Making football safe: A history of injury prevention

Editor's Note: This is the first installment of a series by Peter DeLuca, MD, Head Team Physician for the Philadelphia Eagles.

I was recently covering a high school football game as a Team Physician. Gazing down the sideline, I saw boys of various sizes and body types. There were young adults who have reached full maturity and those who seem to be just entering puberty. I asked myself: should these boys be playing football? Should this sport be banned?

Football connects generations. Many of us remember watching games with parents and grandparents, and going on to introduce the game to our own children. It inspires us to rally around our players, teams and cities. It brings together families, friends and communities.

Football has earned a vital place in the rhythm of American life. Nearly 6 million kids play flag or tackle football; another 1.1 million play in high school and 75,000 play in college. The game of football is thriving. But it is also seen by some as a game at a crossroads.

The NFL is well aware of social commentators who now question football's future. The simple truth is that any physical activity comes with risk and reward. I'm sure all of us have asked ourselves the same tough questions others ask: When there is risk associated with playing tackle football, why do people continue to play? And for parents, should I let my kids play tackle football?

The health and safety of players involves many facets. It includes the quality of playing fields, the equipment players wear and rules to protect them from unnecessary risk. Over the years we have identified a multitude of risks associated with playing football; unfortunately, some of those risks were not clearly identified until after a serious injury occurred.

1940s-1980s: Spinal Cord Injuries

At one time spinal cord injuries were considered one of the greatest risks of playing football. From a historical perspective, between 1945 and 1994 nearly 85 percent of all football-related fatalities resulted from head and cervical spine injuries. The greatest number of those injuries occurred between 1965 and 1974, with a dramatic decrease in the last two decades.

Injuries to the cervical spinal cord occur when a player makes a tackle with his head down striking the opponent with the crown of the helmet, known as "spear-tackling". Largely due to the work performed by Dr. Joseph Torg, a renowned orthopaedic surgeon in Philadelphia, a rule was passed to outlaw spear-tackling. With the adoption of this rule, the occurrence of cervical quadriplegia in football decreased from 34 cases in 1976 to only 5 in 1985. The current incidence of cervical spine injuries in football is 0.4 cases per 100,000. This was the first rule change in the NFL that had a direct impact in decreasing the incidence of this catastrophic injury and making the game safer.

1990s: Performance-Enhancing Drugs

Protecting the health and safety of players has included taking drug abuse and steroids out of the game. The NFL started to perform random, year-round steroid testing since 1990—the first league to do so—with immediate suspensions for any violation.

All players get tested for illicit drugs every year. If positive, players are required to enroll in a drug rehabilitation program and are tested more frequently. Players who continue to test positive for illegal drugs will get suspended and even permanently banned from playing football in the NFL. The NFL is now exploring testing to make sure human growth hormone (HGH) is not being used by the players. There are some studies that have suggested that there may be a link between performance enhancing drugs and concussions and brain disease.

2000s: Heat and Hydration

In 2001, Korey Stringer, a lineman for the Minnesota Vikings, died of heat stroke during training camp. This unfortunate event led to greater research in heat and hydration and better education for our medical staffs and players. The Philadelphia Eagles have led the NFL in such research. Our players swallow a capsule containing a thermometer to record accurate core temperature of our players during training camp. This helps us identify players that become overheated and are then pulled form practice and are allowed to cool down. These players then drink a fluid to replace those lost electrolytes.

All players are weighed before and after practice. If a player has lost a significant amount of water-weight, then they are not permitted to return to practice until their weight has returned to pre-practice weight. The players are encouraged to drink fluids with electrolytes before, during and after practice. In addition, IV fluids are administered to players that start to develop cramping.

Injuries to the lower extremities such as to the knee and ankle continue to be problematic for football players and have shortened many careers. The NFL is studying the relationship between cleat wear and playing surfaces on the incidence of knee and ankle injuries. The Injury and Safety Panel is currently evaluating potential rule changes to decrease knee and ankle injuries.

Present Day: Concussion and Head Injury

In recent years, there has been a much sharper focus on concussions in football and other sports. There are still unanswered questions, but researchers and doctors know more about concussions and their long-term potential effects than they did even a few years ago. The NFL recently committed $30 million to the National Institutes of Health for research on the brain.

There is no question that there are tremendous benefits to playing team sports like football: benefits such as physical fitness, self-discipline, friendships, leadership opportunities, self-esteem, college scholarships and, most importantly, just plain fun. In the future, we will look into how the NFL through leadership, research and rule changes is trying to make football safer to play.

Next week: Dr. DeLuca takes an in-depth look at the measures taken in the NFL and youth football to increase awareness and promote prevention of head injuries.