Perspective

Orthopedic surgeons weigh in on NFL ‘myths’ vs ‘facts’ about youth football injuries

Troy Vincent Sr., the executive vice president of football operations at the National Football League, recently posted five “myths” about youth football and related injuries, as well as “facts” to debunk each myth, on his Facebook page. The document has come under fire in some circles because it has been said the league’s sole intent in issuing it is to refute some of the beliefs that playing tackle football at the high school and lower levels is unsafe.

The list of myths/facts also appears on the youth football section of the NFL website.

The five myths listed in the document that Vincent posted May 7, which were each followed by a fact or facts, are as follows:

The risk of injury with youth football is higher than any other sport;

There are long-term mental health and cognitive function [e]ffects of playing tackle football during high school;

There are long-term brain injury [e]ffects of playing tackle football before high school;

High school football injuries are at an all[-]time high; and

Football players don’t do well in school.

The facts are one sentence each and include statistics and citations from independent and published studies that are meant to be counterarguments to the myths.

Mark Brunell and Chad Pennington, who are members of the NFL Youth Advisory Committee, said in a statement at the NFL website, “As legends, we know how great the game of football is. Many of us have fond memories of playing football in our youth. However, youth football is under attack. As high school football coaches, Chad and I are seeing fewer kids playing tackle football because of misconceptions about our sport. As keepers of the game, we must equip ourselves with the correct information supported by good science to protect our great game. Check out these ‘Myths vs. Facts.’ You might be surprised by what you read!”

Read perspectives on the issues raised that Healio.com/Orthopedics received from orthopedic surgeons whose backgrounds include spine, trauma and concussion clinical and research experience. – by Susan M. Rapp

Troy Vincent Sr., the executive vice president of football operations at the National Football League, recently posted five “myths” about youth football and related injuries, as well as “facts” to debunk each myth, on his Facebook page. The document has come under fire in some circles because it has been said the league’s sole intent in issuing it is to refute some of the beliefs that playing tackle football at the high school and lower levels is unsafe.

The list of myths/facts also appears on the youth football section of the NFL website.

The five myths listed in the document that Vincent posted May 7, which were each followed by a fact or facts, are as follows:

The risk of injury with youth football is higher than any other sport;

There are long-term mental health and cognitive function [e]ffects of playing tackle football during high school;

There are long-term brain injury [e]ffects of playing tackle football before high school;

High school football injuries are at an all[-]time high; and

Football players don’t do well in school.

The facts are one sentence each and include statistics and citations from independent and published studies that are meant to be counterarguments to the myths.

Mark Brunell and Chad Pennington, who are members of the NFL Youth Advisory Committee, said in a statement at the NFL website, “As legends, we know how great the game of football is. Many of us have fond memories of playing football in our youth. However, youth football is under attack. As high school football coaches, Chad and I are seeing fewer kids playing tackle football because of misconceptions about our sport. As keepers of the game, we must equip ourselves with the correct information supported by good science to protect our great game. Check out these ‘Myths vs. Facts.’ You might be surprised by what you read!”

Read perspectives on the issues raised that Healio.com/Orthopedics received from orthopedic surgeons whose backgrounds include spine, trauma and concussion clinical and research experience. – by Susan M. Rapp

    Perspective
    Joseph D. Smucker

    Joseph D. Smucker

    Athletic involvement has intrinsic benefit and risk. There are so many positive attributes to sports participation that in the circumstances where negative things occur, it can be difficult to confront those issues. There are many parties that become responsible for the health and safety of the athletes, in addition to the athletes themselves — many seats at the table.

    The health concern of head injury is present in multiple sports. In professional football, the health care needed to diagnose a head injury on the sideline has made some progress with the institution of independent examiners and the protocol-based clearance of athletes over time in return-to-play circumstances. This NFL-based example demonstrates the concept of recognition of a health care concern vs. editorial commentary on that concern. In practice, it also drives other institutions to consider similar interventions. Over time, these protocols may lead to better diagnosis of head injury.

    In a recent publication, “NFL Play Football; Myth vs. Fact,” the NFL creates a series of “myths” that it counters with “facts.” The unauthored, non-dated document lists four peer-reviewed medical references and a medical institutional reference to refute “myths” that are listed in a statement/response format. This document appears to make non-attributable, editorial commentary on medical articles.

    In medical science, we investigate hypotheses and design investigations to examine these questions. The result of these investigations is data that contribute to understanding and principles over time. While there is a growing body of research and medical investigation into sports-related head injury, there are few statements that may be made with broad, evidence-based medical support. “Fact” is a term rarely used in medical literature nor is there a defined understanding of the term “myth.”

    The NFL has a responsibility to participate in the health and safety of football. Certainly, this document is not the only effort being made by the NFL in this regard. However, there is a difference between medical evidence and attempting to drive commentary or modify perceptions. When faced with controversy, many institutions choose a different path when it comes to commentary, stewardship, research and publication. In health care writing, these concepts follow the ideas of transparency, disclosure, peer-review, and management of conflict interest. In the U.S., many pharmaceutical and medical device companies choose to provide unrestricted funding of independent research into controversies regarding a product or drug when a public health concern or conflict arises. They allow medical professionals and researchers to comment on the outcome of those investigations.

    The NFL is correct to be a part of the conversation with respect to player health and head injury; however, they have a single seat at a table with many participants.

    • Joseph D. Smucker, MD
    • Orthopedics Today Editorial Board Member
      Indiana Spine Group
      Carmel, Indiana

    Disclosures: Smucker reports no relevant financial disclosures.

    Perspective
    David A. Wong

    David A. Wong

    Participation in team sports, including football, is an excellent learning, growing and physical conditioning experience. However, the positive aspects of sports must always be considered against the relative risk of physical injury, such as concussion. When considering involvement in a sport, athletes and parents should research the relative risks in order to make a rational decision.

    The CDC has developed an excellent online resource for concussions. In addition to basic information, such as the definition and symptoms of concussion, the website outlines educational programs for coaches and athletic trainers and has useful tips on topics such as how to properly fit a helmet. I would encourage everyone involved in contact sports to use the CDC programs as an authoritative resource on concussions.

    Reference:

    www.cdc.gov/headsup/index.html

    • David A. Wong, MD, MSc, FRCS(C)
    • Past President North American Spine Society (NASS)
      Past Chairman NASS Patient Safety Committee
      Past Chairman American Academy of Orthopaedic Surgeons Patient Safety Committee
      Former Team Surgeon U.S. Ski Team

    Disclosures: Wong reports no relevant financial disclosures.

    Perspective
    Toufic R. Jildeh

    Toufic R. Jildeh

    Regarding myth 1, my data presented at this year’s American Academy of Orthopaedic Surgeons Annual Meeting, which is slated for publication, showed that among a consecutive cohort of high school athletes who presented to a single health care system between September 2013 and December 2016, a preponderance of concussions can be attributed to football. Nearly 30% of concussions were attributed to football injuries, the most commonly concussed sport among high school athletes. The next highest was hockey at about 21% and soccer at 17%.

    Although data evaluating varsity high school football players from 1956 to 1970 did not show an increased risk of developing neurodegenerative diseases compared to athletes in other varsity sports, I question the applicability to contemporary football. The game has changed, and it has become significantly more physical. Moreover, it is difficult to control for athlete game exposure in a cohort of high school athletes. When investigating retired NFL players, who undoubtedly had a high-level of exposure to football throughout their careers, it is evident that the rate of neurodegenerative diseases is significantly higher among football players.

    Regarding myth 2, my recent data show that among high school athletes who sustained multiple concussions and received multiple rounds of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) score as their primary neuropsychological exam, the subdomains of mean visual motor speed and reaction time showed predictable decreases with each recurrent concussion. This echoes previous findings in the literature that multiple concussions cause a decrease in cognitive function among athletes.

    Moreover, in my study, patients were only permitted to return to sport after completing the six-step pathway recommended by the CDC. We found a significant increase in return to sport timing in those with a previous history of concussion. This suggests that prior concussions may have lingering effects and that incomplete recovery may cause additive cortical and subcortical pathogenesis in a dose-response manner. Furthermore, this may have long-term implications and could potentially contribute to chronic traumatic encephalopathy

    My comments above also apply to myth 3.

    Concerning myth 4 about the frequency of high school football injuries being at an all-time high, this is likely true. Injury detection, injury surveillance and adherence to protocol have all increased significantly in recent years. In 2000, Kevin M. Guskiewicz, PhD, ATC, and colleagues conducted an epidemiological study of high school and college football players who sustained concussions. The study demonstrated that an alarming 30.8% of concussed players returned to competition on the same day, and 20% of athletes never left the game. A study by Margot Putukian, MD, FACSM, and colleagues, suggested that high school athletes take about 30 days to return to sport after a concussion. This finding was likely due to a more contemporary approach to young athletes that emphasizes more careful and conservative treatment. My study found similar findings, as high school athletes required approximately 30 days of recovery before return to sport after a concussion.

    References:

    Guskiewicz KM, et al. Am J Sports Med. 2000;doi:10.1177/03635465000280050401.

    Jildeh TR, et al. Abstract 306. Presented at: AAOS Annual Meeting; March 12-16, 2019. Las Vegas.

    Putukian M, et al. Br J Sports Med. 2009;doi:10.1136/bjsm.2009.058230

    • Toufic R. Jildeh, MD
    • Henry Ford Health System
      Detroit

    Disclosures: Jildeh reports no relevant financial disclosures.