Football High

Attention: Players, Parents, Coaches

Frequently asked questions on head injuries, heatstroke and how to protect young players' health and safety


Head Injuries

How big a problem are high school football head injuries?

At least 60,000 concussions occur every year on high school football fields. But now there's a new piece of the story: Researchers' neurological tests are showing that young players who never reported symptoms of a concussion, but had taken sub-concussive hits, have suffered significant damage to their memories. As the season wore on, these players performed increasingly worse on cognitive tests.

What happens to the brain in a concussion?

A concussion is a blow to the head that results in the brain crashing into the skull. Dr. Ann McKee, a neuropathologist at Boston University describes the impact of a concussion:

"The brain isn't hard. It's this firm gelatinous tissue. It elongates and stretches and deforms ... so all the individual nerve cells in there are actually being stretched and undergoing shearing forces, and they're being damaged just by the elongation of the brain or the torsion on the brain. What happens after a concussion is that a nerve cell has all sorts of changes in its covering. All sorts of ions flow into the nerve cell that are damaging to it. There are changes in the blood flow to regions."

She warns that the damage inside the nerve cell doesn't repair immediately; at the very least it can take days, if not weeks or months, for the brain to return to its resting normal state. Repetitive brain trauma makes recovery even more difficult. A second concussion before the first has fully healed, known as second impact syndrome, can lead to permanent brain damage and is often a fatal condition.

View NOVA's special, Brain Trauma, which shows how concussion affects the brain and can have long-term consequences.

Why the special concern about hits to young players?

Because a young athlete's brain is still developing, the effects of a concussion, or even many smaller hits over a season, can be far more detrimental, compared to head injury in an older player.

Professor Tom Talavage, an expert in functional neuroimaging and co-director of Purdue University's MRI facility, conducted a study [PDF] on the cognitive impairment of high school football players. He tells FRONTLINE:

"By the end of the season we found that in 50 percent of the players [who] were brought in not concussed, we were detecting changes, either in their computer-based testing and/or in their functional MRI data, showing that something had changed in the way their brain was performing a particular set of simple tasks."

Could better helmets reduce the impact of hard blows?

Researchers are working on this with helmet designers. But despite advancements in helmet protection, Texas high school athletic trainer Mike Carroll warns there is "no such thing as a concussion-proof helmet."

Neuroimaging expert Tom Talavage points out that with technology making helmets stiffer, harder and more protective against skull fracture, players are using them as a "tactical weapon" -- and when an athlete uses his helmet to hit and tackle another player, he may be causing damage to his own brain. Talavage says it's unclear whether helmets reduce the energy force being delivered to the brain; some of his data suggests that they may be amplifying it.

Why not conduct regular neurological testing of high school players?

Some high schools have begun using Immediate Post-Concussion Assessment and Cognitive Testing, or imPACT testing, a computerized concussion-evaluation system measuring players' reaction time and cognitive abilities. At the start of a season, players can be administered an imPACT test to determine their baseline of cognitive abilities. After an injury, players can be retested and prevented from playing until they achieve the original baseline score.

Texas high school athletic trainer Mike Carroll says the number of schools using imPACT testing grows each year, although high school administrations cite cost as a barrier to implementing imPACT or another form of neurological testing.

What other steps are needed to improve the health and safety of young players?

ESPN writer Gregg Easterbrook is one of many close observers of high school football who cite the need for strict rules for the licensing of coaches: They should be required to pass courses in heatstroke and head injury symptoms and know first aid for both; they should be penalized for mistreating players and not properly caring for them when they go into heatstroke or have a head injury. And he suggests having a neutral observer always present at practices as another significant step in improving young players' safety and health.

"There are a lot of things we can do -- from the hardware of the helmet, to the technique of the tackling, to the way we manage hits in practice -- that can make football as safe as possible," suggests Sports Illustrated writer David Epstein. "Good technique for tackling has to start at a really young age."

What organizations and states are taking the lead in setting up regulations?

Chris Nowinsky, co-director of the Sports Legacy Institute says there is no major organization or authority that is pushing the conversation on dealing with brain injury in youth sports, and at the national level, high school football is an unregulated sport.

However, at the state level the Public Health Law Network reports that at least 11 states -- Connecticut, Idaho, Maine, Massachusetts, New Jersey, New Mexico, Oklahoma, Oregon, Rhode Island, Virginia and Washington -- have laws requiring education for coaches, athletes and parents; concussion management protocols; and return-to-play guidelines. Details on what these states are doing are listed here [PDF].

According to the National Conference of State Legislatures, an additional 36 states currently have bills pending on youth sports-related concussions.

Update: As of August 2013, every state except for one -- Mississippi -- has enacted legislation designed to minimize the risk of football-related head injuries.

Most of these laws follow the framework established in Washington state in 2009 with the Zachary Lystedt law. Lystedt, the law's namesake, suffered a devastating brain injury during a high school game in 2006. The injury left him on life support for seven days, unable to speak for nine months, and dependent on a feeding tube for two years.

Under the Lystedt law, athletes, parents and coaches must be educated each year about the dangers of concussions. The law also requires players suspected of having a head injury to be removed from the field and prohibits them from returning until cleared by a licensed health care professional.

Still, states vary in their interpretation of the law. For example, in Texas, each element of the Lystedt law is in place, but in Wyoming, injured players do not need to receive medical clearance before returning to the field.

This map below shows the breakdown. [Sources: LawAtlas/Temple University/Robert Wood Johnson Foundation; Education Week; National Conference on State Legislatures;; USA Football.]

Has GuidelinesNo Guidelines


What is the degenerative brain disease CTE? What is its connection to hard hits to the head?

Chronic traumatic encephalopathy, or CTE, is a neurodegenerative disease often found in athletes who have experienced repetitive mild head trauma. Long known to have affected boxers who have taken many blows to the head, CTE has been recently discovered in football players. Dr. Ann McKee, a neuropathologist at Boston University, conducted post-mortem studies on the brains of more than 20 NFL players and discovered almost all of them had CTE.

"This Is Your Brain on Football" (Time)

Since the disease progresses with aging, CTE often appears in mid-life, and a person's memory and cognition is affected. According to Dr. McKee's research, CTE symptoms can at first include "behavioral and personality changes, sometimes moodiness, depression, and heightened suicidality and erratic behaviors." McKee's research has shown that in some instances symptoms can include motor neuron disease or mimic amyotrophic lateral sclerosis (A.L.S.), commonly known as Lou Gehrig's disease.

Last year, research showed that Owen Thomas, the 21-year-old captain of the University of Pennsylvania football team who committed suicide in April 2010, was in the early stages of CTE. He had never been diagnosed with a concussion.

Can a medical test identify early signs of CTE?

CTE can only be confirmed through a post-mortem examination of brain tissue. But improvements in magnetic resonance spectroscopsy scans have raised hopes that in the future, CTE will also be diagnosable in a living person. Research indicates that at least 17 percent of individuals who experience multiple concussions develop CTE, but Dr. Ann McKee estimates the incidence rate is likely higher.

What other sports do medical experts cite as brain trauma risks for young people?

Hockey, professional wrestling and boxing are on the high-risk list for brain trauma injury. Boxers, in particular, have been found to have a 20 percent CTE rate.

Where can parents and families go for more advice?

The National Athletic Trainers Association [NATA] has resources on concussions and brain injury, including tips on how to reduce the severity of concussion in high school and college athletics and a video on proper tackling techniques in football.

MomsTeam, a youth sports parenting site, offers resources on protecting children from concussions, including this portal on concussion safety.

The New York Times has this portal on brain injuries in football, which includes an article specifically looking at the silence on concussions among high school athletes.

The National Center for Catastrophic Sports Injury Research at the University of North Carolina at Chapel Hill, publishes an annual survey of football injury research with recommendations for making the sport safer. Read the 2010 report, here [PDF].

Read more about traumatic brain injury, or TBI, which includes concussions, from our FAQs on TBI in young soldiers.


What is heatstroke? What are the symptoms?

Heatstroke occurs when a person's body temperature reaches 104 degrees or higher, and usually happens during strenuous physical activity or intense heat and humidity. During heatstroke, a person's body temperature climbs at a faster rate than the body can cool itself. Symptoms include:

  • High body temperature
  • Flushed skin
  • Rapid breathing
  • Racing heart rate
  • Headache
  • Muscle cramps/weakness
  • Neurological symptoms, such as seizures, loss of consciousness, hallucinations, difficulty speaking or understanding others
  • Source: Mayo Clinic

How hot does it have to be to worry about heatstroke?

The heat index, which factors in humidity and temperature, is the key indicator for heatstroke risk.

When the heat index is in the 80s and 90s, Doug Casa of the Korey Stringer Institute [KSI], recommends modifying outdoor practices to include more rest periods and hydration. "When it gets up into the 100s, you want to ask yourself, is the benefit of that practice really necessary at that time?" he says.  If so, Casa recommends having medical professionals, such as an athletic trainer, around as a precaution: "If you don't have medical staff there, you really should have much more conservative guidelines in place at your high school, because you don't want the coach caring for the serious circumstances that may unfold."

How is heatstroke treated?

Cool down the affected person as quickly and aggressively as possible and then transport them to the hospital. "The key to surviving an exertional heatstroke is what you do in the first five to 10 minutes," explains Dr. Casa.   Cold-water immersion is the optimal way to quickly lower body temperature. The Korey Stringer Institute has cold-water immersion guidelines here. If a cold-water immersion tub is unavailable, cover as much of the body as possible with ice or cooling blankets. KSI recommends immersing 12 towels in a cooler filled with ice and water; cover the body with 6 towels for two to three minutes; then put those towels back in the cooler and use the other six on the body. Continue the rotation every two to three minutes.

How can you prevent it?

Heatstroke can be prevented with simple measures like drinking extra fluids to stay hydrated, wearing loose clothing, taking breaks if strenuous activity cannot be avoided, and scheduling activities in the early morning or evening.

The Korey Stringer Institute recommends a 14-day heat acclimatization plan for high school athletics departments to use in preseason practices. Here is its seven-point checklist:

  1. Only hold one practice per day on the first five days of formal practice.
  2. Total practice time should not exceed three hours in any one day.
  3. A walk-through (a teaching opportunity where athletes do not wear or carry any sports-related equipment) should last no longer than one hour during the first five days of the heat-acclimatization period. There should be at least a three-hour recovery period between the practice and walk-through.
  4. A helmet should be the only protective gear allowed during the first two days of the heat acclimatization period. Players can wear helmets and shoulder pads during days 3-5. After day 6, players can wear all protective equipment and begin full contact.
    1. Football only: Drills with blocking sleds and tackling dummies can be initiated on days 3-5.
    2. Full-contact sports: 100 percent live contact drills should begin no earlier than day 6.
  5. On days 6-14, double-practice days must alternate with single-practice or rest days. Single-practice days can include one walk-through, so long as it is separated from the practice by at least three hours of continuous rest.
  6. Neither practice on a double-practice day should exceed three hours in duration and the combined practice should not exceed five hours -- including warm-up, stretching, cool down, walk-through, conditioning and weight training. The two practices should be separated by at least three continuous hours in a cool environment.
  7. An athletic trainer should be on site before, during and after all practices during the heat acclimatization period.

What states have requirements or guidelines on heat acclimatization?

With the exception of Hawaii and West Virginia, all states now have heat acclimatization guidelines.

But after ranking state guidelines against its seven-point checklist, KSI tells FRONTLINE that only two -- Florida and Maryland -- have gotten its full seal of approval. The institute plans to release full data on its website in May 2011.


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Posted April 12, 2011; Updated August 23, 2011

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