Mark E. Halstead, MD, is Assistant Professor, Departments of Orthopedics and Pediatrics, Washington University School of Medicine, St. Louis, Missouri.
Dr. Halstead has disclosed no relevant financial relationships.
Address correspondence to: Mark E. Halstead, MD, Washington University School of Medicine, 14532 S. Outer Forty Drive, Chesterfield, MO 63017; fax 314-514-3689; or e-mail: firstname.lastname@example.org.
More than 7.5 million young athletes participated in high school sports in the 2008–2009 academic year. Among the most popular sports by total participants, four of the top six boys’ sports are classified as contact sports, including football, basketball, soccer, and wrestling. Two of the top five most popular girls’ sports, basketball and soccer, are classified as contact sports.1
Participation in a contact sport (see Sidebar, page 276) carries some inherent additional risk that the limited contact or non-contact sports do not. There is, obviously, the increased risk for higher velocity injuries, which have the potential to result in more serious or even catastrophic injuries. Many contact sports require the use of additional protective equipment, intended to reduce the risk of these injuries. It has been debated if the use of protective equipment may make a sport more dangerous. The theory is that athletes could be more inclined to take additional risks that they would not without the protective equipment, thereby creating additional injuries that likely would not have occurred, negating any injury rate reduction from the new equipment. This theory has yet to be proven through prospective research studies.
Sports Classified as Contact Sports
From: Rice SG; American Academy of Pediatrics Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics. 2008;121(4):841–848.
Soccer is arguably the most popular sport worldwide. In 2008–2009, there were 728,358 male and female U.S. high school soccer players, with hundreds of thousands more participants at the club and recreational level throughout the United States.1 Although tears of the anterior cruciate ligament (ACL) in the female soccer player have garnered much attention, the majority of ACL tears occur without contact. The most common injuries in soccer are strains, sprains, and contusions, primarily of the lower extremity. Concussions, however, are the fourth most common injury in the female soccer player. Concussions also account for the largest proportion of injuries in high school males who require more than 3 weeks to return to play, while in high school females, it is the fourth most common injury with a longer than 3-week return to play.2
Currently, headgear in soccer is allowed, but it is not mandatory. Several companies have developed headgear with the intention of lowering the risk of concussion. Most concussions in soccer occur from head-to-head contact while attempting to head the ball rather than the heading itself. Concussions also occur from contact with the ground or a ball kicked at the head that the athlete cannot react to.
Several studies have investigated the ability of soccer headgear to reduce impact forces. Headgear has been shown to reduce impact force, primarily at higher velocities and forces than typically seen on a soccer field.3,4 These studies have been conducted primarily in a laboratory setting, however, and there are currently no prospective studies that demonstrated clinically significant differences in concussion rates from the use of headgear.
The Institute of Medicine (IOM) published a clinical report in 2002 on the role of heading in soccer. The Institute recommends no heading of the ball in athletes younger than 10 years; no evidence existed supporting the mandatory use of headgear in soccer. There was also no recommendation against heading in older soccer players.5
Soccer balls have also been modified with more water-resistant materials to lessen the likelihood of a ball becoming water logged. Coaches and players should be alert while playing in rainy conditions for the development of a water logged ball. A heavier, wet ball could more easily create a force capable of causing a concussion.
The only required protective equipment for a soccer player is the shin guard. Given the nature of the sport as a kicking sport, injuries to the lower extremity are common. Significant force can be transmitted to the lower extremity through contact with the ball, the goal post, or with another player, such as through a slide tackle. It has been estimated that injuries to the shin account for 7.6% to 13% of all soccer injuries.2,6 The majority of lower leg injuries are abrasions, contusions, and lacerations. Less commonly, fractures of the tibia and/or fibula can occur. Myositis ossificans may also develop following a significant contusion with hematoma to the shin.
Although the actual incidence of tibia and fibula fractures in soccer players is unclear, these fractures account for a prolonged period of time out of sports, varying from 18 to 35 weeks, on average. In one study, 90% of the fractures occurred while wearing shin guards, raising the question of the effectiveness of the shin guard in protecting against tibia and fibula fractures.7 Shin guards most likely reduce the incidence of contusions and abrasions to the shin but may need to be reevaluated or redesigned to help reduce the risk of the more disabling fractures in the lower leg.
Football is, by far, the most popular high school sport for boys, with more than 1.1 million participants during the 2008–2009 year.1 The sheer nature of the sport embodies the definition of a contact sport. Protective equipment for football include helmets, mouth guards, shoulder pads, hip pads, and thigh pads. As participation levels of football increase, the game becomes faster with harder hits, necessitating the need for protective equipment. Concussions in football have taken center stage in part because of increasing scrutiny of past management of concussions at the professional level as well as several deaths linked to concussions in recent years on the high school field. This increased awareness has led to a renewed interest in improving protective equipment, such as the helmet, hopefully to reduce the incidence of this common injury.
The helmet is the football athlete’s primary passive form of defense to reduce the risk of concussions, as well as other serious injuries to the head. Helmets offer substantial protection to football players from skull fractures and significantly reduce the risk of intracranial bleeding. Despite most helmet design modifications, technological advancements in padding materials, and adjustments to helmet fit, unfortunately, none currently has the ability to eliminate concussions from the sport.
Throughout the past several years, newer helmet designs and padding technologies have been implemented for football. A limited number of studies have been conducted on these newer helmets to evaluate the ineffectiveness in reducing the incidence of concussions or severity of the force causing the concussion. Of the newer helmets, only the “Riddell Revolution” has been evaluated “on the field.” The “Revolution” was found to provide a 31% reduction in relative risk of concussions, compared with a standard football helmet.8 There were no statistically significant differences in severity of symptoms or time to return to play, however.
The National Football League’s (NFL) mild traumatic brain injury (TBI) committee performed a laboratory assessment recreating concussions based on video from actual NFL games. Of several newer helmets, a trend was suggested in reduction in the severity index of the recreated hits.9 It is unclear if such reduction would have allowed the evaluated athlete to avoid sustaining a concussion. Continued research is necessary to validate the newer helmet designs and claims for concussion risk reduction.
Mouth guards have been mandated for use in practice and games in high school football since the early 1960s. The incidence of dental trauma declined significantly with the initiation of the mandated use of the mouth guard. Currently, there are several types of mouth guards, including a basic off-the-shelf variety, a “boil-and-bite” self fitting mouth guard, and a custom mouth guard fabricated from a mold of the individual player’s teeth. A “boil-and-bite” mouth guard is heated in boiling water, then the athlete bites down on it to create an impression in the mouth guard to improve fit. Custom mouth guards are generally more expensive than the non-custom mouth guards but are felt to offer much better protection to a player’s mouth and teeth.
It has been suggested that mouth guards may reduce concussions that occur from blows to the player’s mandible. There have been evaluations of the effectiveness of mouth guards in reducing the incidence of concussions, although no convincing evidence of a reduction has been demonstrated.10,11
Various neck collars have been developed to help reduce the risk of brachial plexus injuries, commonly referred to as “stingers” or “burners,” as well as cervical spine injuries. Most stingers are transient, but there are instances in which symptoms are prolonged or even permanent. The most commonly used collars include the cowboy collar and neck rolls. The purpose of the collar or roll is to reduce the excessive motion of the neck, which may produce these injuries.
Limited studies evaluating the motion restriction provided by various collars suggest the greatest role in reducing is in neck extension.12 Most collars do not provide much benefit to restrict lateral motion of the neck. This may provide less protection than one would expect because many stingers occur from lateral traction on the brachial plexus. There has been demonstration of reduced neck loads with more restriction of motion of the neck.13
One sport viewed as emerging in popularity is lacrosse. In the 2008–2009 academic year, the sport added an additional 9,579 athletes to its rosters.1 Despite similarities in the game, use of safety equipment and contact rules vary significantly between male and female participants. Male lacrosse players are required to wear a helmet and face mask, mouth guard, shoulder pads, protective cup, and gloves. The goalie is required additionally to wear a throat and chest protector. Female lacrosse players are only required to wear eye protection and a mouth guard. The female goalie is also required to wear a face mask and helmet, chest protector, and throat protector.
In addition to the stick and other players, lacrosse athletes have to deal with a small, hard ball that can travel at very high velocities. It has been estimated that a lacrosse ball may travel at speeds of up to 60 miles per hour in the women’s game and up to 90 miles per hour in the men’s game. This high speed of the ball can lead to concussions, contusions, lacerations, and fractures. Head, face, and eye injuries have been found to be higher in female players at the high school and the collegiate levels.14
Despite the contact nature of the sport, currently only male lacrosse players and female goalies are mandated to wear helmets. There has been reluctance to add helmets to the women’s game because there has not been consistent research showing significant differences in concussion rates between men and women. This may be because of the men’s game rule of allowing body checking, compared with only stick checking for women. This also allows one to argue the theory discussed previously that, in two similar sports with different equipment and slightly different rules, an equipment change may not make much of a difference in injury reduction. The increased aggressiveness from body checking may be the reason for no net change in injury rates.
One study demonstrated that in high school boys, concussions that occurred in games most frequently happened through contact with another player. Contact with a stick and direct impact were second and third most frequent, respectively. For high school girls, concussions in games most frequently occurred from contact with a stick, with contact from the ground being a distant second. In fact, the incidence of concussions per athlete exposure in high school girl lacrosse players was almost 7 times higher through contact with a stick than from contact with the ground.14 The highest rates of concussions occur through mechanisms of contact that the rulebooks allow, through body checking with the boys and stick checking with the girls.
The use of protective eyewear has been mandated with the use of a helmet and face mask in boys’ lacrosse, but only since 2005 has protective eyewear been mandated for girls. As with many mandated equipment or rule changes, there initially was resistance from coaches and players to the eye-wear requirement.
Before the rule change for women, the incidence of eye injuries in high school females was 15 times higher than that for boys. College women had an even higher incidence, 34 times that of their male counterparts.14 The use of protective eyewear was demonstrated to reduce head and face injuries in game situations by 51%, which was a strong motivator to make the eye-wear mandatory for females.15 There have not been any published studies on rates of eye injuries in girls lacrosse since the mandatory implementation of the eyewear.
One of the hot topics in the area of sports medicine is better recognition and management of sports-related concussions. In the past 10 years, there has been a significant increase in published research on the diagnosis, management, and short-term, as well as long-term, effects of concussions on the athlete. In a 2004 study, seven of nine high school sports with the highest rates of concussions were classified as contact sports, with the other two classified as limited contact.16
Since 2001, three international symposia on concussions in sports have been held. The most recent was in Zurich in 2008. Each addressed new research conducted in this area and modified recommendations for the diagnosis and management of sports-related concussions.17
One of the major changes in the management of concussions was the abandonment of the previous return-to-play criteria based on the grading of concussions. Each concussion and athlete is unique, and it has been recommended that they be treated as such rather than following criteria based on few symptoms or loss of consciousness. Currently, athletes are not to return to play until they have been asymptomatic at rest as well as with exertion. High school and younger athletes are recommended not to return to the same contest or practice where they suffered the concussion.17 Studies have demonstrated a longer recovery time in high school athletes than their older counterparts.18
A concussion rehabilitation protocol has also been proposed, with a gradual return to play over a several day course. This allows an athlete to increase the intensity of exertion slowly to evaluate for any return of symptoms that would be suggestive of an incomplete recovery from the concussion.
- National Federation of High Schools. www.nfhs.org. Accessed November 15, 2009.
- Yard EE, Schroeder MJ, Fields SK, et al. The epidemiology of United States high school soccer injuries, 2005–2007. Am J Sport Med. 2008;36(10):1930–1937. doi:10.1177/0363546508318047 [CrossRef]
- Broglio SP, Ju YY, Broglio MD, Sell TC. The efficacy of soccer headgear. J Athl Train. 2003;38(3):220–224.
- Naunheim RS, Ryden A, Standeven J, et al. Does soccer headgear attenuate the impact when heading a soccer ball?Acad Emerg Med. 2003;10(1):85–90. doi:10.1111/j.1553-2712.2003.tb01983.x [CrossRef]
- Institute of Medicine. Is Soccer Bad for Children’s Heads? Summary of the IOM Workshop on Neuropsychological Consequences of Head Impact in Youth Soccer. Washington, DC: National Academy Press; 2002.
- McCarroll JR, Meaney C, Sieber JM. Profile of youth soccer injuries. Phys Sportsmed. 1984;12:113–117.
- Boden BP, Lohnes JH, Nunley JA, Garrett WE. Tibia and fibula fractures in soccer players. Knee Surg Sports Traumatol Arthrosc. 1999;7(4):262–266. doi:10.1007/s001670050160 [CrossRef]
- Collins M, Lovell MR, Iverson GL, et al. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study. Neurosurg. 2006;58(2):275–286. doi:10.1227/01.NEU.0000200441.92742.46 [CrossRef]
- Viano DC, Pellman EJ, Withnall C, Shewchenko N. Concussion in professional football : performance of newer helmets in reconstructed game impacts. Neurosurg. 2006;59(3):591–606. doi:10.1227/01.NEU.0000231851.97287.C2 [CrossRef]
- Barbic D, Pater J, Brison RJ. Comparison of mouth guard designs and concussion prevention in contact sports : a multicenter randomized controlled trial. Clin J Sport Med. 2005;15(5):294–298. doi:10.1097/01.jsm.0000171883.74056.21 [CrossRef]
- Labella CR, Smith BW, Sigurdsson A. Effect of mouthguards on dental injuries and concussions in college basketball. Med Sci Sports Exerc. 2002;34(1):41–44. doi:10.1097/00005768-200201000-00007 [CrossRef]
- Gorden JA, Straub SJ, Swanik CB, Swanik KA. Effect of football collars on cervical hyperextension and lateral flexion. J Athl Train. 2003;38:209–215.
- Rowson S, McNeely DE, Brolinson PG, Duma SM. Biomechanical analysis of football neck collars. Clin J Sport Med. 2008;18(4):316–321. doi:10.1097/JSM.0b013e31817f016a [CrossRef]
- Lincoln AE, Hinton RY, Almquist JL, et al. Head, face, and eye injuries in scholastic and collegiate lacrosse: a 4-year prospective study. Am J Sport Med. 2007;35(2):207–215. doi:10.1177/0363546506293900 [CrossRef]
- Webster DA, Bayliss GV, Spadaro JA. Head and face injuries in scholastic women’s lacrosse with and without eyewear. Med Sci Sports Exerc. 1999;31(7):938–941. doi:10.1097/00005768-199907000-00004 [CrossRef]
- Schulz MR, Marshall SW, Mueller FO, et al. Incidence and risk factors for concussion in high school athletes, North Carolina, 1996–1999. Am J Epidemiol. 2004;160(10):937–944. doi:10.1093/aje/kwh304 [CrossRef]
- McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport : 3rd international conference on concussion in sport held in Zurich, November 2008. Clin J Sport Med. 2009;19(3):185–200. doi:10.1097/JSM.0b013e3181a501db [CrossRef]
- Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatrics. 2003;142(5):546–555. doi:10.1067/mpd.2003.190 [CrossRef]