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

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.

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.

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.