe cumulative number of impacts tothe head.69 The authors examinedboth linear acceleration androtational acceleration with blows tothe front, side, rear, and top of the

head. The average number of impactsper player was 107, with moreimpacts occurring during practices(59% of recorded impacts) thangames (41% of recorded impacts). Agreater number of high-force impacts(.95th percentile for acceleration)occurred during practices thangames. The number of impactsexperienced by these youth playerswas lower than that reported for highschool and college players and moreheavily weighted toward lower levelsof impact. As might be expected, thenumber of impacts increased withincreasing level of play, likely becauseof the increased size and strength ofolder players. The authors arguedthat restructuring practices mightlead to a lower number of headimpacts.69 This study was limited bya small sample size.

Neck Injuries Associated WithTackling

Fortunately, most neck injuries thatoccur during football are strains,sprains, and contusions.12,15 Cervicalspine fractures and spinal cordinjuries do occur, however, and somelead to permanent neurologicdamage.15,16

Catastrophic Head and Neck InjuriesAssociated With Tackling

Although the rates of catastrophicinjury in football are low, most of thecases that occur are sustained duringtackling.29,70–73 Most cases ofquadriplegia occur while the injuredplayer is making a tackle.29 Amajority of brain and cervical spineinjury–related fatalities result fromtackling or being tackled.67,74,75

Brain injury–related fatalities accountfor approximately 69% of all footballfatalities.67 Subdural hemorrhagesare the most common injuryassociated with brain injury–relatedfatalities; tackling and beingtackled67,74–76 are the most frequentactivities when subduralhemorrhages occur.67 The annualincidence of catastrophic headinjuries sustained by football players

appears higher for high schoolathletes than college players (0.67 vs0.21 per 100 000 participants).29 Themajority are sustained by an athletewho is tackling or being tackled.29

Football players are among the teamsport athletes at highest risk forcatastrophic cervical spine injuries.71

The annual incidence of catastrophiccervical spine injuries appears higherfor collegiate players than for highschool players (4.72 vs 1.10 per100 000 participants).77 Mostcatastrophic cervical spine injuriesoccur during tackling, often whenimproper technique is used.Specifically, most spinal cord injuriesare caused by axial loading of thecervical spine during head-downcontact, often as a result of “speartackling,” a method in which theathlete lowers his head, thereby liningup the vertebral bodies, and uses hisbody as a battering ram to delivera blow to another player with thecrown of his head.19,70,72,73

Fortunately, the incidence ofcatastrophic cervical spine injuriesdecreased after the banning of speartackling in 1976.71,72 Catastrophicspine injuries still occur, however, andspear tackling remains a problemdespite the ban.19,29,70,73

THE EFFECT OF DECREASING CONTACTPRACTICES ON INJURY INCIDENCE

Given the association of player-to-player contact with incidence ofinjury, decreasing the number ofcontact practices has been proposedas a method of decreasing injury risk,particularly concussions. Althoughthe incidence of concussion is lowerduring practice than it is duringgames, there are far more practicesthan games. Because most impacts tothe head occur during practices,decreasing the number of contactpractices has been shown to decreasethe overall number of head impactsthat occur during the course ofa season, thereby reducing the risk ofany potential cumulative effects ofsuch exposures.23,68,69,78 Some argue



this may also lead to a decrease in thenumber of concussions.79

Other authors, however, note that therisk of concussion is higher duringgames than it is during practices andargue that decreasing the number ofcontact practices is unlikely to reducethe number of concussions. In fact,they propose that the decrease intime spent practicing proper tacklingtechnique may lead to an increase inthe magnitude of impacts duringgames and an increase in the risk ofconcussion.23,68 Therefore, someauthors have suggested that if contactpractices are to be reduced asa means of decreasing overall headimpact exposures, then extraemphasis should be placed onteaching appropriate tacklingtechnique to avoid an increased riskduring games.68 Other authors havealso cautioned that a lack of propertraining may increase risk ofinjury.18,24

In a study of high school varsityfootball players, Broglio et al reportedthat limiting the number of contactpractices to 1 per week would resultin an 18% decrease in the number ofimpacts, whereas eliminating contactpractices entirely would result ina 39% decrease in the number ofimpacts.68 That same study showedthat games resulted in botha significantly higher number ofimpacts than practices as well ashigher magnitude impacts thanpractices. The authors cautioned thatlimiting contact practices mayincrease the risk of high-magnitudeimpacts and concussions that occurduring game time, especially ifadditional efforts are not made toteach proper tackling and techniquesfor safely absorbing tackles.68

As opposed to high school andcollegiate players,68 preliminaryevidence suggests younger playersmay sustain higher magnitudeimpacts during practices as opposedto games.69 Thus, for younger players,limiting full contact practices whilesimultaneously teaching fundamental

skills required for proper tackling andproperly absorbing tackles mayreduce the overall exposure to headimpacts and high magnitude impacts.If CTE proves to be the result ofcumulative impacts to the head,including subconcussive impacts,then limiting contact practices shoulddecrease the risk of CTE.68,69,80

A recent report from the Institute ofMedicine concluded that although theconcept of limiting the number ofhead impacts is sound, setting a limiton number of impacts or themagnitude of impacts per week or perseason is without scientific basis.81

The Effect of Delaying Tackling Untila Certain Age

Some physicians have recently arguedthat because the brain is in a rapidperiod of development during youth,contact should be eliminated fromfootball until a certain age.4,6 Othershave argued, however, thateliminating contact at a young agewould prevent young athletes fromlearning the skills required to tackle,absorb a tackle, and fall to the groundsafely. Then, when contact is laterintroduced, athletes will be illprepared and forced to learn theseskills at an age where they are bigger,faster, stronger, more coordinated,and capable of delivering moreforceful blows. Some have suggestedthat this might increase the risk ofinjury23 and have argued the correctcontact techniques should be taughtat the earliest organized level.72,81 Aprevious study of high school footballplayers in Wisconsin suggested thatprevious tackling experience is notindependently associated with therisk of sustaining a sport-relatedconcussion.82 Further investigationinto the effects of delaying theintroduction of tackling until a certainage must be conducted beforeinformed recommendations can bemade.

Although there does not appear to beany study to date showing the effectof delaying the age at which tackling

is introduced to football on risk ofinjury, data from other sports suggestthat eliminating tackling woulddecrease the risk of certain injuriesfor athletes participating at ages forwhich tackling would beprohibited.83,84 In a study ofCanadian youth ice hockey players,Emery et al showed that the risk ofinjury, severe injury, concussion, andsevere concussion was higher inleagues that allowed body checkingthan in leagues that did not allowbody checking,83 confirming previouswork that had demonstrated anassociation between body checkingand the incidence of concussion.85 Ina follow-up study, however, the sameinvestigators reported that, onceexposed to body checking, playerswho were not introduced to bodychecking until a later age were atsignificantly higher risk of severeinjuries than those exposed to bodychecking at an earlier age.86 The riskof sport-related concussion was alsohigher in those previously unexposedto body checking, although thefindings were not statisticallysignificant.86 Other studies of youthice hockey players have shown nosignificant difference in the incidenceof injury between those exposed tobody checking at differing ages.However, a previous study byMacPherson et al showed that hockeyplayers exposed to body checking ata younger age had a significantlyhigher odds of suffering a checkinginjury than those exposed to checkingat a later age.85

OTHER STRATEGIES FOR REDUCINGINJURIES

Teaching Proper Tackling Technique

Initiating contact with the shoulderwhile the head is up is believed to bethe safest way to tackle in football.Most experts recommend that propertechnique be learned and practicedregularly as a means of reducing therisk of injury.17,18,71,72,79 A recentinitiative by USA Football emphasizeskeeping the head up during tackling



to prevent catastrophic injuries aswell as concussions, although thisnew coaching method needs furtherstudy.

Rule Changes

In addition to changing practiceregimens and teaching propertackling techniques, some haveproposed changes to the rules offootball as a means of reducing headand neck injuries. Indeed, the 1976banning of spear tackling has beenwidely credited with reducing thenumbers of cervical spinal injuriesresulting in quadriplegia.70–73,77,87,88

Unfortunately, spear tackling haspersisted even since the 1976 rulechange, and cervical spine injuriescontinue to occur.73,88,89 Modificationand consistent enforcement of therules may lead to a further decreasein the risk of injury, includingcatastrophic injuries.73,79,89

Protective Equipment

The introduction of helmets tofootball and the updating of helmetdesign is widely credited for playinga role in the reduction of headinjuries, particularly catastrophichead injuries and brain injury–relatedfatalities.67,90,91 Therefore, athletesparticipating in football should wearundamaged, properly fitted helmetswith secured chin straps. Byprotecting the scalp from thediscomfort of blows to the vertex ofthe head, however, helmets areconsidered, in part, to have led to anincrease in the number of cases ofquadriplegia by encouraging the useof the head as the point of impact.92

This trend was fortunately reducedby the banning of spear tackling, asnoted previously. The role of helmetsin preventing concussions is lessclear. Although some studies suggestthat helmet design might play a rolein reducing the incidence ofconcussion,93,94 many experts refutesuch a claim.82,95,96 In a recent studyof more than 2000 high schoolfootball players, McGuine et alreported that helmet model had no

significant effect on the incidence ofsport-related concussion.82 As of now,there is little reliable evidence thatconcussions can be prevented ormitigated by any of the currentlyavailable helmet designs.95–97

Mouth guards are effective atreducing the incidence of dentalinjuries.97,98 Although some studieshave suggested an effect ofmouthguard type on the incidence ofconcussion,82,99,100 there are fewreliable data suggesting that anycurrently available mouth guards areeffective at preventing or reducingthe incidence ofconcussion.95,96,101–103

Although there is some evidence thatneck rolls and cowboy collars canreduce movement of the head andneck, there is limited evidenceregarding their effect on the incidenceof burners or stingers, injuries to thenerve of the upper arm that result ina burning or stingingsensation.104–106 Because neck rollslimit extension of the neck, they may,theoretically, interfere with the abilityof the proper head-up tacklingtechnique.

Neck Muscle Strengthening

Neck muscle strengthening has beenrecommended by the NationalAthletic Trainers’ Association asa means of decreasing neck fatigue,thereby allowing for maintenance ofthe head-up position associated withproper tackling technique anddecreasing the risk of burners andstingers.72 Furthermore, weak neckmusculature has been proposed asa risk factor for concussion.107–109

Acceleration of a struck object isinversely proportional to its mass.Because concussion results froma rotational acceleration of the brain,it has been suggested that increasingthe effective mass of the head mightresult in a decreased acceleration ofthe brain after impact. The headbecomes more firmly bonded to therest of the body when the neckmuscles are contracted, thereby

increasing the effective mass of thehead and decreasing the resultantacceleration after impact.109 Thisincrease in effective mass is thoughtto explain the decreased risk ofconcussion when collisions areanticipated.108,109 Thus, by increasingcervical muscle strength, athletesmight decrease their risk ofconcussion.108,110 Preliminaryevidence supports this hypothesis.111

Other preliminary studies suggestthat it may be cervical stiffness, asopposed to strength alone, that isassociated with risk of injury.112

CONCLUSIONS ANDRECOMMENDATIONS

Most injuries sustained duringparticipation in youth football areminor, including injuries to the headand neck. The incidences of severeinjuries, catastrophic injuries, andconcussion, however, are higher infootball than most other team sportsand appear to increase with age.Player-to-player contact results in anincrease in the number ofsubconcussive impacts that occurduring football. Concussion isassociated with player-to-playercontact and tackling, in particular.Severe and catastrophic injuries,particularly those of the head andneck, are associated with tackling,often when improper and illegaltechnique, such as spear tackling, isused. Efforts should be made toimprove the teaching of propertackling technique and enforceexisting rules prohibiting the use ofimproper technique.

1. Officials and coaches must ensureproper enforcement of the rules ofthe game. A significant number ofconcussions and catastrophicinjuries occur because of improperand illegal contact, such as speartackling. There is a culture of tol-erance of head first, illegal hits.This culture has to change to onethat protects the head for both thetackler and those players beingtackled. Stronger sanctions for



contact to the head, especially ofa defenseless player, should beconsidered, up to and includingexpulsion from the game. The cul-ture should change to one of zerotolerance of illegal, head-first hits.

2. Removing tackling from footballaltogether would likely lead toa decrease in the incidence ofoverall injuries, severe injuries,catastrophic injuries, and con-cussions. The American Academyof Pediatrics recognizes, however,that the removal of tackling fromfootball would lead to a funda-mental change in the way thegame is played. Participants infootball must decide whether thepotential health risks of sustainingthese injuries are outweighed bythe recreational benefits associ-ated with proper tackling.

3. The expansion of nontacklingleagues for young athletes whoenjoy the game of football andwant to be physically active butdo not want to be exposed to thecollisions currently associatedwith the game should be consid-ered by football leagues andorganizations. This would allowathletes to choose to participate infootball without tackling and itsassociated risks, even after the ageat which tackling is introduced.

4. Although the effect of subcon-cussive blows on long-term cogni-tive function, incidence of CTE, andother health outcomes remainsunclear, repetitive trauma to thehead is of no clear benefit to thegame of football or the health offootball players. If subconcussiveblows to the head result in nega-tive long-term effects on health,then limiting impacts to the headshould reduce the risk of theselong-term health problems. Thus,efforts should be made by coachesand officials to reduce the numberof impacts to the head that occurduring participation in football.Further research is needed in thisarea.

5. Delaying the age at which tacklingis introduced to the game wouldlikely decrease the risk of theseinjuries for the age levels at whichtackling would be prohibited. Oncetackling is introduced, however,athletes who have no previousexperience with tackling would beexposed to collisions for the firsttime at an age at which speeds arefaster, collision forces are greater,and injury risk is higher. Lack ofexperience with tackling and beingtackled may lead to an increase inthe number and severity of inju-ries once tackling is introduced.Therefore, if regulations that callfor the delaying of tackling untila certain age are to be made, theymust be accompanied by coachesoffering instruction in propertackling technique as well as theteaching of the skills necessary toevade tackles and absorb beingtackled. It is unclear whether suchtechniques and the neuromuscularcontrol necessary for performingthem can be adequately learned inthe absence of contact.

6. Although definitive scientific evi-dence is lacking, strengthening ofthe cervical musculature will likelyreduce the risk of concussions infootball by limiting the accelera-tion of the head after impact.Physical therapists, athletic train-ers, or strength and conditioningspecialists, with expertise in thestrengthening and conditioning ofpediatric athletes, are best quali-fied to help young football playersachieve the neck strength that willhelp prevent injuries.

7. Given their importance in themedical management of sport-related injuries and preliminaryevidence suggesting an associationbetween athletic trainers presenceand a decreased incidence ofsport-related injuries,113 effortsshould be made by football teamsto have athletic trainers at thesidelines during organized footballgames and practices.

LEAD AUTHORS

William P. Meehan, III, MD, FAAPGregory L. Landry, MD, FAAP

COUNCIL ON SPORTS MEDICINE ANDFITNESS EXECUTIVE COMMITTEE,2014–2015

Joel S. Brenner, MD, MPH, FAAP, ChairpersonCynthia R. LaBella, MD, FAAP, Chairperson-ElectMargaret A. Brooks, MD, FAAPAlex Diamond, DO, MPH, FAAPAmanda K. Weiss Kelly, MD, FAAPMichele LaBotz, MD, FAAPKelsey Logan, MD, MPH, FAAPKeith J. Loud, MDCM, MSc, FAAPKody A. Moffatt, MD, FAAPBlaise Nemeth, MD, MS, FAAPBrooke Pengel, MD, FAAPWilliam Hennrikus, MD, FAAP

PAST COUNCIL EXECUTIVE COMMITTEEMEMBERS

Rebecca Demorest, MD, FAAP

LIAISONS

Andrew J. M. Gregory, MD, FAAP – American College

of Sports Medicine

Mark Halstead, MD, FAAP – American Medical Society

for Sports Medicine

Lisa K. Kluchurosky, MEd, ATC – National Athletic

Trainers Association

CONSULTANTS

Gregory Canty, MD, FAAPEmily Hanson, ATC, CSCSNeeru A. Jayanthi, MD

STAFF

Anjie Emanuel, MPH

ABBREVIATIONS

AE: athletic exposureCTE: chronic traumatic

encephalopathy

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originally published online October 25, 2015; Pediatrics COUNCIL ON SPORTS MEDICINE AND FITNESS

Tackling in Youth Football

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tackling in youth football

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