Prepared for:

American Football Coaches Association, Waco, Texas
National Collegiate Athletic Association, Indianapolis, Indiana
The National Federation of State High School Associations, Indianapolis, Indiana
 

Copyright 2007 by The American Football Coaches Association,
The National Collegiate Athletic Association and the
National Federation of State High School Associations.

Submitted February 2008

Introduction

    In 1931 the American Football Coaches Association initiated the First Annual Survey of Football Fatalities.  The original survey committee was chaired by Marvin A. Stevens, M.D., of Yale University, who served from 1931-1942.  Floyd R. Eastwood, Ph.D., Purdue University, succeeded Dr. Stevens in 1942 and served through 1964.  Carl S. Blyth, Ph.D., University of North Carolina at Chapel Hill, was appointed in 1965 and served through the 1979 football season.  In January 1980, Frederick O. Mueller, Ph.D., University of North Carolina at Chapel Hill, was appointed by the American Football Coaches Association and the National Collegiate Athletic Association to continue this research under the new title, Annual Survey of Football Injury Research.

    The primary purpose of the Annual Survey of Football Injury Research is to make the game of football a safer, and therefore, a more enjoyable sports activity.  Because of these surveys the game of football has realized many benefits in regard to rule changes, improvement of equipment, improved medical care, and improved coaching techniques.  The 1976 rule change that made it illegal to make initial contact with the head while blocking and tackling was the direct result of this research.

    The 1990 report was historic in that it was the first year since the beginning of the research, 1931, that there was not a direct fatality in football at any level of play. This clearly illustrates that data collection and analysis is important and plays a major role in injury prevention.

Data Collection

    Throughout the year, upon notification of a suspected football fatality, immediate contact is made with the appropriate officials (coaches, administrators, physicians, trainers). Pertinent information is collected through questionnaires and personal contact.

    Football fatalities are classified for this report as direct and indirect.  The criteria used to classify football fatalities are as follows:

Direct - Those fatalities which resulted directly from participation in the fundamental skills of  football.
Indirect - Those fatalities which are caused by systemic failure as a result of  exertion while participating in football activity or by a complication which was secondary to a non-fatal injury.

    Participation numbers were updated in the 1989 report. The National Federation of State High School Associations has estimated that there are approximately 1,500,000 high school, junior high school, and non-federation school football participants in the United States. The college figure of 75,000 participants includes the National Collegiate Athletic Association, the National Association of Intercollegiate Athletics, the National Junior College Athletic Association, and an estimate of schools not associated with any national organization. Sandlot and professional football have been estimated at 225,000 participants. These figures give an estimate of 1,800,000 total football participants in the United States for the 2007 football season.

    Dr. Mueller compiled and prepared the survey report on college, professional, and sandlot levels, and Mr. Jerry Diehl of the National Federation of State High School Associations assumed responsibility for collecting and preparing the senior and junior high school phase of the study. Sandlot is defined as non-school football, but organized and using full protective equipment.

    At the conclusion of the football season, both reports are compiled into this Annual Survey of Football Injury Research. This report is sponsored by the American Football Coaches Association, the National Collegiate Athletic Association, and The National Federation of State High School Associations.

Acknowledgments

    Medical data for the 2007 report were compiled by Dr. Robert C. Cantu, Chairman, Department of Surgery and Chief, Neurosurgery Service, Emerson Hospital, in Concord, MA.  Dr. Cantu is a Past-President of the American College of Sports Medicine and is the Medical Director for the National Center for Catastrophic Sports Injury Research at the University of North Carolina at Chapel Hill.

Summary

1. There were four fatalities directly related to football during the 2007 football season. Three were in high school football, and one was at the professional level (World Indoor Football League) The one fatality was related to high school football. (Table I).
2. The rate of direct fatal injuries is very low on a 100,000 player exposure basis. For the approximately 1,800,000 participants in 2007, the rate of direct fatalities was 0.22 per 100,000 participants.
3. The rate of direct fatalities in high school and junior high school football was 0.02 per 100,000 participants. The rate of direct fatalities in college was 0.00 per 100,000 participants.  (Table III)
4. Most direct fatalities usually occur during regularly scheduled games. In 2007 the one direct fatality occurred in practice.
5. The 2007 survey shows that three of the fatalities took place in October and one in February.
6. The major activities in football would naturally account for the greatest number of fatalities. In 2007 two of the fatalities happened while tackling and two while being tackled.  (Table V)
7. In 2007 tow fatalities resulted from injuries to the brain,one from an injury to the spinal cord, and one to internal injuries. (Table VI)
8. In many cases football cannot be directly responsible for fatal injuries (heat stroke, heart related and so forth). In 2007 there were 9 indirect fatalities. Six were associated with high school football, one with college football, one with sandlot, and one with semi-professional football.  The high school indirect deaths were two heart related, two heat stroke, one pulmuonary embolism and one unknown.  The college indirect deaths were one heart related death. The sandlot death was also heart related, and the semi-proessional death was related to being diabetic.  The professional player did not have a physical exam, but signed a medical waiver in order to play.  (Table VIII)

    After a slight rise in the number of football fatalities during the 1986 season, the 1990 data revealed the elimination of direct football fatalities. That was the first time in the past 59 years that there have been no direct football fatalities. The 2006 data continues the trend of single digit direct fatalities that started in the 1978 football season.  There was a decrease from nine direct fatalities in 2001, to six in 2002, three in 2003, five in 2004, three in 2005, one in 2006, and four in 2007..  The data illustrates the importance of data collection and the analysis of this data in making changes in the game of football that help reduce the incidence of serious injuries. This effort must be continued in order to keep these numbers low and to strive for the elimination of football fatalities. Indirect injuries have been in double figures since 1999 with the exception of 2003 and 2007. The 2007 indirect injuries show a reduction of seven when compared to the 2006 data.

Head and Neck Injuries

    Past efforts that were successful in reducing fatalities to the levels indicated from 1990 through 2007, and the elimination of direct fatalities in 1990 should again be emphasized.  Rule changes for the 1976 football season which eliminated the head as a primary and initial contact area for blocking and tackling is of utmost importance.  The original 1976 rule defined spearing as "the intentional use of the helmet (including the face mask) in an attempt to punish an opponent."  In the new 2005 definition in the rules “intentional” has been dropped.  The new rule says “spearing is the use of the helmet (including the face mask) in an attempt to punish an opponent”.    A 2006 point of emphasis covers illegal helmet contact and defines spearing, face tackling, and butt blocking. High shcool rule changes effective during 2006-2007 stated that at least a 4-point chistrap shall be required to secure the helmet, and all mouth guards must be colored, not white or clear. Also, rules revisions regarding illegal helmet contact were made in February of 2007. The committee placed butt blocking, face tackling, and spearing under the heading of "Helmet Contact-Illegal" to place more emphasis on risk-minimization concerns. Examples of illegal helmet contact that could result in disqualification include illegal helmet contact against and opponent lying on the ground, illegal helmet contact against an opponent held up by other players, and illegal helmet-to-helmet contact against a defenseless opponent.   Coaches who are teaching helmet or face to the numbers tackling and blocking are not only breaking the football rules, but are placing their players at risk for permanent paralysis or death. This type of tackling and blocking technique was the direct cause of 36 football fatalities and 30 permanent paralysis injuries in 1968. In addition, if a catastrophic football injury case goes to a court of law, there is no defense for using this type of tackling or blocking technique.  Since 1960 most of the direct fatalities have been caused by head and neck injuries, and in fact since 1990 all but three of the direct deaths have been brain injuries.  We must continue to reduce head and neck injuries.

Several suggestions for reducing head and neck injuries are  as follows:

1.  Athletes must be given proper conditioning exercises which will strengthen their necks so that participants will be able to hold their heads firmly erect when making contact.
2. Coaches should drill the athletes in the proper execution of the fundamental football skills, particularly blocking and tackling. Contact should always be made with the head up and never with the top of the head/helmet. Initial contact should never be made with the head/helmet or face mask.
3. Coaches and officials should discourage the players from using their heads as battering rams when blocking and tackling.  The rules prohibiting spearing should be enforced in practice and in 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.
4. All coaches, physicians, and trainers should take special care to see that the player's equipment is properly fitted, particularly the helmet.
5. 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.
6. A number of the players associated with brain trauma complained of headaches or had a previous concusion prior to their deaths.  Players should be made aware of these signs by the team physician, athletic trainer, or coach.  Players should also be encouraged to inform the team physician, athletic trainer, or coach if they are experiencing any of the above mentioned signs of brain trauma.
7. Coaches should never make the decision whether a player returns to a game or active participation in apractice if that player experiences brain trauma.

    The authors of this research are convinced that the current rules which eliminate the head in blocking and tackling, coaches teaching the proper fundamentals of blocking and tackling, the helmet research conducted by the National Operating Committee on Standards for Athletic Equipment (NOCSAE), excellent physical conditioning, proper medical supervision and a good data collection system have played the major role in reducing fatalities and serious brain and neck injuries in football. This is best illustrated by Table IX and Graph I which show the increase in both brain and cervical spine fatalities during the decade from 1965-1974.  This time period was associated with blocking and tackling techniques that involved the head as the initial point of contact.  The reduction in brain and cervical spine injuries is shown in the decade from 1975-1984.  This decade was associated with the 1976 rule change that eliminated the head as the initial contact point in blocking and tackling.  There is no doubt that the 1976 rule change has made a difference and that a continued effort should be made to keep the head out of the fundamental skills of football. Data from the decade 1985-1994 continues to illustrate the reduction in brain and neck fatalities.  A concern is that the data from 1995-2004 has already shown an increase in brain fatalities over that of 1985-1994.  There has been an increase of 10 brain deaths during the decade 0f 1995-2004, which is an increase of  2.1% over 1985-1994.  The decade from 2005-2014 will have to be watched closely.

Heat Stroke

    A continuous effort should be made to eliminate heat stroke deaths associated with football.  Since the beginning of the survey through 1959 there were five cases of heat stroke death reported.  From 1960 through 2007 there have been 114 heat stroke cases which resulted in death (Table IV). The 2007 data show two cases of heat stroke death at the high school level.There was another high school case that could have been a heat stroke death, but there was autopsy performed. There is no excuse for any number of heat stroke deaths since they are al preventable witht he proper precautions. Since 1995 there have been 33 football players die from heat stroke (25 high school, 5 college, 2 professional, and one sandlot). Every effort should be made to continuously educate coaches concerning the proper procedures and precautions when precautions when practicing or playing in the heat.   .   Since 1995 there have been 31 football players die from heat stroke (23 high school, 5 college, and 2 professional, and one sandlot). Every effort should be made to continuously educate coaches concerning the proper procedures and precautions when practicing or playing in the heat.      Since 1974 there has been a dramatic reduction in heat stroke deaths with the exception of 1978, 1995, 1998,  when there were four each year, and 2000 and 2006 when there were five each year.  There were no heat stroke deaths in 1993, 1994, 2002 and 2003.  All coaches, trainers, and physicians should place special emphasis on eliminating football fatalities which result from physical activity in hot weather.

    Heat stroke and heat exhaustion are prevented by careful control of various factors in the conditioning program of the athlete.  When football activity is carried on in hot weather, the following suggestions and precautions should be taken:

1.  Each athlete should have a complete physical examination with medical history and an annual health history update. History of previous heat illness and type of training activities before organized practice begins should be included.
2. Acclimatize athletes to heat gradually by providing graduated practice sessions for the first seven to ten days and other abnormally hot or humid days.
3. Know both the temperature and the humidity since it is more difficult for the body to cool itself in high humidity.  Use of a sling psychrometer is recommended to measure the relative humidity and anytime the wet-bulb temperature is over 78 degrees practice should be altered.
4. Adjust activity level and provide frequent rest periods.  Rest in cool, shaded areas with some air movement and remove helmets and loosen or remove jerseys.  Rest periods of 15-30 minutes should be provided during workouts of one hour.
5. Provide adequate cold water replacement during practice.  Water should always be available and in unlimited quantities to the athletes. GIVE WATER REGULARLY.
6. Salt should be replaced daily and liberal salting of the athletes' food will accomplish this purpose.  Coaches should not provide salt tablets to athletes.  Attention must be directed to water replacement.
7. Athletes should weigh each day before and after practice and weight charts checked in order to treat the athlete who loses excessive weight each day.  Generally, a three percent body weight loss through sweating is safe, and a five percent loss is in the danger zone.
8. Clothing is important and a player should avoid use of long sleeves, long stockings, and any excess clothing. Never use rubberized clothing or sweatsuits.
9.  Some athletes are more susceptible to heat injury.  These individuals are not accustomed to work in the heat, may be overweight, and may be the eager athlete who constantly competes at his capacity.  Athletes with previous heat problems should be watched closely.
10. It is important to observe for signs of heat illness.  Some trouble signs are nausea, incoherence, fatigue, weakness, vomiting, cramps, weak rapid pulse, flushed appearance, visual disturbances, and unsteadiness. Heat stroke victims, contrary to popular belief, may sweat profusely.  If heat illness is suspected, seek a physician's immediate service.  Recommended emergency procedures are vital.
11. An increasing number of medical personnel are now using  treatment for heat illnesses that involves applying either alcohol or cool water to the victim's skin and is followed by vigorous fanning.  The fanning causes evaporation and cooling.  Immersing the athlete in ice water will also help bring down the body temperature.  Some schools have plastic outdoor swim pools filled with ice water available at practice facilities.  
    
    

 Specific recommendations resulting from the 2007 survey data are as follows:

1. Mandatory medical examinations and medical history should be taken before allowing an athlete to participate in football.  The NCAA recommends a thorough medical examination when the athlete first enters the college athletic program and an annual health history update with use of referral exams when warranted.  If the physician or coach has any questions about the athlete's readiness to participate, the athlete should not be allowed to play.  High school coaches should follow the recommendations set by their State High School Athletic Associations.
2. All personnel concerned with training football athletes should emphasize proper, gradual, and complete physical conditioning.  Particular emphasis should be placed on neck strengthening exercises.
3. A physician should be present at all games and practice sessions.  If it is impossible for a physician to be present at all practice sessions, emergency measures must be provided.  Written emergency procedures are recommended for both coaches and medical staff.
   
4. All personnel associated with football participation should be cognizant of the problems and safety measures related to physical activity in hot weather.
5. Each institution should strive to have a team trainer who is a regular member of the  faculty and is adequately prepared and qualified.
6. Cooperative liaison should be maintained by all groups interested in the field of Athletic Medicine (coaches, trainers, physicians, manufacturers, administrators, and so forth).
7. There should be strict enforcement of game rules, and administrative regulations should be enforced to protect the health of the athlete.  Coaches and school officials must support the game officials in their conduct of the athletic contests.
8. There should be a renewed emphasis on employing well-trained athletic personnel, providing excellent facilities, and securing the safest and best equipment possible.
9. There should be continued research concerning the safety factor in football (rules, facilities, equipment, and so forth).
10. Coaches should continue to teach and emphasize the proper fundamentals of blocking and tackling to help reduce head and neck fatalities. KEEP THE HEAD OUT OF FOOTBALL.
11. Strict enforcement of the rules of the game by both coaches and officials will help reduce serious injuries.  Be aware of the 2005 rule change to the 1976 definition of spearing.
12. 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.
13. The number of indirect heart related deaths has increased over the years and it is recommended that schools have automated external defibrillators (AED) available for emergency situations.
    

High School

Professional

     A 25 year-old World Indoor Football League football player was injured on February 26, 2007, after a helmet-to-helmet tackle. He was 6'1" tall and weighed 180 lbs. The injured athlete was a definsive back making the tackle in the 4th quarter of a game. Injury was diagnosed as a brain injury and he was dead on arrival at the hospital.   . 

High School

     A 17 year-old high school football player collapsed at practice on August 13, 2007, and died on August 20, 2007. He was running laps at the time and cause of death was heart related. He did not have a physical exam before the season  . 

     A 16 year-old high school football player received blunt trauma to the knee during practice on August 30, 2007. He died of a blood clot that broke loose to the lungs, "pulmonary thrombi emboli". Death was on September 8, 2007.  .  .

    A 15 year-old high school football player collapsed on the sidelines during the 3rd quarter of a game. He was treated with CPR and AED and died at the hospital. Cause of death was hear related. (blocked coronary artery caused by fibromuscular dysplasia-a rare condition).    

    A 16 year-old high school football player collapsed at practice on August 1, 2007, during the third practice of year and was in full pads. He was 6'1" tall and weighed 220 lbs. Temperature was in the high 90's but there was no autopsy. 

    A 16 year-old high school football player collapsed on the first day of conditioning on August 17, 2007. He was 5'9" tall and weighed 250 lbs. Practice was three hours and the temperature was 90 degrees. Cause of death was heat stroke.