In 1977 the National Collegiate Athletic Association initiated funding for the First Annual Survey of Catastrophic Football Injuries.  Frederick O. Mueller, Ph.D., and Carl S. Blyth, Ph.D., both professors in the Department of Physical Education at the University of North Carolina at Chapel Hill were selected to conduct the research. The research is now being conducted as part of the National Center for Catastrophic Sports Injury Research, University of North Carolina at Chapel Hill, Frederick O. Mueller, Director and Robert C. Cantu, Medical Director.

    The Annual Survey of Catastrophic Football Injuries was part of a concerted effort put forth by many individuals and research organizations to reduce the steady increase of football head and neck injuries taking place during the 1960's and 1970's.  The primary purpose of the research was and is to make the game of football a safer sport.

Data Collection

    Since 1977 and the initiation of this research, catastrophic injuries were defined as football injuries which resulted in  brain or spinal cord injury or skull or spine fracture.  It should be noted that all cases involved some disability at the time of the injury. Neurological recovery is either complete or incomplete (quadriplegia or quadriparesis). Yearly follow-up is not done, thus neurological status (complete or incomplete recovery) refers to when the athlete is entered into the registry which is usually two to three months after injury.  Injuries which result in death are not included in this report.

    Data were complied with the assistance of high school and college coaches, athletic directors, school administrators, physicians, athletic trainers, executive officers of state and national athletic organizations, sporting goods dealers and manufacturers' representatives, a national newspaper clipping service, and professional associates of the researchers.  Data collection would have been impossible without the help of the National Federation of State High School Associations and the National Collegiate Athletic Association.  The research was funded by a grant provided by the National Collegiate Athletic Association.

    Upon receiving information concerning a possible catastrophic football injury, contact by telephone, personal letter, and questionnaire is made with the injured player's coach, physician and athletic director.  The questionnaire provides background data on the athlete (age, height, weight, experience, previous injury, etc.), accident information, immediate and post-accident treatment, and equipment data.

    In 1987, a joint endeavor was initiated with the section on Sports Medicine of the American Association of Neurological Surgeons.  The purpose of this collaboration was to enhance the collection of medical data.  Dr. Robert C. Cantu, Chairman, Department of Surgery and Chief, Neurosurgery Service, Emerson Hospital, in Concord, MA, and the Medical Director of the National Center for Catastrophic Sports Injury Research has been responsible for collecting the medical data.

Background

    An early investigation into serious head and neck football injuries was conducted by Schneider.  (1)  He reported 30 permanent cervical spinal cord injuries in high school and college football during the period from 1959 - 1963.  A later study by Torg indicated a total of 99 permanent cervical spinal cord injuries in high school and college football from 1971 - 1975.  (3)  Torg has discontinued his research, but his data show a decline in permanent cervical cord injuries in high school and college from 34 cases in 1976 to 5 cases in 1984.  A study published in 1976 reported the incidence of neck injuries based on roentgenorgraphic evidence was as high as 32% in a sample of 104 high school students and 75 college freshmen in Iowa. (2)    

    In order to help alleviate this problem the National Collegiate Athletic Association and the National Federation of State High School Associations implemented rule changes in 1976 to prohibit using the head as the initial contact point when blocking and tackling.  Furthermore, the American Football Coaches Association Ethics Committee went on record opposing this type of blocking and tackling. The National Federation of State High School Associations 2006 Football Rule Book states that butt blocking, face tackling and spearing are illegal.  Butt blocking is defined as a technique involving a blow driven directly into an opponent with the face mask, frontal area or top of the helmet as the primary point of contact either in close line play or in the open field. Face tackling is defined as driving the face mask, frontal area or top of the helmet directly into the runner. Spearing, as opposed to butt blocking and face tackling, is defined as the intentional use of the helmet in an attempt to punish an opponent. All three of these illegal techniques can cause catastrophic head and neck injuries to the athlete. Coaches should not teach these techniques and referees should do a better job of calling these penalties in a game. The college rules have also eliminated the word intentional from the spearing rule.

    Emphasis on complete physical examinations and improved physical conditioning programs has also been recommended to mitigate the injury issue.

Summary
 

1. During the 2007 football season there were a total of eight cervical cord injuries with incomplete neurological recovery.  Six of the injuries occurred at the high school level, none at the college level, and one at the professional level. This is a decreased of two when compared to the 2005 data but comparable to the 2006 data, and increase to the 2005 data and slight decrease from the 2003 and 2004 data.   (Table I)
2. The incidence of catastrophic injuries is very low on a 100,000-player exposure basis.  For the approximately 1,800,000 participants in 2007 the rate of injuries with incomplete neurological recovery was 0.44 per 100,000 participants.
3. The rate of injuries with incomplete neurological recovery in high school and junior high school football was 0.40 per 100,000 players and the rate at the college level was 0.00.   (Table II)
4. A majority of catastrophic spinal cord injuries usually occur in games.  During the 2007 season five injuries took place in games, two in practice, and one in a scrimmage game.
5. Tackling and blocking have been associated with the majority of catastrophic football injuries. In 2007, three injuries were caused by tackling, two by being tackled, one while blocking on a kickoff return, , and the activity of one was unknown..  As shown in Table IV tackling has been associated with 69.1% of the catastrophic injuries since 1977.
6. As indicated in Table III a majority of the catastrophic injuries occur while playing defensive football.  In 2007 four players were on defense, three on offense, and one was unknown.
7. During the 2007 football season there were also four brain injuries which resulted in incomplete recovery. All six were at the high school level. (Table VI).
8.  In 2006 there were also ten injuries that involved either a head or neck injury, but the athlete had full neurological recovery. This is the largest number since the study began in 1977. High school athletes were associated with nine cervical vertebrae fractures, five brain injuries, (one a severe concussion), and four transient paralysis injuries. College athletes were associated with three cervical vertebrae fractures, two brain injuries, one spinal concussion, and one career ending unknown neck injury.  Professional players were involved with four cervical vertebrae fractures, one fractured transverse process, and one spinal concussion. Sandlot football accounted for one fractured cervical vertebra with recovery.  It should be emphasized that the researchers are not confident concerning the number of injuries with full recovery, but data collection in 2007 produced the highest number of catastrophic recovery injuries since the study was initiated in 1977. (Table VII).

    For the past 31 years there have been a total of 278 football players with incomplete neurological recovery from cervical cord injuries. Two hundred and twenty-nine of these injuries have been to high school players, thirty-three to college players, six to sandlot players and ten to professionals.  This data indicate a reduction in the number of cervical cord injuries with incomplete neurological recovery when compared to data published in the early 1970's.  The 2005 data showed a major reduction from the 12 injuries in 2004, but the 2006 data show a major increase to ten.  Any injury that causes permanent disability is a major concern and future reports must be monitored closely.

    The twelve cervical cord injuries with incomplete recovery in 2004 was a dramatic increase from the years of single digits – 1991-2002.  An update in 1999 increased that number to 10.  The 2005 data showed a major reduction to three from the 12 injuries in 2004,, but the 2006 data show an increase to ten.  Three of the last five years show double digits. Since 1984 there have been 110 brain injuries with incomplete recovery. These numbers also are a concern, and if the cervical cord injuries and the cerebral injuries with incomplete recovery are combined, the number of incomplete recovery injuries is 388. That is an average of approximately 12.5 injuries with incomplete recovery for the past 31 years. Coaches, players, trainers, physicians and administrators must continue the emphasis on eliminating permanent disability injuries to football players. 

    The latest participation figures show 1,500,000 players participating in junior and senior high school football and 75,000 in college football.  Table II illustrates the incidence of spinal cord injuries for both high school and college participants.  The incidence rate per 100,000 participants in 2007 is less than one per 100,000 at the high school level (0.40) and 0.00 at the college level. In looking at the incidence rates for the past 30 years, the high school incidence is 0.52 per 100,000 participants and the college incidence is 1.41 per 100,000 participants.

    As indicated in past reports a majority of the permanent cervical cord injuries are taking place in games. In 2007 seven of the ten injuries took place in games, two in practice, and one in a game scrimmage.

    Past reports (Table V) have revealed that defensive backs were injured at a higher rate than other positions.  In 2007, one of the injured players was defensive back, two were on the kick-off team, two were running backs, one was a defensive lineman, and the position of one was unknown.

    In 2007 there were four brain injuries with incomplete neurological recovery.  All four of the injuries were at the high school level.  In addition to the injuries with incomplete recovery, there were there were 33 injuries with complete recovery.  High school football included four brain injuries, nine cervical spine fractures, four transient paralysis injuries, one low back injury, and one severe concussion.   College injuries with full recovery included four cervical fractures and one severe concussion.  There were also four professional players with fractured cervical vertebrae, one with a fractured transverse process, and one spinal concussion. There was also one sandlot player with a fractured cervical vertebrae with full recovery.  As stated earlier the researchers do not have confidence in the full recovery data, but the data in 2007 is the highest number of catastrophic injuries with recovery since the study was initiated in 1977.   It is our belief that there are a higher number of recovery injuries that we are not receiving information on, but the 2007 data show that we are making progress.

Recommendations

    As stated in earlier reports, there has been a reduction of permanent cervical cord injuries when compared to data from the early 1970's. The 1995, 1996, 1997, and 1999 data indicated an increase, but were fewer than the early 1970's. The 1991 and 1994 data show a dramatic reduction to one permanent cervical cord injury in high school football. That was a great accomplishment and every effort should be made to continue that trend. For the past ten years, 1998-2007, there has been an average of 8.1 cervical cord injuries with incomplete neurological recovery, and 4.6 cerebral injuries with incomplete recovery in football. The eight cerebral injuries in 1997 and nine in 2003 were the highest number since we started to collect that data in 1984.

    The initial reduction of permanent disability injuries was the result of efforts put forth by the total athletic community concerned with safety to football participants. Major areas of emphasis that once again should receive attention are the 1976 rule change that eliminated the head as the initial point of contact during blocking and tackling, improved medical care both at the game site and in medical facilities, improved coaching techniques in teaching the fundamentals of tackling and blocking, and the increased concern and awareness of football coaches. The original 1976 rule defined spearing as "the intentional use of the helmet (including face mask) in an attempt to punish an opponent". In the new 2005 definition of spearing the word "intentional" was removed from the rule."

    A concerted effort must be made to continue the reduction of cervical spine and cerebral injuries and to aim for the elimination of these  injuries.  Following are several suggestions for reducing these catastrophic injuries:

1. Brain and spinal injuries in football have been dramatically reduced since the rules were changed in 1976 to prohibit butt blocking and face tackling, and other techniques in which the helmet and facemask purposely received the brunt of the initial impact.  There are still a small number of football players that become paralyzed due to cervical cord injury.  Because head contact largely caused these injuries it is important to remember the lesson to keep the head and face out of blocking and tackling.  Coaches should drill the players in the proper execution of the fundamentals of football - particularly blocking and tackling.  SHOULDER BLOCK AND TACKLE WITH THE HEAD UP- KEEP THE HEAD OUT OF FOOTBALL.
2. Preseason physical exams for all participants.  Identify during the physical exam those athletes with a history of previous brain or spinal injuries.  If the physician has any questions about the athlete’s readiness to participate, the athlete should not be allowed to play.
3.  Athletes must be given proper conditioning exercises which will strengthen their necks in order to be able to hold their heads firmly erect while making contact during a tackle or block.  Strengthening of the neck muscles may also protect the neck from injury.
4. Coaches and officials should discourage the players from using their heads as battering rams when blocking, tackling, and ball carrying  The rules prohibiting spearing should be enforced in practice and games.  The players should be taught to respect the helmet as a protective device and that the helmet should not be used as a weapon. Ball carriers should also be taught not to lower their heads when making contact with the tackler.
5. Football officials can play a major role in reducing catastrophic football injuries. The use of the helmet-face mask in making initial contact while blocking and tackling is illegal and should be called for a penalty.  Officials should concentrate on helmet-face mask contact and call the penalty. If more of these penalties are called there is no doubt that both players and coaches will get the message and discontinue this type of play. A reduction in helmet-face mask contact will result in a reduction of catastrophic football injuries.
6.  All coaches, physicians and trainers should take special care to see that the players' equipment is properly fitted, particularly the helmet.
7. It is important, whenever possible, for a physician to be on the field of play during game and practice.  When this is not possible, arrangements must be made in advance to obtain a physician's immediate services when emergencies arise.  Each institution should have a team trainer who is a regular member of the institution's staff and who is qualified in the emergency care of both treating and preventing injuries.
8. Coaches must be prepared for a possible catastrophic head or neck injury.  The entire staff must know what to do.  Being prepared and knowing what to do may be the difference that prevents permanent disability. Have a              written emergency plan and give copies to all personnel.
9. When a player has experienced or shown signs of head trauma (loss of consciousness, visual disturbances, headache, inability to walk correctly, obvious disorientation, memory loss), he should receive immediate medical attention and should not be allowed to return to practice or game without permission from the proper medical authorities.
10.  Coaches should encourage players to let them know if they have any of the above mentioned symptoms (that can’t be seen by others, such as headaches) and why it is important.
11. Both past and present data show that the football helmet does not cause cervical spine injuries, but that poorly executed tackling and blocking technique is the major problem.

Following is a list of post concussion signs/symptoms:
Depression                 Numbness/Tingling              Dizziness                    Poor Balance
Drowsiness                Poor Concentration             Excess Sleep              Fatigue
Sadness                     Sensitive to Light                 Headache                   Irritability
Memory Problems      Vomiting                             Nausea
Nervousness               Sensitive to Light                 Ringing in Ears
Feel “in fog”                Trouble Falling Asleep 

    Research based on reliable data is essential if progress is to be made. Research provides data that indicate the problems and reveal the adequacy of preventive measures.  It is important to point out that the information in this report is only as good as the data collected.  The report only includes data on cases that are reported to us by the NFHS, the NCAA, coaches, athletic directors, and a national newspaper clipping service.  It is our feeling that we receive information on a majority of the cases, but that it is not possible to state we have information on 100% of the cases.

References
 

1. Schneider, R.C.:  Head and Neck Injuries in Football.  Baltimore, William and Wilkins Co., 1973.
2. Albright, J.P., Moses, J.M., Feldick, H.G., et al.:  Nonfatal Cervical Spine Injuries in Interscholastic Football.  JAMA 236:  1243 - 1245, 1976.
3. Torg, J.S., Trues, R., Quedenfeld, T.C., et al.:  The National Football Head and Neck Injury Registry.  JAMA 241:  1477 - 1479, 1979.
4. Mueller, F.O., Colgate, B..:  Annual Survey of Football Injury Research 1931 - 2006.  National Collegiate Athletic Association, National Federation of State High School Associations and the American Football Coaches Association, 2002.