Variation in State Policies on Sideline Medical Coverage of High School Athletic Events

Across the United States, over 7.8 million student-athletes participated in high school sports during the 2022-2023 school year.¹

Prior research has shown that approximately 2 million injuries, 500,000 doctor visits, and 30,000 hospitalizations occur each year among high school athletes.² However, only 66% of United States secondary schools employ certified athletic trainers (ATCs) in some capacity, which means that approximately 5.9 million high school student-athletes may not have immediate access to an athletic trainer or other healthcare professional following an athletic injury.³

The Importance of Athletic Trainers

At the high school level, ATCs provide sideline medical coverage for a variety of sporting events. Given the substantial participation and number of injuries in high school sports, coverage of athletic events by ATCs is a cost-effective means to safeguard the health and enhance the safety of high school student-athletes through injury prevention, emergent care, and therapeutic rehabilitation. They also perform an essential role as a liaison between student-athletes, parents, guardians, and the healthcare system.⁴ Numerous past studies have analyzed the impact of ATCs on student-athlete health. A 2018 study demonstrated that overall injury rates in girls’ basketball and soccer were significantly higher in schools that did not employ ATCs compared to schools that did.⁵ Another study found that student-athletes with access to ATCs were more likely to report a sports-related concussion and more likely to have post-concussion evaluations than those without access to ATCs.⁶

Current State Policies

Clearly, there is a discrepancy between the numerous medical benefits ATCs provide to student-athletes and the lack of uniform standards regarding their availability at high school athletic events. As a result, we sought to quantify what policies, if any, exist at the state level pertaining to the mandatory presence of ATCs, or other healthcare professionals, for sideline medical coverage of high school athletic events. From November 2023 to July 2024, a 17-question survey was sent electronically to the executive director (or similar position) for each state high school athletic association across the United States (including the District of Columbia) to ascertain their current policies for sideline medical coverage of high school sports. Members of the AOSSM Council of Delegates played a pivotal role in distributing the survey and personally contacting the state directors within their respective regions of the country.

Overall, there was a 94% (48/51) response rate from these high school athletic associations. Mandatory athletic trainer employment and general sideline medical coverage were the two primary variables analyzed for each state, among other factors. Of the 48 states that responded, 37 (77%) had no sideline medical coverage mandate. The 11 states (23%) that did mandate sideline medical coverage based their requirement on the perceived risk of injury. Risk-dependent coverage was required only for those sports with higher injury risk (ie, football); whereas risk-independent coverage was required for all sports regardless of injury risk. Of the 11 states with sideline coverage mandates, eight had risk-dependent sideline coverage mandates and three had risk-independent sideline coverage mandates. Additionally, no state required that high schools employ an athletic trainer in any capacity. Moreover, states with more high schools were significantly less likely to have mandatory sideline medical coverage compared to states with fewer high schools (p = 0.004). Overall, approximately 92% of high schools in the United States do not have mandatory sideline medical coverage for their athletic events based on the state in which they are located.

Table 1. Surveys Completed by State Based on Sideline Coverage Mandate

State Policies by Region

Based on PearlDiver’s regional map of the United States, the Midwest region had no states with a sideline coverage mandate. The West region had three states with sideline coverage mandates (Arizona, Utah, and Hawaii), the South had four states with sideline coverage mandates (West Virginia, North Carolina, Mississippi, and Delaware), and the Northeast had four states with sideline coverage mandates (Vermont, New Hampshire, Massachusetts, and Rhode Island).

The Difference Between Public and Private School State Policies

Information regarding sideline coverage differences between public and private high schools was only available for 29 states (60.4%). Only three states (10%) – New Hampshire, Utah, and North Carolina – reported a difference in sideline medical coverage requirements between public and private high schools. Twenty-five states and the District of Columbia (90%) reported no difference between public and private coverage requirements. Further research is needed at the state level to explore the differences in sideline medical coverage based on school funding given the relationship between financial resources of a high school and the services provided.

Conclusion

This study found that 77% of states and the District of Columbia do not mandate the presence of an ATC, or other healthcare providers, for sideline medical coverage of high school athletic events, even for high-risk sports such as football. Consequentially, approximately 92% of US high schools represented in our survey do not have a requirement for sideline medical coverage of their athletic events based on the state in which they are located. It is possible that, despite the lack of a formal policy, many individual schools may have an ATC or other healthcare professional provide medical coverage for at least some of their athletic events, such as high-risk sports (ie, football). A survey of individual high schools would best capture this possibility; however, it is not feasible to survey each of the 26,727 public and private high schools in the United States. ⁸ The widespread absence of state policies requiring sideline medical coverage of high school athletic events may contribute to disparities in the care and safety of student-athletes. These findings underscore the need for state-wide mandates to guarantee access to trained healthcare professionals, such as ATCs, at high school sporting events, especially for high-risk sports such as football.

References

1. The National Federation of State High School Associations. High School Athletics Participation Survey.

2. Jones NS, Wieschhaus K, Martin B, Tonino PM. Medical Supervision of High School Athletics in Chicago: A Follow-up Study. Orthop J Sports Med. 2019;7(8):2325967119862503. doi:10.1177/2325967119862503

3. Huggins RA, Coleman KA, Attanasio SM, et al. Athletic Trainer Services in the Secondary School Setting: The Athletic Training Locations and Services Project. J Athl Train. 2019;54(11):1129-1139. doi:10.4085/1062-6050-12-19

4. Beaupre J, Meske SW, Buckley M. Athletic Training and Population Health Science. J Athl Train. 2022;57(2):136-139. doi:10.4085/314-19

5. Pierpoint LA, LaBella CR, Collins CL, Fields SK, Dawn Comstock R. Injuries in girls’ soccer and basketball: a comparison of high schools with and without athletic trainers. Inj Epidemiol. 2018;5(1):29. doi:10.1186/s40621-018-0159-6

6. McGuine TA, Pfaller AY, Post EG, Hetzel SJ, Brooks A, Broglio SP. The Influence of Athletic Trainers on the Incidence and Management of Concussions in High School Athletes. J Athl Train. 2018;53(11):1017-1024. doi:10.4085/1062-6050-209-18

7. Pike Lacy AM, Eason CM, Stearns RL, Tosakoon S, Casa DJ. Legislators’ Perceptions and Knowledge of the Athletic Training Profession: Specific Considerations for Secondary Schools. J Athl Train. 2019;54(11):1140-1148. doi:10.4085/1062-6050-29-19

8. George Winograd. How Many Schools in the US (2024 Updated Data). Published online October 22, 2024. https://missiongraduatenm.org/number-of-schools-in-the-us/