Michigan Governors Council on Physical Fitness, Health and Sports
The Prevention of Injuries in
It is the position of the Governors Council on Physical Fitness, Health and Sports that informing the public about safe practices is essential for reducing injuries in amateur sports. Football is a highly physical sport. It is inevitable that some injuries will occur in football. However, there are measures that can reduce the risk that injuries will occur or minimize the severity of injuries. A summary of these measures is presented below. It is acknowledged that it would not be feasible for every athletic program in Michigan to adopt every known preventive measure. However, knowing the best thinking available on safe football practices is the first step toward minimizing injuries.
Preventive Measures Related to the Athlete
Age and Maturation: Children under six years old should not play competitive football. Tackle football should not be played by children under 10 years of age. Youth teams should be matched by skill level and size.
Pre-participation Physical Evaluation: Every athlete should receive a pre-participation physical evaluation (PPE) to (1) detect conditions which could make playing football life-threatening or disabling and (2) detect medical or musculoskeletal conditions that could predispose an athlete to injury or illness during practice or competition. The evaluation should include both a medical history and physical exam.
The PPE should be performed by a physician, physician assistant, or nurse practitioner with the training and medical skills to recognize heart disease and orthopedic conditions of concern for football.
In addition to cardiovascular screening, the PPE for football should include (1) an orthopedic exam focusing on neck strength, joint range of motion, flexibility, anatomical malalignments and muscle-tendon imbalances and (2) documentation/re-examination of past neurological, bone and joint injuries.
Conditions should be documented which have potential implications for an athletes safety during practice or games (e.g., visual impairment, diabetes, hypertension, asthma, severe allergies, sickle cell disease, history of heat illness, history of concussion, use of medications, use of steroids, symptoms of eating disorders, etc.).
Performing the evaluation at least six weeks prior to pre-season practice would allow time for correction or rehabilitation of identified problems.
Knowledge and Skill Development: Before playing football, each athlete should have mastered a basic set of information and skills. At a minimum, athletes should understand the rules of football related to injury prevention and should master the proper execution of the fundamental football skills, particularly blocking and tackling without using the head.
Conditioning: Year-round conditioning programs involving exercise and appropriate nutrition are essential to the athletes safety. Conditioning programs for football should promote anaerobic endurance; cardiovascular endurance; flexibility; range of motion and muscle strength, power and endurance. More intensive conditioning and strength training should be initiated a minimum of six weeks before the start of daily practice, so athletes will be conditioned before the first day of practice.
Muscle Strengthening: Resistance training programs may help to prevent injuries in youth sports. To avoid injury, fitness professionals who have a thorough understanding of resistance training and safety procedures should supervise every exercise session. Equipment should be in good repair and properly adjusted to each individual user. Strengthening exercises should be preceded by 5-10 minutes of general warm-up exercises (low intensity aerobic exercise and stretching). Any individual muscle group should be trained only two to three times per week, to allow two to three days of rest between resistance training sessions for a given muscle group. Resistance training regimens should be individualized for each athlete; competition among athletes for levels of strength should be discouraged.
Weight Equipment for Youth: If weight equipment is used as part of the strengthening regime for youth who have not completed puberty, equipment should be carefully selected and adjusted for immature users. Direct supervision should be provided by a qualified adult. Youth should be carefully instructed in technique and in equipment adjustment. No one-repetition maximal lifts should ever be attempted by physically-immature athletes.
Neck Strengthening: To reduce the risk of spinal injuries, athletes should receive football-specific shoulder, upper back and neck flexibility and strengthening exercises, so players will be able to hold their heads firmly during blocking and tackling. Close supervision is required to check that these exercises are being done and being done correctly. Neck strengthening exercises should not be performed immediately prior to a practice or a game.
Overuse Injuries: Younger athletes are particularly susceptible to overuse injuries. To prevent such injuries, conditioning and skill practicing sessions should be increased gradually in intensity, duration and frequency.
Preventive Measures Related to the Sports Setting
Equipment and Apparel: Each athlete should have equipment that is the safest available. All helmets should meet safety standards set by the National Operating Committee on Standards in Athletic Equipment (NOCSAE). Mouth protectors, properly-sized for each athlete, should be worn. Protective eye devices should be mandatory for players with severely impaired vision or vision in only one eye. All equipment should be carefully examined for damage before it is given to an athlete, and periodically during the season. Old, worn, or damaged equipment should be reconditioned or discarded. Improper fit of protective football equipment may increase the severity of an injury or be the cause of one; therefore, each player should be individually fitted for each piece of equipment. Coaches should pay particular attention when assigning equipment to young or inexperienced players who may not recognize when equipment feels right.
Facilities: Playing fields should be well-lighted and free of holes, broken glass and other hazardous debris. All fields should be well-maintained. Goal posts should be padded to prevent injuries from high-speed collisions. Locker rooms, weight rooms and shower rooms should be sanitary, well-lighted and free of hazardous debris, with ground fault circuit interrupters when water is near electrical outlets. To prevent injuries to spectators, out-of-bounds buffer zones between spectators and the playing field should be adequate to prevent collisions.
Preventive Measures Related to Management of Practice and Competition
Coachs Responsibilities: The coach has overall responsibility for the safety of the athletes, including teaching safety principles to them; overseeing proper selection, fitting and maintenance of equipment; seeing that they are properly conditioned; requiring proper warm-up; teaching appropriate techniques; avoiding unsafe environmental situations; and preventing players from competing beyond their fatigue level. The coach should be certified in first aid and CPR, and should attend state-approved in-service training on coaching football. The coach should have a thorough mastery of the rules of football.
Preventing Catastrophic Spine Injuries: Coaches should teach players not to use the top of their helmets to tackle, block or strike opponents. 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.
Practices: Pre-season practices are injury-prone times. Controlled activities should be emphasized at this time and coaching staff should be particularly vigilant of technique. A significant percent of injuries occur during contact practice drills. A reduction in the amount of contact practice should be considered as the season progresses.
Officials Responsibilities: Officials should promote the safety of athletes by having a thorough mastery of the rules of football and by enforcing the rules strictly.
Trainer Responsibilities: Each institution responsible for football competition should identify a staff member with first aid training whose roles are to develop an injury prevention program, work with injuries and develop a conditioning program. This person should be present at all practices and all games. These roles are best accomplished by an athletic trainer who is certified by the National Athletic Trainers Association (NATA).
Parents Responsibilities: Parents of young athletes are important for safe football. They should be well-informed about specific injury prevention measures, including safer blocking and tackling techniques that do not use the head. They should be free to make unannounced visits to practices and should ask questions if they see something that seems unsafe. In addition, parents should be sure any injury is reported to the athletic program staff, should reinforce compliance with treatments or rehabilitation after injury and be sure that athletes immunizations are up-to-date.
Athletes Responsibilities: Athletes can reduce their risk of injuries by cooperating with conditioning programs, mastering correct execution of football techniques, wearing protective equipment, following the rules of football, reporting all injuries (even minor ones) to the athletic program staff and complying with injury treatment and rehabilitation programs.
Financial Support: Running athletic programs on a shoestring budget to maximize opportunities for participation is understandable. For football, however, because of the risk for permanent disabling injury and death, adequate financial support is needed to assure that each child has the safest possible equipment, fields are well-maintained, children can receive good pre-participation physicals and adequate medical supervision during practices and games.
Emergency Preparation: To minimize delays in treating injured athletes:
A telephone should be immediately available at all game and practice sites, with prominent posting of numbers of ambulance, paramedics, first aid personnel and police.
Plainly-marked emergency first aid equipment should be accessible on the field. This equipment should be inspected periodically to assure its completeness, cleanliness and usability.
An emergency action plan should be developed and rehearsed. Key personnel who are to carry out the plan should be identified. The plan should include responses to severe injuries, hypothermia, heat illness and allergic reactions to plants and stinging insects.
An NATA-certified athletic trainer or a physician should be available at every game and practice. If this is not possible, a physician should be available by phone or pager. At a minimum, a specific agreement should be negotiated with a local emergency department and/or emergency medical service (EMS) provider to deal with injured athletes.
Up-to-date medical information for each athlete should be immediately accessible at the site of every game and practice. This information should include emergency contacts, preferred physician, preferred hospital and a signed consent form giving permission to provide emergency care. In addition, any health conditions or medications should be documented.
Emergency transportation should be available on the scene or within six minutes from the football field. There should be no cars blocking ambulance routes to the field.
Managing Severe Weather: Extreme weather conditions threaten the health of athletes, coaches and spectators. Policies for modifying or canceling games and practices under conditions of lightning, severe storms, tornadoes, high heat/humidity and low wind-chill index should be clearly defined before a season begins. Weather policies should include the chain of command for making weather decisions, the method to be used to document weather and the specific weather conditions that would result in specific precautions. Athletic programs should use Weather Radio equipped with the emergency alert system provided by the National Weather Service to be fully informed about life-threatening weather conditions.
Precautions for Lightning: Know where the closest safe shelter is and how long it takes to get there. Monitor how close lightning is striking and how fast it is approaching by counting the number of seconds between the time lightning is sighted and the time thunder is heard. Before the flash-to-bang count reaches 30 seconds, all individuals should have left the athletic site and reached safe shelter. Athletic activity should not be resumed until 15-30 minutes after the last flash of lightning or last clap of thunder.
Precautions for Severe Storms and Tornadoes: Weather Radio should be consulted before practices and games to check for storm warnings. If a tornado watch or severe thunder storm watch is issued during a practice, practice can continue, as long as coaching staff and athletes know how to get to nearby safe shelter and Weather Radio is being continually monitored. However, if a watch is issued during a game or three hours before a game, the competition should be suspended or canceled. If a tornado warning or severe thunderstorm warning is issued during either a practice or game, athletic activity should be suspended and all participants moved as rapidly as possible to safe shelter. Athletic activity should not be resumed until the National Weather Service suspends the watch or warning.
Precautions for Extreme Heat: Acclimatize athletes to heat gradually. During hot weather, conduct practices and early season games in light-weight uniforms, without stockings or long-sleeved jerseys. Make cold water available at all times. Encourage drinking before, during and after practices and games. Weigh athletes before and after practice to monitor water loss. To avoid cumulative fluid depletion, track pre-practice weights over several days. Observe all athletes for signs of heat illness-fatigue, weakness, dizziness, pounding headache, visual disturbances, lethargy, cramps, inattention, confusion, nausea or vomiting, awkwardness, weak and rapid pulse, flushed appearance or fainting. Identify and observe more closely athletes at higher-than-normal risk for heat illness. If heat illness is suspected, cool the victim down and seek a physicians immediate service. Salt and electrolytes lost through sweating should be replaced through a normal diet with plenty of fruits and vegetables. Salt tablets are inappropriate and are potentially dangerous. Determine the degree of risk for heat illness, taking both temperature and relative humidity into account. During high risk conditions, rest and water breaks should be scheduled and enforced. During very high risk conditions provide rest periods of 15-30 minutes for each hour of workout, keep high risk athletes out of play and cancel practices and games in youth sports programs.
Precautions for Cold Weather: Temperature, wind speed and degree of wetness should all be taken into account when considering cold weather safety policies. The risk of freezing of exposed flesh is increased when the wind-chill index is -20°F. No outdoor athletic activity should be permitted when the wind-chill index is -50°F.
Warm-up: Players should stretch before and after workouts. There should be a minimum of 15 minutes of warm-up before any game or practice and a cool-down period afterward. Athletes should also warm up for five minutes during any prolonged breaks in activity (half-time, between quarters, etc.).
Re-injuries: To minimize the occurrence of re-injuries, early intervention on a new injury and appropriate rehabilitation are important. Athletes should not be allowed to return to practice or play until injuries are healed, range of motion is restored and strength has been recovered. Medical consultants should agree on guidelines for return to play following head injuries such as those developed by the American Academy of Neurology. Each serious head injury should be dealt with by an experienced physician.
Prevention of Communicable Diseases: Before any piece of equipment is reassigned from one athlete to another, it should be sanitized. All players should be immunized for hepatitis B. Athletic staff should follow universal precautions for protecting themselves and athletes from exposure to blood-borne illnesses.
Use of Drugs: School districts and youth leagues should aggressively discourage children from using steroids and all other performance-enhancing drugs as well as from use of alcohol and recreational drugs.
Transportation: When an athletic program is transporting athletes, the vehicles used should be carefully maintained, inspected for safety and driven by appropriately-licensed drivers.
Documenting Injuries: Each organization administering a football program should establish a system for documenting injuries, working toward a surveillance system based on uniform definitions of injuries and exposures.
Purpose of Paper: This position paper was developed at the request of the Michigan Governors Council on Physical Fitness, Health and Sports. Its purpose is to establish the scientific basis for future injury prevention initiatives by the Michigan Department of Community Health and the Michigan Fitness Foundation.
Two sources of information served as the basis for the paper-the scientific literature related to injuries in football and the official recommendations of respected sports injury authorities. Based on the review of those sources, the Sports Injury Prevention Advisory Group to the Michigan Department of Community Health developed specific recommendations for reducing the risk of injury, which are listed at the beginning of the paper.
The rest of the document summarizes the reasoning behind the recommendations and also describes areas of concern for football safety for which there is not yet a consensus. The advisory group acknowledges that it would not be feasible for every athletic program in Michigan to adopt every known preventive measure. However, they believe that having a well-informed public is the most effective way to reduce injuries in sports, so they decided to include all recommendations in the paper, even those that are not easy to adopt.
Popularity of Football: Football is a popular sport. In Michigan, 42,081 children played high school football during the 1996-97 season.1 Nationally, approximately 1.5 million individuals played football at the high school and junior high level during the 1997 football season.2 An additional 300,000 played at the professional, collegiate, or organized recreation level. The total number of football players has increased slightly every year over the past decade. Most football players are male; in 1997, there were only about 740 female high school football players in the United States.3
Risk/Benefit of Playing Football: The critical importance of physical activity for both physical and mental health has been well-documented.4 Increasing participation in sports is a widely acknowledged strategy for increasing physical activity. In epidemiological studies of physical activity and health, adults who participate in sports have a greater life expectancy and fewer chronic disease conditions than their sedentary peers.5 Participation in sports fosters excitement, fun, fitness and improved health and offers the opportunity to encounter challenges and achieve goals. For young people, team sports can provide positive adult role models and valuable life lessons of discipline, working cooperatively and the meaning of fair play.6,7 Playing a sport can help establish self-confidence and physical coordination and can mark the beginning of a pattern of lifetime physical activity.
Being physically active, no matter what type of activity is adopted, creates some risk of injury.8 While acknowledging this fact, the U.S. Department of Health and Human Services still recommends increasing the proportion of Americans who engage in vigorous physical activity.9 Contact sports such as football are more likely to cause injury than non-contact sports.10 Each individual must balance the considerable benefits from participation in a sport such as football with the possibility of injury.
OCCURRENCE OF INJURY IN
Football is a high-risk sport because of the inherently physical nature of the game, combined with the speed, strength and size of players.11 Injuries fall into two categories-acute and chronic. Acute injuries are caused by sudden trauma.12 Chronic, or overuse, injuries are caused by systematic, repetitive training. Most sources of injury information do not differentiate between these two types of injuries. It is generally agreed that overuse injuries have risen over the past two decades.13 The actual number of injuries-both overuse and acute-that occur is not known because there is no national or statewide system for documenting amateur sports injuries. Estimates of the numbers and types of injuries vary widely depending on how an injury is defined and on the population being studied. Several sources of football injury are described below.
Catastrophic Injuries: Football injuries resulting in death or permanent disability are very rare. The National Center for Catastrophic Sports Injury Research reports that in 1997, six deaths (0.333 per 100,000 participants) were directly attributed to participation in the fundamental skills of football-five from brain injuries and one from a blow to the chest. Five of the deaths occurred as part of high school football activities and one as part of middle school football. There were eight deaths indirectly associated with football playing-one due to heat illness and seven from cardiac complications. Seven of the indirect deaths occurred during high school football; one occurred during organized recreational football.2 There were 17 cases of permanent disability-14 at the high school level, two in college football and one in professional football.14 Defensive players are at greatest risk for catastrophic injury. Over the past 21 years, 71% of the players with cervical cord injuries were playing defense, the majority of whom were tackling at the time of injury.14
Severe Injuries: One source of information about severe injuries is the National Electronic Injury Surveillance System (NEISS),15 which estimates the number of emergency room visits that are associated with sports activity, equipment and apparel. Football is one of the three sports associated with the most visits to emergency rooms. This statistic is not easily interpreted, since the total number of individuals playing each sport is not taken into account. NEISS data also does not make any distinction between professional and amateur sports, or between organized sports where protective equipment is used and backyard sports. In 1995, the NEISS national estimate for football injuries requiring emergency room visits was 389,880. Of those injuries, 98.5% of the patients were treated and released. Only 1.5% were admitted to the hospital or transferred elsewhere. The vast majority of injuries were strains or sprains (33%), fractures (24%) and bruises or abrasions (17%). Concussions accounted for 1.6% of the injuries, of which only 2% were subsequently admitted to hospital. The body parts most frequently injured were, in order of frequency, finger (16%), knee (10%), shoulder (10%), ankle (9%), wrist (7%), face (6%), head (5%), hand (5%), upper trunk (5%), lower arm (4%) and lower trunk (4%).
Another source of information on severe football injuries is the National Pediatric Trauma Registry, which documents injuries severe enough for admission to pediatric trauma centers among children under 20 years of age. In an analysis by Di Scala et al.16 of injuries at schools occurring between 1988 and 1995, sports injuries accounted for one-third of all unintentional injuries. Football was the largest contributor to sports injuries-one-third of all sports injuries serious enough for hospital admission were sustained during football activities. As with the NEISS, this ranking does not take into account the total number of individuals playing each sport.
College Football: A national injury surveillance system has been established by the National Collegiate Athletic Association (NCAA).17 In 1997, a representative sample consisting of 101 of the 902 colleges that are members of the NCAA supplied injury information. In this system, an injury is reported if it requires medical attention and results in restriction of the athletes sport participation for one or more days beyond the date of injury. Rates of injuries per 1,000 athletic exposures are calculated, where one athletic exposure is equivalent to one athlete participating in one practice or game. Because the NCAA surveillance system can express injuries as rates, it is possible to compare football with other college sports in terms of rate of injury. When data for each of the eleven sports included in the surveillance system are combined over an 8-10 year period, football resulted in the highest rate of injury during games-36.1 injuries per 1,000 athletic game exposures. One-third of these injuries resulted in loss of seven or more days of practice; 6.7% of injuries required surgical treatment.
For the 1997 season, there were 34.1 injuries per 1,000 athletic exposures during games and 3.8 injuries per 1,000 athletic exposures during practices. The body parts most commonly injured were the knee (18%), the ankle (16%) and the shoulder (13%). The most common types of injuries were sprains (32%), strains (21%) and bruises (13%).17
High School Football: Data describing injuries in college football players are not applicable to younger athletes, among whom there are much wider variations in size, maturity and skill level.18 Many small surveys of high school football injuries have been conducted, using variable definitions of injury. Estimates of the percent of high school football players injured range from 11% to 81%.19 The most reasonable estimate currently available is that approximately 39% of varsity high school football players received some form of injury in 1995. This estimate is based on a three-year study being conducted by the National Athletic Trainers Association (NATA),20 with injury information from a sample of 123 high schools across the nation. An injury is reported in the NATA study if an athlete was forced to miss the remainder of the current game or practice or was required to miss the game or practice the day after the onset of the injury.
As seen in the NCAA surveillance system, the NATA study found that football accounts for a higher rate of injury than any of the other nine sports monitored. However, 80% of the injuries were minor, with the player returning to activity within a week. Eleven percent of injuries were moderately severe, with return to activity delayed for 8-21 days. Eight percent of injuries were considered major, with return to activity delayed for three or more weeks. Most of the injuries (61%) occurred during practices, since there are many more practices than games. The areas of the body most frequently injured were the hip/leg/thigh (17.3%), the forearm/wrist/hand (15%), knee (14.5%) and ankle/foot (14.2%). The injuries of greatest concern-to the head, neck and spine-constituted 11.3% of the injuries observed.20
Because NATA conducted a similar study of football injuries over the 1986-88 seasons, it will be possible to detect trends in injury occurrence. Based on 1995 data, two very encouraging findings have emerged. (1) Although the number of overall injuries did not change, there appeared to be 3% fewer injuries in the major category. (2) There appeared to be a lower proportion of re-injury, suggesting that athletes may have received better rehabilitation in recent years than in the 1980s.20
Younger Athletes: For recreation leagues and elementary school programs, injury information is not available on either a statewide or a national basis.
The Importance of Documenting Injuries: To evaluate whether sports injury prevention efforts are working, it is important to be able to document the injuries that are occurring.6 The lack of comparable data on sports injuries hampers the development of effective preventive strategies.21 The National Council of Athletic Training recommends that each school sports program have an injury notification system and keep injury reports accessible.22 It would be ideal if each organization administering a football program established a system for documenting injuries, one which was based on uniform definitions of injuries and exposures. With a uniform system, each program administrator could evaluate whether injury rates were increasing or decreasing. Comparisons of injury rates could also be made between football programs. Computer software and technology are available to establish such systems,23 but most athletic programs lack the financial resources and the expertise necessary to implement them. Working toward the establishment of uniform sports injury surveillance systems is a worthwhile goal, at the local, state and national levels.6,24
METHODS OF INJURY PREVENTION
To reduce the chance that a football player will be injured and to minimize the severity of any injuries that do occur, three areas of preventive activities can be identified. First, individual risk factors related to the athlete can be identified and, to some extent, corrected. Second, hazards in the sports setting can be identified and eliminated. Third, practices and games can be managed in ways that minimize the risk of injuries. Preventive measures in each of these areas are described below.
Injury Prevention Measures Related to the Athlete
Each athlete brings into the football experience unique characteristics which could predispose the athlete to injury.
Age and Maturation: It is often advised that very young children should not play football. The National Youth Sports Safety Foundation recommends that children under six not play the sport. Findlay25 recommends that collision sports like ice hockey and tackle football should not be allowed until age 10.
The different levels of performance with a given age group are often the result of different levels of maturity rather than differences in skill. Classification on the basis of chronological age is not satisfactory during adolescence.26 Maturity assessment as a basis for matching athletes for football makes sense, since more physically-mature children can inflict considerable physical harm to their less mature chronological peers. Youth who are not sufficiently mature can be advised to go into one of the many sports in which there is less risk of injury.27
Although there is widespread support for the concept of matching of children according to maturity level,27,28,29,30 there is not consensus on methods for doing so. The International Federation of Sports Medicine26 and others27 suggest that maturity determinations be based on estimation of secondary sexual development, as determined by Tanner staging. However, since there is no definitive data to support an injury-reduction benefit from matching children according to Tanner stages, Tanner staging is no longer recommended as a routine part of the pre-participation physical examination by the American Academy of Pediatrics.31 An alternative to matching by maturity level is to simply match by skill level and size.29,32
One aspect of maturity assessment is periodic height measurement during a season to identify periods of rapid growth in athletes. Rapid growth is assumed to be a risk factor for injury because childrens muscles and tendons grow at a slower rate than their bones. The muscles and tendons cannot keep up and become tight, resulting in a temporary loss of flexibility.33 Some experts recommend reducing the amount and intensity of training during growth spurts.26,27,34
Health Conditions-The Pre-participation Physical Evaluation: The pre-participation physical evaluation (PPE) is one of the most critical aspects of injury prevention in amateur sports programs.35 The purposes of the PPE are to (1) detect conditions which could make football playing life-threatening or disabling and (2) detect medical or musculoskeletal conditions that could predispose to injury or illness during practice or competition. The evaluation should include both a medical history and physical exam. This screening should be performed by a health care worker with the training and medical skills to recognize heart disease and the orthopedic conditions of concern. The American Academy of Pediatrics recommends that ultimate responsibility for the PPE should ideally fall to an M.D. or D.O. physician, however, other health care professionals could perform components of the evaluation.31 In Michigan, medical doctors, osteopathic physicians, nurse practitioners and physician assistants are authorized to sign PPE forms.
Ideally, the evaluation would be performed at least six weeks prior to preseason practice, to allow time for correction of identified problems, such as use of specific strengthening or flexibility exercises.31,36
The manual Preparticipation Physical Evaluation is a practical, comprehensive guide for conducting the PPE that has been developed cooperatively by the American Academy of Family Physicians, the American Academy of Pediatrics, the American Medical Society for Sports Medicine and the American Osteopathic Academy of Sports Medicine.31 It includes specific questions that can be asked in the medical history as well as instructions for conducting sports-related musculoskeletal screening. Some of the conditions that should be assessed in the PPE are described below.
Cardiac Conditions: Most medical problems causing sudden death are cardiac in origin. Sudden death in athletes under age 35 is generally caused by congenital heart disease, hypertrophic cardiomyopathy being the most common cause.37 In older athletes, coronary artery disease is the most common cause. Medical syndromes such as Marfans syndrome, homocystinuria, Downs syndrome and Turners syndrome all have underlying cardiac abnormalities which predispose young people to sudden death during exercise.38 The American Heart Association39 recommends that the PPE include a "personal and family history and physical examination designed to identify (or raise suspicion of) those cardiovascular lesions known to cause sudden death or disease progression in young athletes."
Critical elements of the cardiovascular history and physical examination are clearly described in Preparticipation Physical Evaluation31 and in a statement by the American Heart Association.39 Parents or legal guardians should provide health history information for children in elementary or high school.31,39 A history of steroid or cocaine use should be obtained, since use of these drugs has been associated with sudden death of cardiac origin.
Conditions Predisposing to Head and Neck Injuries: Since individuals with previous concussions are at risk of subsequent concussions or second impact syndrome, the PPE should include a detailed history of previous head and neck injury, as well as questions about recurrent symptoms such as burning sensations in the shoulder or arms, or pain directly in the neck area during contact or during the execution of specific sport techniques.31,40,41 Any recurrent problems should be followed up by additional physical evaluation by a physician.31 An athlete with unresolved symptoms of previous concussions should not be permitted to return to contact sports.42,43,44,45
During physical examination, the athlete should be evaluated for normal range of motion and normal neurological integrity of the cervical spine. Neck muscle strength should be checked by manual resistance to each of the six movements of the neck-flexion, extension, rotation to the right, rotation to the left, lateral flexion to the right and lateral flexion to the left.46
Orthopedic Conditions: The National Youth Sports Safety Foundation describes several conditions which can increase a young athletes risk of injury, including (1) a history of previous muscle injuries or broken bones; (2) anatomical malalignments of the legs (differences in leg length, abnormal position of the kneecap, bowlegs, knock-knees, or flat feet); (3) other structural defects within the body; (4) muscle-tendon imbalances and (5) limited or excessive range of motion.33 The American College of Sports Medicine recommends that the examiner check the strength and flexibility of the athletes muscles and the alignment and range of motion in the major joints. Sites of previous bone and joint injuries should be re-examined to verify that complete healing has taken place. If weaknesses are spotted, special training can be prescribed to correct abnormalities.47
Visual Impairment: The PPE should include a history of eye disease or injury and a check of central and peripheral vision. Extra eye protection should be required for any athlete with corrected vision poorer than 20/40 in either eye or with a history of eye injury or eye surgery.31,48
Other Medical Conditions: Some athletes have conditions which do not preclude participation in football, but which have potential implications for an athletes safety during practice or games. Such conditions should be documented in the PPE. For example, a history of heat illness should be noted before the season begins and athletes with previous history of heat illness should be watched closely during practice in hot weather.2 Severe hypertension requires restriction from weight training.31 A child with asthma should have appropriate education and medical supervision.31,38 A child taking drugs containing photoreactive agents (some antihistamines, non-steroidal anti-inflammatory drugs and antibiotics of the tetracycline and sulfonamide classes) should be protected from exposure to sunlight or artificial sources of ultraviolet light such as purple-lighted mosquito zappers.49 Conditions such as diabetes, sickle cell trait, severe allergies, bleeding disorders, etc., should be known by the training staff.
Availability of Medical Information: Any medical conditions identified in the PPE should be noted on medical information cards which are kept on site on the practice and playing fields.50 Having the information on site makes it available to care givers if an injury or emergency arises.
Athletes Knowledge and Skill Development: No football program can be successful in minimizing the risk that injuries will occur until each athlete has learned a basic set of information and skills. At a minimum, athletes should understand the rules of football related to injury prevention and should master the proper execution of the fundamental football skills, particularly blocking and tackling without using the head.51
Conditioning: A large percentage of athletic injuries are caused by inadequate physical conditioning and could be prevented if coaches conditioned athletes better.52 Conditioning programs should be safe and based on scientific principles. Football training and conditioning programs should include (1) development of anaerobic endurance; (2) development of cardiovascular endurance; (3) establishment and maintenance of good joint range of motion; (4) development of muscle strength, power and endurance; (5) development of connective tissue strength (ligaments, tendons, bones); and (6) development of speed of movement and change of direction abilities.53,54 Training requires a continuing and progressive effort. Adaptations to training take time. The increased rate of applied stresses should not exceed the capacity of the body to adapt. Because each athlete has unique physical characteristics, a standardized team conditioning program is not appropriate for every athlete.33
Endurance Training: From an injury prevention perspective, endurance training (both cardiovascular and anaerobic/interval) improve the athletes tolerance to fatigue. When players compete beyond their fatigue level, the likelihood of injury increases.55 Cardiovascular training is not as important for performing well in football as for some other sports. However, some cardiovascular training should be incorporated into football training along with interval training.56 Athletic conditioning, like non-athletic fitness development, should be designed so individuals avoid cycling between being in shape and out of shape. Year-long programs of training and suitable nutrition are recommended.
In addition to a year-round program, the National Athletic Trainers Association recommends that athletes engage in more intensive conditioning programs for a minimum of six weeks before the start of daily practice,57 thus making certain that players are well-conditioned before showing up for the first day of practice.58 For example, Cahill describes a pre-season conditioning program for high school football.59 It began six weeks before the official beginning date of football. Teams met 80 minutes per session three evenings per week. No drills, plays, football, or team meetings were permitted. The program emphasized total body conditioning through cardiovascular stressing, acclimatization to heat, weight training, flexibility drills and agility exercises.
Muscle Strengthening: According to the National Strength and Conditioning Association,60 "appropriately designed and supervised resistance training programs appear to be an effective injury prevention strategy for adults and may help to prevent injuries in youth sports." Improving muscle strength through resistance training may prevent or lessen the severity of an injury in three ways: (1) supporting structures-ligaments, tendons and bones-may be strengthened;61,62,63 (2) trained muscles may be able to absorb more energy prior to failure;64 and (3) muscle balance around a specific joint may be developed.65
To avoid injury and maximize the value of resistance training, fitness professionals who have a thorough understanding of resistance training and safety procedures should supervise every exercise session. Equipment should be in good repair and properly adjusted to each individual user. Resistance training should be preceded by 5-10 minutes of general warm-up exercises (stretching plus low intensity aerobic exercise such as rope jumping, stationery bike riding, etc.). Any individual muscle group should be trained only two to three times per week, to allow two to three days of rest between sessions.66 Training regimens should be individualized for each athlete. Competition among athletes for levels of strength should be discouraged, as this practice increases injury risk and inappropriately shifts the focus away from the individuals personal and physical development. Resistance training programs may also need to be specific to position on the team since different physical abilities are necessary for success in different positions (for example, defensive tackle vs. quarterback).
Neck and Shoulder Strengthening: Injuries to the spine are relatively uncommon in football, but when they occur, they can be catastrophic. It is generally accepted that the risk of spinal injuries is probably reduced if athletes receive football-specific shoulder and neck strengthening exercises, so players will be able to hold their heads firmly without dropping or ducking during blocking and tackling.14,57 Exercises which gradually strengthen the neck should be emphasized,51,67 in a year-round program, using strengthening machines or manual resistance. Manual neck resistance exercises should include extension, flexion, lateral flexion and rotation.67,68 To increase stability at the base of the neck, athletes should also strengthen muscles of the upper back including the upper trapezius, with exercises such as shoulder shrugs and upright rows.69
Strengthening exercises for the neck should be done at slow speed, with constant tension; ballistic movement is inappropriate and dangerous.67 Doing these exercises incorrectly can cause serious injury. The exercises assigned should be based on a respected authority such as Brzycki69,70 or Pauletto.71 Coaches and athletes should understand the neck exercises and practice applying resistance correctly to avoid possible injury to the exerciser. These exercises should not be posted and left to the athletes to practice on their own. Constant supervision is required to check that the exercises are being done and being done correctly.72
Neck flexibility exercises should be done daily. Neck strengthening exercises should be done two to three times per week, to allow two to three days of rest between exercise sessions.66 Neck strengthening exercises should never be done immediately prior to a practice or game, since the exercises will tire the neck and may increase susceptibility to injury.46,51
Weight Equipment for Youth: If weight equipment is used for youth who have not completed puberty, guidelines for safety described above should be scrupulously followed. In addition, the National Strength and Conditioning Association recommends that equipment be carefully selected for suitability for youth, qualified adult supervision be provided in a ratio of no more than 10 children per one adult and youth be carefully instructed in technique and in equipment adjustment. Competition between young people should be vigorously discouraged, with emphasis on participation and personal improvement.60 One-repetition maximal lifts should not be attempted by physically-immature athletes.73
Overuse Injury Prevention: Overuse injuries arise from systematic, repetitive training. Overuse injuries occur when the athletes body is not given time to adapt gradually to increases in physical activities.34 Typical examples of overuse injuries include stress fractures, tendonitis, bursitis and shin splints.
Young athletes may be prone to overuse injury because of the presence of growing tissue as well as the growth process itself, which may induce muscular imbalances around the joints and increase risk of injuries.36 In addition, young athletes may be overly-eager to please their coaches and may not have enough experience to discriminate between the muscle discomfort from healthy exercise and the discomfort that is a signal of injury.
Some children with relatively immature musculoskeletal systems may be intolerant of the same exercise dose that the majority of the children in the same athletic program can tolerate. For this reason, training regimens should be individualized. Each child should be observed for signs of incipient overuse injury which would require a modification of the frequency, volume, intensity and progression of training.60
Dr. Stephen Rice describes stages of overuse injuries as follows: (1) pain only after activity which is gone the next morning; (2) pain that begins near the end of an activity and which continues after the activity, but which does not interfere with performance; (3) pain throughout most of an activity which causes a decline in performance; and (4) constant pain during everyday activities.34
Overuse injuries are preventable if conditioning and skill practicing sessions are increased gradually in intensity, duration and frequency. Overuse injuries may also be reduced if children who are in rapid growth periods are allowed reductions in the intensity of training.34 Specific compensatory exercise programs can be introduced to compensate for muscular imbalances occurring during rapid growth.26
The International Federation of Sports Medicine offers recommendations to prevent overuse injuries among children and adolescents: For young children, responsibility for the childs overall development should take precedence over training and competition. "If coaching takes the form of training for maximum performance at any price, it is to be roundly condemned on ethical and medical grounds." Children should be exposed to a wide variety of sporting activities to insure they identify the games that best meet their needs, interests, body build and physical capacities. Early specialization should be discouraged. The rules and duration of games should be appropriate to the age of the participants.26
Preventive Measures Related to the Sports Setting
Equipment and Apparel: Properly fitted equipment that meets the current standards for safety is essential to the safety of football players.51
Helmets: Helmets used by football players at every level should meet safety standards set by the National Operating Committee on Standards in Athletic Equipment (NOCSAE).
Mouth Protection: Mouth protectors are effective in preventing injuries to the teeth and mouth.74 Football rules requiring mouthpieces should be strictly enforced. The size of the oral cavity varies greatly, even among children the same age. Mouth guards should fit properly to afford needed protection.75 The better the fit of the mouth guard, the more comfortable it will be for the athlete and the more likely he or she will be to wear it.76 The best-fitting devices are those that are custom-made by a dentist. The second-best fit is obtained with a mouth-formed guard, which is purchased by size, then is boiled in water until it softens and is allowed to cool in the athletes mouth, at which point it conforms to the shape of the oral cavity. If a mouth-formed device is used, it is important to read and follow the manufacturers directions. About half of consumers fail to follow the directions, thus getting less protection than they might have had.76 Stock mouth guards provide protection, but are not as comfortable as the other types.
A football program can ask a local dentist or dental society to help develop a mouth guard program. Many dentists donate mouth guards or offer reduced prices for sports teams. At a minimum, a dentist could check to see that mouth-formed guards are fitting properly.76
Eye Protection: In football, eye injuries usually occur when an opponents fingers push through a players face guard. Proper use of an eye protective device can significantly lower the risk of eye injury. Protective eye devices should be mandatory for athletes who have severely impaired vision. Because of the risk for complete loss of vision, an athlete who has vision in only one eye, whose best corrected vision is poorer than 20/40 in either eye or who has a history of eye injury or eye surgery should not be permitted to play without extra eye protection.31,48 Use of a polycarbonate shield that attaches to the helmet is often recommended for football players. Polycarbonate is the material of choice for the lenses of eye protective equipment because of its superior impact resistance.48 For the one-eyed athlete, Stock48 recommends a racquet sports eye protective device worn under a polycarbonate face shield.
Shoes: Although a number of researchers77,78 have recommended use of the soccer-style shoe, others79,80 have found that such shoes are associated with sprains of the great toe metatarsophalangeal joint (turf toe) when playing is done on hard artificial surfaces. For this reason, relatively firm-soled football shoes should be used on hard artificial playing surfaces.
Lambson et al.81 evaluated various football cleat designs with respect to the incidence of anterior cruciate ligament tears among 3,119 high school football players. They found significantly more ligament tears among athletes who used shoes with long irregular cleats placed at the peripheral margin of the sole with a number of smaller pointed cleats positioned interiorly.
Rodeo80 points out the importance of shoes that fit properly with respect to width. Most football shoes do not come in wide widths, so athletes with wide feet are given shoes that are too long, contributing to the risk of turf toe. Shoes should be fitted late in the day when the foot is the widest, with the number of socks the player expects to wear during competition.82
Ankle Protection: Ankle sprains account for 6-16% of football injuries. Ankle taping is a time-consuming and expensive practice aimed at preventing such sprains. Rovere et al.83 assessed the effectiveness of taping versus the effectiveness of wearing a laced stabilizer in preventing ankle injuries and re-injuries over six seasons of collegiate football practices and games. High-top versus low-top shoes were also evaluated. The combination of low-top shoes with laced ankle stabilizers resulted in the fewest injuries overall.
Knee Braces: There has been controversy regarding whether knee braces prevent injury. Some researchers have found that knee braces can prevent injury,84 while others have not85 or have found increased injuries with knee braces.86 The American Academy of Orthopedic Surgeons (AAOS) reports that although prophylactic knee braces have not been shown to be effective in preventing injury, rehabilitative knee braces for individuals who have already had knee injuries have been proven effective. The AAOS further recommended that muscle strengthening and conditioning programs and well-groomed grass athletic fields are better prevention measures for knee injuries than prophylactic braces.86
Protective Collars: The National Athletic Trainers Association suggests use of the protective neck roll to reduce the severity of football neck injuries.68 Several types of protective collars worn around the neck inside the shoulder pads are available. Collars can be custom-made with stockinette placed over a sponge rubber, towel or other resilient material, or can be the commercial inflatable type.68 Gibbs87 recommends their use to prevent re-injury when players have experienced at least one neck injury, to prevent injuries involving extension, forced flexion and lateral flexion.
Checking Equipment for Damage: Equipment should be carefully examined for damage before being given to an athlete and should be examined periodically during the season. At least once a year, football programs should conduct a complete review and analysis of all protective gear. The annual review should be done carefully and systematically, keeping in mind that printed warnings on equipment may not be adequate or there may be differences between the league requirements and the manufacturers instructions.88
Helmets should be checked for cracks in the shell; loose screws, rivets, Velcro attachments, or other fasteners; worn suspension; compressed pads; holes/cracks in fluid or air compartments and distorted face masks.89 Sharp edges, scratch marks or paint marks from previous games are also unacceptable-these can increase friction on the surface of the helmet and contribute to greater force against the head during impact. Rusted or stripped screws holding the face mask in place should be replaced, since they could slow down face mask removal during emergency care.90 Old, worn, or damaged equipment should be properly reconditioned or discarded.51
Reconditioning: Helmets that are damaged can be reconditioned. If reconditioning is desired, only a reputable company should be used, since reconditioning can remove warning labels and damage the gear. Reconditioners should be required to carry substantial liability insurance.88 There is not universal agreement on how many years a helmet can be used. Some programs make policies to discard helmets after eight or 10 years of use. Others keep helmets in service, with periodic reconditioning, indefinitely. However, damaged shells cannot be repaired. If anything is wrong with the shell, the helmet should be discarded.91
Fitting Protective Equipment: Proper fit is as important for athlete safety as the quality of protective equipment. Improper fit of equipment may increase the severity of an injury or be the cause of an injury. Players should be individually fitted for each piece of equipment.82 For young or inexperienced players who may not have enough experience to know when equipment feels right, adults associated with the football program should pay particular attention to the fit of the equipment. Some fitting techniques described by Wilkerson,89 Gieck and McCue82 and Roberts92 are described below.
Helmets: Helmets should be fitted by a knowledgeable person experienced in the process. During fitting, the players hair should be at normal length and should be wet, to best simulate the actual condition of the hair during play. If a player changes his hair style during the season, especially if he shaves his head, the helmet should be re-fitted. An individual with an irregular head shape may get a better fit with an air helmet because this type of helmet conforms better. Proper entering of the helmet is important. Players should be instructed to (1) put thumbs in ear holes with the helmet tilted back, (2) roll helmet forward onto head. The front edge of the shell should rest approximately 3/4" above the eyebrow. The athletes ear and the helmet ear hole should match up. There should be 3/4" to no more than 1-1/2" space between the athletes head and the plastic outer shell. The back of the helmet should not impinge on the cervical spine when the neck is extended.
Checking the fit: The best fit resists motion of the helmet on the head. To test the fit, the jaw pads should be removed and the athlete should flex his neck, resisting efforts to rotate the helmet from side to side. If the skin on the forehead does not move with the helmet, the helmet is not snug enough. Also, the helmet should be rotated up and down to be sure that the front edge of the shell does not come down on the bridge of the nose and that the rear side of the shell does not impinge on the nape of the neck. Helmets should be comfortable but snug. Before a helmet is judged to be too tight, allow several days for the padding material between the head and the shell to adjust to the individuals head. Excessive tightness can be detected by examining the forehead after removing the helmet. If the helmet is too tight, the forehead will be white, due to poor blood circulation and will be deformed for a short time.
All helmets should have a nose bumper guard. Jaw pads of proper thickness will help minimize side-to-side rotation of the helmet. There should be no space between the jaw pads and the jaw and cheek. A four-point chin strap should always be used, with equal tension on all four attachments and no slack in the straps. The cup should be centered on the chin strap.89 National Federation rules prohibiting bandanas or other head covering under the helmet should be followed.89
Face Masks: If the helmet is fitted without a face mask or if the mask is changed, the fit should be rechecked after one has been attached. The sides of the shell may be slightly spread or pulled in by the mask, distorting the shell and changing the fit. The width of the mask should therefore match the width of the shell as closely as possible. The mask should be 1-1/2" from the nose. If the cage mask is fitted too closely to the face, the face can be cut when the cage is driven back during violent contact.82
The face opening should be small enough to keep forearms and shoes out. If the bar style is fitted too low it doesnt protect the facial area sufficiently. If it is fitted too high it obstructs vision and exposes the mandible to injury. The space between the top edge of the shells face opening and the top bar of the face mask should not exceed 3". The mask should be attached with plastic straps that help absorb shock when a blow is delivered to the face. Plastic or rubber straps also make it possible to remove the mask quickly and easily in the event of an emergency.
After a helmet has been properly fitted, it should be marked with the athletes name or number, to avoid it getting mixed up with other helmets.89 Periodic refitting may be necessary due to haircuts, compression of pads or loss of air from compartments.
Shoulder Pads: Football shoulder pad manufacturers design different styles of pads for different team positions. Before a shoulder pad is fitted, the position for which it was designed should be determined. Roberts92 suggests making shoulder, neck and chest measurements on both the pad and the athlete, and using those measurements in fitting. The end of the pad should cover the end of the shoulder (deltoid). The neck should have a 1/2" to 3/4" clearance on each side, allowing mobility and comfort, without allowing excessive sliding about the shoulder. The flaps should cover the deltoid area. One check of fit is to lift the deltoid cap and look for a gap. A gap is necessary, so the shoulder pad can properly disperse the force of a blow throughout the entire pad. The pectoralis pad should cover the entire pectoralis muscle. The back of the pad should cover the entire shoulder blade. The elastic axilla straps which hold the pads tight to the chest and back should be tight yet comfortable.
Once a pad is fitted, it should always be used by the particular player it was fitted for unless it becomes damaged or the athlete outgrows it or changes position.92 The shoulder pads should be constantly inspected for cracks, frayed strings and straps, loose rivets and other possible failures.82
Hip Pads: Hip pads are designed to protect the iliac crest, greater trochanter and coccyx. Coaches should watch for errors in hip pad use. For example, some athletes trim hip pads for comfort so the pads no longer cover the iliac crest. Others let them slide down, eliminating their protective effect. Athletes often fail to keep the girdle pad in place.82
Thigh Pads, Knee Pads and Pants: Thigh and knee pads should be large enough to cover the respective areas. The pants are important in maintaining proper placement of the knee, thigh and snap-in pads. The pants should be tight enough to prevent thigh pads from sliding medially or laterally.82
Elbow, Forearm, Wrist and Hand Pads: No hard fiber pads should be worn at or below the elbow. Custom-fitted pads are particularly valuable in this area.82
Facilities: Some injuries can be prevented if hazards in the sports environment can be identified and eliminated.
Field Conditions: Maintenance of playing fields is one of the most basic strategies for preventing injuries.77 Turf should be well-maintained. Practice and playing fields should be well-lighted and free of holes, broken glass and other hazardous debris.22,57
Structural Hazards: Locker rooms, weight rooms and shower rooms should be sanitary, well-lighted and free of hazardous debris, with ground fault circuit interrupters when there is water near electrical outlets.22 Sporting events can be the occasion of injuries among spectators as well as athletes. Out-of bounds buffer zones between spectators and the playing field should be adequate to prevent collisions.93 Goal posts should be padded to prevent injuries from high speed collisions.
Injury Prevention Measures Related to Management of Practice and Competitions
Coachs Responsibilities: The coach has overall responsibility for the safety of the athletes. It is his or her responsibility to teach safety principles to athletes; to see that athletes are properly conditioned; to require proper warm-up; to teach appropriate techniques; to avoid unsafe environmental situations; and to prevent players from competing beyond their fatigue level. The National Council of Athletic Training22 further recommends that all coaches be certified in first aid and CPR and know current rules and regulations of football.
Training of Coaches: It is widely acknowledged that in-service training for coaches is essential for injury prevention and for appropriate treatment of injuries that do occur.94,22 Several models for promoting coaching education have been developed. Under New Jersey law, coaches and other volunteer football staff have liability immunity only if they undergo a safety training program meeting minimal standards set by the New Jersey Governors Council on Physical Fitness and Sports.95 In Seattle, Washington, all school coaches must take a 31-hour athletic training course every three years, taught by university medical personnel.94 The American Red Cross and the United States Olympic Committee have recently developed a course titled Sports Safety Training. This 8-hour training, available at local American Red Cross offices, includes basic first aid skills and knowledge needed to care for athletic injuries. In Michigan, the Michigan High School Athletic Association recommends that all coaches participate in the Program for Athletic Coach Education (PACE), conducted by Michigan State Universitys Institute for the Study of Youth Sports.
Coaches and Stress Management: Several researchers96,97 have reported that players experiencing extreme life stress are more likely to sustain an injury. Cryan and Alles96 recommend that coaches be educated to help their players deal with life stress. Coaches can help by teaching coping techniques such as relaxation response, meditation or biofeedback, or by encouraging counseling provided by professional counselors.
Teaching Safety to Athletes and Parents: Coaches should teach athletes information on safety by giving the players check lists and lectures and showing training films, if they are available.88 Granger88 suggests that communication on safety be documented. Requirements for documenting that safety information has been provided would remind coaches, administrators and officials that safety instruction is an important part of the athletic program. Safety principles should also be presented to parents, so they can reinforce messages from coaches.98
Warm Up: Warm-up and cool-down sessions before and after practices and games help prevent injuries.47,57 The National Athletic Trainers Association recommends a minimum of 15 minutes of warm-up before any game or practice and a cool-down period afterward. Athletes should also warm up for five minutes during any prolonged breaks in activity (half-time, between periods, etc.).57
Teaching Appropriate Techniques and Drills: In addition to verbal instruction on safety, coaches should design proper drills that will ensure that athletes are using correct, safe procedures. Of highest priority is the prevention of catastrophic injuries to the spine. This requires that coaches drill athletes in proper execution of the fundamentals of football skills, particularly blocking and tackling-without using the head.2,51,99 Players should be taught that the helmet is a protective device, not a weapon;95 heads should not be used as battering rams when blocking and tackling.2 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.2
Because tackling below the waist increases the likelihood of head-down tackling, Drake recommends that frontal and lateral tackling at the pelvic, thigh and knee levels be eliminated.100 The National Athletic Trainers Association recommends that blocking below the waist should be minimized during practice.57 Robinson recommends that coaches review game films to check the number of times the players are hitting with head gear with their heads down while blocking and tackling.101
Practice Issues: Pre-season practices are considered injury-prone times. Controlled activities could be emphasized at this time and coaching staff should be particularly vigilant of technique.77 Because a significant percent of injuries occur during contact practice drills, the National Youth Sports Safety Foundation recommends that a reduction in the amount of contact practice should be considered.102 Such a reduction is particularly feasible as the season progresses, after athletes have mastered appropriate techniques for blocking and tackling. The National Athletic Trainers Association recommends that blocking below the waist be minimized during practice.57
Officials Responsibilities: Officials contribute to the safety of football players by having a thorough mastery of the rules of football and by enforcing the rules strictly.99 The importance of knowing and following the official rules of football cannot be emphasized enough. Many of the rules which have been put in place by national and state governing bodies were developed specifically to reduce injuries. Many injuries take place when players violate rules.88 Rules for blocking and tackling prohibiting spearing were adopted in 1976 in response to the occurrence of approximately 30 cases per year of head and neck injuries leading to permanent quadriplegia among football players. Since that time, the number of cases of quadriplegia have dropped dramatically. The Michigan High School Athletic Association is working toward developing training programs for football officials.1
Trainer Responsibilities: Each institution responsible for football playing should identify an individual with first aid training who is a regular member of the institutions staff whose roles are to develop an injury prevention program, work with injuries and develop a conditioning program.51 This person should be present at all practices and all games. These roles are best accomplished by an NATA-certified athletic trainer.22,57 Athletic trainers can free up coaches to do the skill training that is crucial for injury prevention.94 In some communities, local health care facilities such as community hospitals provide NATA-certified athletic trainers for school athletic programs as a public service.
Parents Responsibilities: The National Youth Sports Safety Foundation recommends that education of parents about the inherent risks of football and specific injury prevention measures should be part of every youth sports program.58 Parents who understand safety principles-correct blocking and tackling procedures, the importance of correctly fitted equipment, the importance of training for coaches, etc.-are in unique positions to monitor and advocate for injury prevention practices in an athletic program. Parents should be free to make unannounced visits to practices. Parents should ask questions if they see something that seems unsafe. Other roles that are important for parents include (1) being sure any injury is reported to the athletic program staff, (2) reinforcing compliance with treatments or rehabilitation after injury and (3) being sure that athletes immunizations are up to date.
Athletes Responsibilities: Athletes can reduce their risk of injuries by cooperating with conditioning programs mastering correct execution of football techniques, wearing protective equipment, following the rules of football, reporting all injuries (even minor ones) to the athletic program staff and complying with injury treatment and rehabilitation programs.
Being Ready for Emergencies: No matter how conscientiously an athletic program applies injury-prevention strategies, it is inevitable that some injuries will occur. Once an injury has occurred, the priority becomes getting high quality care as rapidly as possible. To minimize delays in treating injured athletes:
A telephone should be available at all game and practice sites, with prominent posting of phone numbers of ambulance, paramedics, first aid personnel and police.
Plainly marked emergency first aid equipment should be accessible on the field. This equipment should be inspected periodically to assure its completeness, cleanliness and usability.103,104 See Appendix A for a list of such supplies.
A medical emergency action plan should be developed and rehearsed. Key personnel who are to carry it out should be identified. The plan includes responses to severe injuries, hypothermia, hyperthermia and allergic reactions to plants and stinging insects.38,58
An NATA-certified athletic trainer or a physician should be available at every game and practice.29,105 If this is not possible, a physician should be available by phone or pager.51 At a minimum, a specific agreement should be negotiated with a local emergency department and/or emergency medical service (EMS) provider to deal with injured athletes.
Up-to-date medical information for each athlete should be immediately accessible at the site of every game and practice. The information should include emergency contacts, preferred physician, preferred hospital and a signed consent form giving permission to provide emergency care. In addition, any health conditions and medications should be documented.50
Emergency transportation should be available on the scene or within six minutes from the football field. There should be no cars blocking ambulance routes to the field.104
Managing Severe Weather Conditions: Extreme weather conditions threaten the health of athletes, staff and spectators. Before a football season begins, policies should be defined for modifying or canceling practices and games under conditions of lightning, severe storms, tornado watches and warnings, extreme heat and extreme cold. There are no national standards for such policies. Each program should work with medical advisors, athletic trainers and administrators to come up with a policy that is scientifically valid and acceptable in the community. The Site Emergency Planning Workbook, available free from the Michigan State Police,106 offers sample emergency weather plans.
A weather policy should always include the chain of command for making the decision to modify or cancel a practice or game. The policy should also spell out the person responsible for documenting weather conditions (progress of thunderstorms, temperature, relative humidity, or wind-chill), method of documenting weather conditions and the specific weather conditions that would result in specific precautions.
Obtaining and monitoring official weather forecasts is easy using the National Oceanic and Atmospheric Administration (NOAA) Weather Radio. For under $50, hand-held, battery-operated weather radios can be obtained which broadcast National Weather Service warnings, watches, forecasts and other hazard information 24 hours a day. Radios should be equipped with the tone alarm and should be operated in the standby alert mode when no one is listening. In this mode, the Emergency Alert System will produce an alarm that is broadcast by the Weather Radio whenever the National Weather Service issues a warning of an urgent life-threatening situation.
Most Michigan counties are in range of these broadcasts. The communities that are not in range can have access to the Emergency Alert System if their local commercial or public radio stations have voluntarily agreed to participate. For participating stations, regular broadcasts are automatically interrupted for urgent life-threatening weather warnings. National Weather Service Offices can verify the availability of Weather Radio, confirm which commercial stations participate in the Emergency Alert System and give advice on severe weather policies. See Appendix B for the National Weather Service offices that serve Michigan.
Some recognized precautions related to extreme weather are discussed in the following sections.
Precautions for Lightning: More deaths from lightning occur in Michigan than in any other state except Florida.107 Seventy percent of lightning injuries occur in the afternoon, when football practices and games are most likely to be held.107 The NCAA and the National Severe Storms Laboratory108 recently developed lightning safety recommendations that could be adopted or modified by any football program. The highlights of those recommendations are as follows:
1. Designate a chain of command as to who monitors threatening weather and who makes the decision to remove individuals from an athletic site.
2. Obtain a weather forecast each day before a practice or event to know the potential for thunderstorms.
3. Know where the closest safe shelter is and how long it takes to get there. Safe shelter is defined as any building normally occupied or frequently used by people, with plumbing and/or wiring that electrically grounds the structure. Avoid using shower facilities for safe shelter and do not use showers or plumbing during a thunderstorm. In the absence of a sturdy building, getting inside a vehicle with a hard metal roof and rolled-up windows can provide some safety.
4. Blue sky and the absence of rain are no guarantee that severe weather is not threatening. Lightning can strike as far as 10 miles away from the rain shaft. Monitor how close lightning is striking and how fast it is approaching. The flash-to-bang method is recommended. Count the number of seconds from the time lightning is sighted to the time thunder is heard. Dividing this number by five provides a good estimate of the number of miles between the observer and the lightning. For example, if the observer counts 30 seconds between seeing the flash and hearing the thunder, the lightning is approximately six miles away. When the first flash of lightning or clap of thunder is noticed, careful monitoring of the storms approach should begin.
5. Well before the flash-to-bang count reaches 30 seconds, all individuals should have left the athletic site and reached safe shelter.
6. If no safe shelter is available within a reasonable distance, try to find a thick grove of small trees surrounded by taller trees or find a dry ditch. Minimize contact with the ground because lightning current often enters a victim from the ground. Do not lie flat. Assume a crouched position with only the balls of the feet touching the ground. Wrap arms around knees and lower the head. If a person feels his or her hair stand on end or skin tingle, assume this crouch position immediately.
7. Phone calls should be made only from inside a safe shelter and only with a cellular phone or portable remote phone. Avoid using a standard land-line phone except in emergency situations.
8. Athletic activity should not be resumed until 30 minutes after the last flash of lightning or last clap of thunder. (The Michigan High School Athletic Association suggests a return to play 15 minutes after the last visible lightning.109)
9. People who have been struck by lightning need emergency help immediately. Lightning victims do not carry an electrical charge, so cardiopulmonary resuscitation and other first aid procedures are safe for the responder if conducted in a safe shelter.
Precautions for Severe Storms and Tornadoes: In 1997, 19 tornadoes struck Michigan, killing seven people and injuring 108 people.110 Tornadoes generally develop from severe thunderstorms. Severe thunderstorm winds can be as strong and dangerous as a tornado. Protecting athletes and spectators once severe storms or tornadoes begin moving into an area is essentially impossible because there is so little time to act and because safe shelter is much more difficult to find for tornadoes than for other types of severe weather. Suggesting that everyone go home when there is an imminent tornado is not truly acceptable, because automobiles are not safe shelters under these conditions.
In light of these considerations, the MHSAA policy that competitions be canceled when there is a tornado watch or warning in effect makes very good sense.109 The single most effective tornado precaution an athletic program can take is to obtain accurate, current weather information and shut down athletic events when violent weather threatens.
For tornado safety, football programs should:
1. Designate a chain of command for making the decision to remove individuals from an athletic site.
2. Designate an individual who will obtain a weather forecast each day before a practice or event and monitor weather forecasts constantly when there is any threat of severe storms or tornadoes.
3. Athletes and coaching staff should know where the closest safe shelter is. Safe shelter for tornadoes is defined as the basement of a sturdy building, away from windows, glass doors and chimneys. If a basement is not available, an interior hallway on the lowest floor is best. Rooms with large, free-span roofs like gymnasiums should be avoided. The inside of an automobile is not a safe place if a tornado is imminent. If no safe building is nearby, individuals should seek shelter in a ditch, ravine, or other place below ground level and stay as low as possible.110
4. Tornado watch or severe thunderstorm watch: If a watch is issued during a practice, practice can continue, as long as coaching staff and athletes know how to get to nearby safe shelter and Weather Radio is being continually monitored.111 However, if a watch is issued three hours before a game or during a game, the competition should be canceled or suspended.109
5. Tornado warning or severe thunderstorm warning: If a warning is issued during either a practice or game, athletic activity should be suspended and all participants moved as rapidly as possible to safe shelter.109 Athletic activity should not be resumed until the National Weather Service suspends the warning.
Precautions for Extreme Heat: Seven football players in the United States died from heat illness between 1995 and 1997.2 Heat-related deaths are always preventable. The major health risk associated with exercising in hot weather is from water loss through sweating.112 Recognized precautions are summarized below.
1. Acclimatize athletes to heat gradually. Pre-season conditioning programs that accustom players gradually to exercise in hot weather are recommended. Early season practices (the first 7-10 days) should be shorter and less intense.2
2. During hot weather, conduct practices and early season games in light-weight uniforms, without stockings or long-sleeved jerseys.113 Never use rubberized clothing or sweat suits.2
3. Make cold water available at all times. Encourage drinking before, during and after practices and games.
4. Weigh athletes before and after practice to monitor water loss during the first two weeks of practice and under conditions of high risk for heat illness.114 Weight loss greater than 3% during a practice indicates substantial risk for heat illness.113,114 A 5% loss is in the danger zone.113 Record the weights on a chart so weight changes can be tracked over several days. For every pound of weight lost through sweating, a pint of fluid should be consumed.115
5. Avoid cumulative fluid depletion over several practices by comparing pre-practice weights. Any athlete whose weight is more than 2% lower than the previous pre-practice weight should not be allowed to participate in the practice session until the fluid has been replaced.114
6. Observe all athletes for signs of heat illness. These may include fatigue, weakness, dizziness, pounding headache, visual disturbances, lethargy, cramps, inattention, confusion, nausea or vomiting, awkwardness, weak and rapid pulse, flushed appearance or fainting.2,51,114
7. Identify and observe more closely athletes at higher-than-normal risk for heat illness. Susceptibility is increased in athletes who are unaccustomed to working in heat, are poorly conditioned, over-eager, overweight, have a previous history of heat illness,38 or who have lost more than 3% of their body weight in a practice.114 Recent alcohol consumption may reduce heat tolerance and contribute to dehydration. Some medical conditions also increase risk of heat illness, including cystic fibrosis, diabetes, mental retardation and acute illness.38
8. Coaches and athletic trainers should be thoroughly trained in first aid for symptoms of heat illness. If heat stroke is suspected, emergency medical services should be summoned immediately. An increasing number of medical personnel are suggesting as a first response applying alcohol or cool water to the victims skin, and then fanning the victim vigorously to increase evaporation and cooling.2
9. Salt and electrolytes lost through sweating should be replaced through a normal diet with plenty of fruits and vegetables. Salt tablets are inappropriate and are potentially dangerous.
10. Determine the degree of risk for heat illness. Both heat and relative humidity must be taken into account, because high humidity slows down the evaporation of sweat, making it more difficult for the body to cool down. The most accurate way to determine risk is to measure the wet bulb temperature, which reflects both temperature and relative humidity. Sling psychrometers are simple and inexpensive instruments that measure wet bulb temperature. Wet bulb temperatures are taken in the shade.
If a sling psychrometer is not available, local weather forecasts of temperature and humidity can be consulted, but they are far less reliable, since they are based on heat and humidity measurements taken at weather stations that may be quite distant from the field of play. See Appendix C, for a table defining risk of heat illness based on reported temperature and relative humidity. Whenever relative humidity is 95% or higher, some precautions should be taken.116
The extent of precautions necessary to prevent heat illness depends on the degree of risk that exists. Respected authorities differ somewhat on the temperature cut-off points to define risk categories, but all agree that precautions should be more aggressive when weather conditions present greater risk. Table 1 combines recommended precautions suggested by several authorities. A football programs hot weather policy could be based on an adaptation of this table. Note that wet bulb temperatures are taken in the shade. If players are exposed to direct sunlight, the risk of heat illness is even higher than suggested in Table 1.
Precautions for Cold Weather: Although it is not customary to cancel football games because of cold weather, policies to do so are worth considering, particularly for high school and youth football programs. Snow and ice on the athletic field can make a field unplayable, creating risk of injury from falling. More critical, however, are the risks for hypothermia and frostbite that arise under conditions of extreme cold. Both of these conditions occur more rapidly under windy or wet conditions.112,118
When wet snow is falling or the field is very wet, risk of hypothermia is heightened because it is impossible to keep uniforms dry, and wet clothing speeds heat loss.112 Hypothermia can occur at temperatures as high as 40°F under damp and windy conditions. Players on the sidelines may be more at risk for hypothermia than those in play.111 At a minimum athletes should be provided with gloves and protective covering for faces when the wind chill index is low, with extra dry gloves available when conditions are wet.
Table 1. Guidelines for Adjusting Football Games and Practices to Avoid Heat Illness
Wet Bulb Temperature (°F) Risk Level and Recommendations 60 and below Low Risk. No special precautions necessary. Assure unlimited access to cold water.114 61-65 Moderate Risk: Observe all squad members for symptoms, especially those at higher risk.116 Alert athletes of risk of heat illness and importance of drinking water.117 66-75 High Risk: Rest breaks should be scheduled every 30 minutes,113,116 with required drinking of 9-12 ounces every half hour.114 Limit intense activity.114 76-79 Very High Risk: Modify the practice schedule to reduce training demands.2 Hold practice only in the coolest parts of the day.38 Provide rest periods of 15-30 minutes for each hour of workout, in shaded areas, with helmets removed and jerseys loosened.2,38 Athletes at high risk should not play.114 Cancel practices and games in youth sports programs.114 80 and above Cancel games and practices.117
Frostbite can develop almost instantaneously on areas of skin surface that are unprotected.112 The risk of freezing of exposed flesh is increased when the wind chill index is -20 or lower. In Michigan, the wind chill index reaches -30 only a few times per year. When this occurs, the National Weather Service issues a Wind Chill Advisory, which means that the weather is life-threatening unless precautions are taken. At a wind chill index of -50 or below, the National Weather Service issues a Wind Chill Warning (once every few years in Michigan). This means that the weather is life-threatening, even if precautions are taken. It would be very reasonable to cancel games and practices when the wind chill index reaches -20 or lower. Under wet conditions, a higher wind chill index would be suitable for cancellation. No outdoor athletic activity should be held at a wind chill index of -50. See Appendix C for a method of estimating wind-chill and for a wind-chill risk chart.
Under conditions of extreme cold, athletic staff should be alert for symptoms of hypothermia (confusion, memory loss, drowsiness, fumbling hands, slurred speech) and frostbite (white or grayish-yellow skin area, skin that feels unusually firm or waxy, numbness). Victims are generally unaware that they are experiencing these conditions.119 If these conditions are suspected, recognized first aid procedures should be followed.
A cold weather policy could include (1) the chain of command for making cold weather decisions, (2) the method that will be used to document wind chill level (i.e., estimation by a staff member or use of the National Weather Service reports), (3) wind chill levels at which athletes wear gloves and face covering-under both wet and dry conditions, (4) wind chill levels at which practices are held indoors-under wet and dry conditions and (5) wind chill levels at which games are postponed-under wet and dry conditions.
Preventing Re-injuries and Reducing Severity of Injuries: To minimize the occurrence of re-injuries, early intervention on a new injury and appropriate rehabilitation are important.
Moving an Injured Athlete: An injured athlete should not be moved until conditions such as uncontrolled bleeding, suffocation and cardiac arrest have been addressed. If possible, medical supervision should be obtained before the athlete is moved. If this is not possible, standard first aid procedures should be used.104
If an athlete has a suspected head, neck or spine injury, movement of the head should be minimized. For the individual with a cervical spine fracture, a single movement of the head can cause paralysis or death. If an athlete is unconscious, it should be assumed that there is a spinal injury, until it can be determined otherwise.120 In such cases, the helmet should never be removed at the scene of the injury because of the risk of aggravating the injury,103,121,122,123 unless there are special circumstances such as respiratory distress coupled with an inability to access the airway. To allow emergency personnel to monitor breathing, provide initial care for facial injury, or institute resuscitation, the face mask can be removed by unscrewing the bolts, or cutting the plastic loops that attach the mask to the helmet. The head should be stabilized as the face mask loops are cut and removed from the helmet. The chin strap can be left in place unless resuscitation is required. Ray et al.90 describe a method of beginning rescue breathing without removing the face mask, using a pocket mask fitted with a one-way air valve.
If respiration is not occurring and the head is in a skewed position, the head can be gently straightened, but only far enough to open the airway.120 If there is any possibility of a neck injury, the athlete should be transported on a rigid stretcher with the neck immobilized by a brace or sand bags until appropriate neck x-rays can be taken.124,120
Returning to Play After an Injury: Athletes who are injured should be kept out of practice and play until the injuries are healed. Premature return to play can delay healing and can even cause permanent damage. The decision as to when to return should be made by a trained medical person who has the childs health interest as the primary concern. Adults associated with the athletic program may not be completely impartial. During each game and practice, an adult (preferably an NATA-certified athletic trainer) should be assigned to observe, evaluate and control injured players so that they cannot return to competition without appropriate evaluation.105
Concussion Management: Concussions are characterized by dizziness, headache, tinnitus, blurred vision, double vision, inability to walk correctly, nausea, vomiting, confusion, lack of awareness, hallucination, drowsiness, amnesia or loss of consciousness. Of these symptoms, amnesia and loss of consciousness are the prime indicators of severity.40
Once injured, the brain is more susceptible to injury.68,40,31 Repeated mild brain injuries occurring over an extended period (i.e., months or years) can result in cumulative neurologic and cognitive deficits.125 Repeated mild brain injuries occurring within a short period (i.e., hours, days or weeks) can be catastrophic or fatal. Athletes who return to play before concussion symptoms have completely cleared are at risk for "second impact syndrome," where a very minor second head injury can result in rapid brainstem failure (within two to five minutes of the second injury) followed precipitously by coma, ocular involvement and respiratory failure.42,43 The athlete should never be allowed to return to practice or competition while he or she is still experiencing concussion symptoms.44,45 After a severe head injury, CAT scans or magnetic resonance imaging scans should be used to document evidence of structural brain damage. (See the Table 2.) Even one concussion with evidence of brain damage should preclude further football participation.126,40,127
Athletes who have experienced forceful head contact should be questioned specifically about symptoms and evaluated for recent memory integrity. Unless this is done, it may not be recognized that a concussion has been sustained.41,128 To verify whether a concussion has occurred, the American Academy of Neurology recommends that standardized systematic sideline evaluation be used.127 Standardized sideline evaluations have been published by the National Athletic Trainers Association68 and by McCrea et al.128
A football program administrator should work with a knowledgeable physician to develop clear guidelines for identifying and giving initial treatment for concussions, including guidelines for an athletes return to play. The concussion policies would be used primarily by the football staff. They would not take the place of sound clinical judgment and experience of a physician treating head injuries. The policies should be reviewed annually because there is no national consensus within the medical community as to how to classify the severity of concussions. Research is going on now so that definitive guidelines can be developed. In the meantime, several different suggested guidelines for concussion management have been published.40,129,130 The 1997 Recommendations for Management of Concussion in Sports of the American Academy of Neurology127 are summarized in Table 2.
A related issue is evaluation of an athlete with temporary paralysis of arms and legs after an injury. Competition should not be resumed until the athlete is completely asymptomatic and the extent of the neurological injury has been evaluated. Evaluation should include a detailed neurologic examination, plain radiographs and magnetic resonance imaging to verify that the athlete has no conditions which would increase the risk of quadriplegia, such as fractures and herniated disks.131
Prevention of Communicable Diseases: Infectious dermatologic conditions such as scabies, louse infestation or impetigo could be transmitted during practices and games.31 Athletes with contagious conditions should receive treatment. Before any piece of equipment is reassigned from one athlete to another, it should be sanitized.
The risk of transmission of blood-borne illnesses including HIV and hepatitis B, C and D viruses during football practices or games is very small. Brown et al. calculated the risk of transmission of HIV among college football athletes to be less than one per 85 million game contacts.132 The risk of transmission of hepatitis B is somewhat greater. Nevertheless, the American Academy of Pediatrics and others31,133 have concluded that positive HIV status or infection with hepatitis in an asymptomatic individual does not mandate discontinuation of athletic participation. Immunization for hepatitis B is generally available and is recommended for all football players.
Table 2. Summary of Suggestions for Management of Concussion in Sports, American Academy of Neurology127
Severity Description Initial Treatment and Return to Play Guidelines
Grade 1: Mild Transient confusion, no loss of consciousness and a duration of mental status abnormalities of less than 15 minutes. The athlete should be removed from sports activity, examined immediately and at 5-minute intervals and allowed to return that day to the sports activity only if postconcussive symptoms resolve within 15 minutes. Any athlete who incurs a second Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for one week.
Grade 2: Moderate Transient confusion, no loss of consciousness and a duration of mental status abnormalities of greater than or equal to 15 minutes. The athlete should be removed from sports activity and examined frequently to assess the evolution of symptoms, with more extensive diagnostic evaluation if the symptoms worsen or persist for more than one week. The athlete should return to sports activity only after asymptomatic for two weeks.
Grade 3: Severe Loss of consciousness, either brief (seconds) or prolonged (minutes or longer). The athlete should be removed from sports activity for one full week without symptoms if the loss of consciousness is brief or two full weeks without symptoms if the loss of consciousness is prolonged. If still unconscious or if abnormal neurologic signs are present at the time of initial evaluation, the athlete should be transported by ambulance to the nearest hospital emergency department. An athlete who suffers a second Grade 3 concussion should be removed from sports activity until asymptomatic for one month. CT or MRI scanning is recommended if headache or symptoms worsen or persist longer than one week. Any athlete with any abnormality on computed tomography or magnetic resonance imaging brain scan consistent with brain swelling, contusion, or other intracranial pathology should be removed from sports activities for the season and be discouraged from future return to participation in contact sports.
Although risk of transmission of blood-borne illnesses is small, athletic staff should follow universal precautions for protecting themselves and athletes from exposure to blood-borne illnesses. Specific precautions include proper disposal of needles and using disposable latex gloves and other protective garments and equipment. All employers in Michigan are required by the Michigan Occupational Safety and Health Act (MiOSHA) to establish an exposure control plan and to offer training to workers. The MiOSHA Blood-Borne Infectious Disease Standard can be obtained from the Michigan Department of Consumer and Industry Services.134
Rules Modifications Suggested for Youth: Special rule modifications have been suggested by several experts for pre-high school football. Since a disproportionate number of injuries occur during kick-off and punt returns, this aspect of the game could be eliminated, minimizing high-speed collisions.30,105 Youth league administrators could consider limiting the number and types of offensive sets and defensive formations allowed. For example, in North Syracuse Central Schools in New York, the alignment of the defensive team in junior high-level football is controlled in a 6-2-2-1 defense, eliminating the element of surprise and confusion.30
Use of Drugs: An estimated 500,000 young athletes, boys and girls, use black-market anabolic steroids to improve their athletic performance. Steroids increase muscle mass but can cause potentially life-threatening complications, including heart attacks and stroke.32 The uncontrolled rage and aggression sometimes associated with anabolic steroid use could lead to injuries on the football field. School districts and youth leagues should aggressively discourage children from using steroids or any other performance-enhancing drugs, as well as from use of alcohol and recreational drugs.
Safe Transportation: When an athletic program is transporting athletes, the vehicles used should be carefully maintained, inspected for safety and driven by appropriately licensed drivers.22
First Aid Supplies for Practice and Sports Events 68,104,135
A copy of the Medical Emergency Action Plan Hand towels or washcloths Automatic hot/cold packs Head restraint (paramedic-approved) Adhesive tape (assorted widths) Knife (Swiss Army-type) or trainers angel Airways, disposable Mask, CPR Antiseptic cream or ointment Moleskin (for blisters) Isopropyl alcohol Oral airway Bags, small plastic - for ice Pads, sterile 2x2 (for small wounds and eye injuries) Bandages, elastic (2", 3", 6") Pads, sterile 4x4 Bandages, sterile-2" (roller or conforming) Petroleum jelly Bandages, triangular (for slings, etc.) Safety pins Band-aids-several sizes Sandbags-5 pounds Bandage scissors Skin adhesive Biohazard waste material container Spine board, stretcher Blankets Splints, assorted (malleable metal or air type) Cervical collar Suction device Communication with physician and medical facility Suture strips Cotton tip applicators (or sterile cotton and applicator sticks) Tape, elastic Double action bolt cutter (to remove face mask) Tape cutter Fingernail cutter Thermometer Flashlight or pen light
Tongue blades (for splints)
First Aid Manual
Foam rubber and/or felt
Tube gauze and applicator (finger size)
Gloves-latex or latex-free
Grasping instrument (forceps and/or hemostat)
National Weather Service Offices Serving Michigan
NWS Office, NOAA
9200 White Lake Rd.
White Lake, MI 48386-1126
(248) 625-3309, Ext. 726
Contact: Darin Figurskey
NWS Office, NOAA
8800 Passenheim Rd.
Gaylord, MI 49735-9454
(517) 731-1194, Ext. 726
Contact: Brian Hirsch
NWS Office, NOAA
4899 South Complex Dr. SE
Grand Rapids, MI 49512-4034
(616) 949-0643, Ext. 726
Contact: Mike Heathfield
NWS Office, NOAA
112 Airport Dr., South
Negaunee, MI 49866
(906) 475-5782, Ext. 726
Contact: Jack Pellett
NWS Office, NOAA
7550 East 850 N.
Syracuse, IN 46567
(219) 834-5178, Ext. 726
Contact: Jane Hollingsworth
Severe Weather Guides
Guidelines for Identifying Risk of Heat Illness for Activities Lasting 30 Minutes or More, Using Reported Temperature and Relative Humidity112
Air Temperature High Risk
Very High Risk
70°F 80% 100% 75°F 70% 100% 80°F 50% 80% 85°F 40% 68% 90°F 30% 55% 95°F 20% 40% 100°F 10% 30%
Wind Chill Chart* 136 with National Weather Service Alert Levels137
Air Temperature Wind Speeds (mph)
0 10 20 30 30°F 30 16 4 -2 20°F 20 4 -10 -18 10°F 10 -9 -25 -33 Wind Chill Advisory: 0°F 0 -24 -39 -48 Life-threatening without precautions -10°F -10 -33 -53 -63 Wind Chill Warning: -20°F -20 -46 -67 -79 Life-threatening even with precautions
*Wind speed can be estimated. If wind can be felt on the face it is at least 10 mph. If small tree branches move or if snow and dust are raised, it is approximately 20 mph. If large tree branches move, 30 mph. If an entire tree bends, wind speed is about 40 mph.118