HIGH SCHOOL FOOTBALL-RELATED CERVICAL SPINAL CORD INJURIES IN LOUISIANA: THE ATHLETE'S PERSPECTIVE

 

DAVID W. LAWRENCE, MPH, RN,CS; GREGORY W. STEWART, MD; DENA M. CHRISTY, MPH; LYNN I. GIBBS, MPH; MARCY OUELLETTE, MD, MPH

 

ABSTRACT

Louisiana has one of the highest rates in the nation of cervical spinal cord injuries to high school football players. When the national rate of these injuries is applied to the number of high school participants in Louisiana, we would expect there to be only one catastrophic neck injury every 14 years. Louisiana, however, has averaged 2.3 spinal cord injuries per year for the past seven football seasons. Players who use the top of their helmets to tackle, block or strike opponents are at greatest risk for these injuries. This study was undertaken to describe the safe tackling knowledge, attitudes, and practices of Louisiana high school football players. We surveyed 596 players from 16 Louisiana high schools. When asked if it was within the rules to tackle anyone by using the top of their helmet, 29% incorrectly answered "yes''. Similarly, when asked if they had ever tackled anyone using the top of their helmet) 33% reported that they had. Twenty-eight percent said that they had been taught to use this unsafe method. Of these, 83% said that their coach taught them this dangerous and illegal method. Using the helmet as a battering ram must be discouraged. Education for officials, coaches, and players is needed to improve recognition of improper tackling. Proper training in tackling and blocking is an important means of minimizing the possibility of catastrophic injury.


 

INTRODUCTION

Football has been demonstrated to be among the most hazardous of organized team sports(1). Serious football-related injuries have been the subject of reports in both the medical literature and popular press throughout the United States. In 1989, four Louisiana high school students sustained cervical spinal cord injuries while playing football (2). Based upon the national rate of 0.4 per 100,000 players per year and the 1989 population of Louisiana high school players, only one such injury would be expected during a 14 year period (3). The higher-than-expected rate of these injuries (2.3 per season) in Louisiana has continued through 1995 (Table).

 

Axial loading of excessive force to the cervical spine has been documented as the primary cause of these injuries (4). When the head is in a neutral position, the normal alignment of the spine is one of extension because of the lordotic curve. With the head in a neutral position or further extended, forces of contact can be partially dissipated by an athlete's well-developed musculature of the neck. When the head is rotated to a chin-down position even as little as 30 degrees the normal cervical lordosis (Figure 1) is straightened and the forces of impact to the top of the head are transmitted directly to the cervical vertebrae (Figure 2). When a player in this position collides with another player (termed spearing), the head is stopped, the trunk is still moving, and the cervical spine is crushed between the two (5). Therefore, players who use the top of their helmets to tackle, block, or strike opponents are at greatest risk (3).

 

Figure 1. This radiograph shows the position of the cervical spine with the neck in a neutral position.

 

Figure 2. This radiograph shows the position of the cervical spine with the neck flexed forward 30 degrees.

In an attempt to inform athletes and coaches of the risks of unsafe tackling techniques, a training video on proper tackling was produced through support from the Louisiana Sports Medicine and Safety Advisory Council; the Louisiana Office of Public Health, Disability Prevention Program; Children's Hospital of New Orleans; Tulane University, and the US Centers for Disease Control and Prevention (6). Coaches' game officials, and parents assisted with developing the script for this 8-minute video. It was introduced before the 1992 football season. Through the cooperation of the Louisiana State Medical Society Auxiliary, Louisiana parent-teacher organizations, and parish school boards, copies of the video were distributed to every junior and senior high school and municipal athletic department in the state. The tape identified college and professional players who suffered disabling neck injuries due to improper tackling, showed how those injuries occurred, and demonstrated proper technique. However, the program did not have the desired effect of reducing injury occurrence (Table).

TABLE

Traumatic Spinal Cord Injuries to

High School Football Players

Louisiana 1989-1995

 

Year

Number

1989

4

1990

1

1991

1

1992

4

1993

1

1994

4

1995

1

Source: Louisiana Office of Public Health, Injury Research and Prevention Section, Central Nervous System Registry.

 

Before the 1994 football season, the Louisiana Office of Public Health and the US Centers for Disease Control and Prevention collaborated with the Tulane Institute of Sports Medicine to present a conference for coaches, trainers, and physicians on the causes and prevention of cervical spine injuries to football players. Again, no demonstrable decrease in injuries was noted.

 

This study was undertaken to quantitatively describe the safe tackling knowledge, attitudes, and practices of high school football players in Louisiana.

 

METHODS

In 1994, we surveyed 596 football players from 16 Louisiana high schools (13 public, 3 private) in southeastern Louisiana. Players voluntarily completed a questionnaire during pre-participation physical examinations. The design was a cross-sectional survey using convenience sampling. The survey consisted of questions pertaining to player demographics, attitudes about the game) behavior during practice and competition, and injury prevention knowledge. Questions about tackling technique were asked two ways with and without the term "spearing", as a check for accuracy.

All players attending each physical received and completed a questionnaire.

 

The coaches from each of the schools were contacted by telephone to participate in an interview about their use of Louisiana's safe-tackling video.

 

RESULTS

The respondents ranged from 14 to 20 years of age with a mean age of 16.2 years. Results did not differ significantly when stratified by age, race, grade-level, school, player position, player specialty (defense, offense, special teams), or number of years played.

 

When asked if it was within the rules to tackle by using the top of their helmet, 29% of the respondents incorrectly answered "yes". However, when asked if they had ever tackled anyone using the top of their helmet, 33% reported that they had. With regard to being penalized for this type of improper tackling 13% said that they had been and 47% said that a teammate had been. Twenty-three percent of the respondents indicated that they had been warned by an official in a game not to tackle with their head down. The results for questions in which the term "spearing" was used were similar.

 

When asked if it was legal to "run over" or "butt block" a player using the top of their helmet, 35% and 32% of the respondents, respectively, said that it was -- 30% and 22% indicated that they had done so.

 

When asked if the athlete had ever been taught to tackle, block, or run over someone using the top of their helmet, 28% responded that they had been taught this unsafe method -- 83% of these reported that their coach had given them this training. In another question, only 65% of the athletes indicated that they had been taught the proper way to tackle, block, or run over an opponent. With regard to knowledge of any high school, college, or professional football player who had been paralyzed from breaking their necks; the response was 39%, 34%, and 64% respectively. Overall, 32% of respondents denied knowledge of any player who suffered a paralyzing neck injury.

 

A large proportion of the athletes surveyed responded that they thought that their equipment and pads would prevent them from breaking their necks, 40% of the players thought that the neck roll provided this protection and 18% thought that the helmet did.

 

Only 12% of the players acknowledged that they had seen the Louisiana Safe Tackling video. These players were limited to two of the schools that participated in the survey. Coaches at the other schools were interviewed by telephone to determine if they were aware of the video and if so, why their players had not seen it. We were able to contact a coach from each of the 14 schools with players who hadn't seen the tape. Three coaches refused to be interviewed. All of the 11 coaches interviewed said that they were aware of the tape. When asked why the tape had not been shown, five coaches responded that they had not found the time. The other six expressed the concern that the video might make their players play less aggressively.

 

 

DISCUSSION

In 1976, the National Collegiate Athletic Association (NCAA) and the National Federation of State High School Athletic Associations (NFSHSA) changed their football rules, making the deliberate use of the helmet against an opponent illegal (7, 8) Despite a significant reduction nationally in catastrophic football injuries since the introduction of these rules (9-11), these injuries continue to be a problem in Louisiana.

 

It is apparent from this study that the prevalence of unsafe and illegal tackling methods is significant despite rule changes and intensive educational programs. Due to the forces encountered in football collisions, catastrophic injuries may never be entirely prevented. They can be minimized, however, if players, coaches, and officials comply with accepted rules.

 

Among the rules relating to head-first contact, almost all indicate that head-first contact is illegal in high school football, regardless of the athletes intention or the part of the helmet used. The one exception is for the ball carrier his head-first contact must be intentional. Football officials, therefore, play an important role in the prevention of catastrophic injuries. They alone can use the spearing penalty as a deterrent to this unsafe tackling method. One study reported that officials were unlikely to call a spearing penalty but instead, would warn the athlete to keep his head out of contact. This is consistent with the present study where 23% of the athletes have themselves been warned but only 13% had been penalized.

 

Coaches and team physicians must become more actively involved in prevention. It is of serious concern that of the one fourth of the players who reported that they had been taught how to tackle using their helmet, most said that their coach had taught them this risky technique. Proper training in tackling and blocking is an important means of minimizing the possibility of catastrophic injury. Even those coaches who teach proper tackling technique may not be stressing its importance for the prevention of catastrophic injuries. We are concerned that when asked about their reasons for not showing the safe-tackling video, more than half of the responding coaches said that their players may perform less aggressively as a result. As one of the coaches put it, seeing the video "might make the players afraid to hit".

 

Although using the helmet as an offensive, battering ram must be discouraged, it is likely that many neck-flexed tackles are performed not from intentional spearing or butt-blocking but from sloppy, poorly executed tackles and blocks. The athlete must overcome a natural tendency to tuck one's head when about to collide with an opponent. If this inferior tackling technique is tolerated by coaches of peewee and youth teams, the habit will be difficult to overcome by the time a student reaches high school competition.

 

The most important preventive action is avoidance of contact with the top of the player's head. However, sometimes such contact is unavoidable. One of the more important functions of the posterior and lateral neck muscles is to maintain the integrity of the cervical vertebrae through a powerful compression load (13). Thus, adequate conditioning of neck muscles is essential. Athletes should be given proper exercises to strengthen their necks thus enabling them to hold their heads firmly erect while making contact during a tackle or block. Good musculature will also better distribute or dissipate the force of impact.

 

Coaches and team physicians must take an active role in educating players about the purpose of protective equipment. An alarmingly high percentage of players display poor knowledge of the effectiveness of their equipment. Although the helmet and neck roll do not protect the spinal column, many of the players surveyed thought that they did.

 

Although this study had several limitations, the information provided about the prevalence of dangerous practices and misconceptions about safety is useful despite its drawbacks. The questionnaire was worded very simply so that all respondents, even those with low reading skills, would be able to answer the questions. This prohibited fine tuning questions to allow for the assessment of any temporal association between the time a student gained knowledge of players with disabling injuries and their own unsafe practices. Another limitation was the use of a convenience sample, rather than a randomized design. However, at each school, all players attending the pre-season physical examinations participated in the study. These limitations notwithstanding, this report documents widespread hazardous tackling technique, misunderstanding of the rules of play, and confusion about the purpose of safety equipment.

 

The occurrence of spinal cord injuries during football competition is not a "freak accident" but a problem that has a defined cause and a solution. With information about the players' knowledge, attitudes, and practices, it becomes evident that these injuries may be prevented with changes in coaching and in game officials' enforcement of the rules. Several recommendations follow from this research:

 

 

 

 

 

 

 

 

 

REFERENCES

1. Kraus IF, Conroy C. Mortality and morbidity from injuries in sports and recreation. Ann Rev Public Health 1984;5:163-192.

 

2. Liggett GM, Madison JB, Nitzkin JL, et al. Football-related spinal cord injuries among high school players—Louisiana, 1989. MMWR 1990;39:586-587.

 

3. Tom Vegso JJ, Sennett B. The National Football Head and Neck Registry: 14 year report on cervical quadriplegic (1971-1984). Clin Sports Med 1987;7:61-72.

 

4. Torg JS, Negro JJ, O'Neill MJ, et al. The epidemiologic, pathologic, biomechanical, and cinematographic analysis of football-induced cervical spine trauma. Am J Sports Med 1990;18:50-57.

 

5. Torg JS, Thibault L, Sennett B. et al. The pathomechanics and pathophysiology of cervical spinal cord injury. Clin Orthop 1995;321:259-269.

 

6. Louisiana Sports Medicine and Safety Advisory Council. Safe tackling: a training video. New Orleans: Louisiana Office of Public Health, Disability Prevention Program, 1991.

 

7. National Collegiate Athletic Association football rules changes. Rule 2, Section 24; Rule 9, Section 1; Article 2-N. January 23, 1976.

 

8. National Federation of State High School Associations. Official Football Rules. Kansas City, MO: NFSHSA, 1992:15,22,50.

 

9. Anderson C. Neck injuries—backboard, bench, or return to play. Phys Sportsmed 1993; 21:23-34.

 

10. Mueller FO, Blyth CS, Fatalities from head and cervical spine injuries in tackle football: 40 years/ experience. Clin Sports Med 1987; 6:185-196.

 

11. Albright JP, McAuley E/ Martin RK et al. Head and neck injuries in college football: an eight-year analysis. Am J Sports Med 1985; 13:147-152.

 

12. Heck IF. A survey of New Jersey high school football officials regarding spearing rules. J Athletic Training 1995; 30:63-68.

 

13. Reid SE, Reid SE, Jr. Prevention of head and neck injuries In football. Surg Annu 1981; 13:251-270.

 

 

ABOUT THE AUTHORS

Mr. Lawrence is supervisor of injury epidemiology with the Louisiana State Office of Public Health, Injury Research and Prevention Section.

 

Dr. Stewart is associate professor, Dept of Orthopedics at Tulane University School of Medicine.

 

Ms. Christy is an injury prevention specialist, Agenda for Children.

 

Ms. Gibbs is an epidemiologist with the Louisiana State Office of Public Health, Disability Prevention Program and Injury Research and Prevention Section.

 

Dr. Ouellette is a medical consultant with the Louisiana State Office of Public Health.

 

 

This project was funded in part by grant MU59 CCU603362 from the Centers for Disease Control and Prevention (CDC), National Center for Environmental Health, Disabilities Prevention Program, and with technical support from the CDC, National Center for Injury Prevention and Control, Division of Acute Care, Rehabilitation Research, and Disability Prevention.

 

Copyright 1996 Journal of the Louisiana State Medical Society, Inc.


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