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Most Catastrophic Injuries Are Preventable

By Barry P. Boden, MD, Scott A. Anderson, ATC, Frances T. Sheehan, PhD

    • Physicians' Corner

We have too often witnessed the devastation catastrophic sports injuries inflict on athletes and their community.

Catastrophic injuries are separate from recoverable sports injuries (e.g. ACL injury, concussion, fracture) and include fatalities, severe head and neck injuries, cardiac, heat, and sickle cell trait illness. These injuries significantly impact athletes in terms of return to play and, more importantly, in loss of long-term quality of life and loss of life. Football is associated with the majority of catastrophic injuries for all athletes1. Fatalities are primarily caused by cardiac, brain and exertional heat illness2. The purpose of this blog is to present the “10 commandments” of preventing and preparing for a catastrophic sports injury in order to disseminate this information amongst the key players interacting with athletes.

#1. Develop An Emergency Action Plan (EAP)

An EAP is critical for preparing and responding to a catastrophic injury. This process should start with a pre-participation physical examination (PPE) by physicians. The leader (coach, athletic trainer, etc.) responsible for triaging an athlete in the event of a catastrophic injury should be notified of any medical conditions (e.g. sickle cell trait, asthma, seizures) that may predispose to a catastrophic injury. In addition, the leader should have a list of athlete medications, such as asthma inhaler or seizure medication, and be certain they are readily available during practice and game situations.

The EAP should be documented, regularly rehearsed, and reviewed prior to competitions. Important components of the EAP are to identify the personnel involved in executing the plan, specify the equipment available (e.g. automated external defibrillator), and ascertain that the equipment is functional and readily accessible. The EAP should document clear communication mechanisms for on-site personnel with the emergency medical system and the closest emergency care facility. A “medical time out” should be conducted 30 minutes prior to each event, especially for high-risk sports, during which the individuals responsible for executing the EAP should review protocols for head and spinal injuries, sudden cardiac arrest, heat illness, seizure activity, and other emergencies.

#2. Automated External Defibrillators (AED) Should Be Readily Available

Sudden cardiac death is the leading cause of death across all sports and occurs most frequently in males and African Americans during basketball, soccer, and footbal1.

Cardiac disease screening during the PPE should include a complete history and physical examination. Sudden cardiac arrest is recognized by sudden collapse, continued breathing, eyes open and rolled back, often brief seizure activity, and unresponsive to verbal stimuli. Responders should immediately call 9-1-1 and initiate CPR.

Sudden cardiac arrest has a high survival rate when an AED (Fig. 1) is readily available for use within 1-3 minutes. For each minute of delay, the survival rates decrease approximately 10%. Schools and sports organizations should make every effort possible to have AEDs available at sporting events. AEDs are also effective at treating commotio cordis, an arrhythmia caused by low-impact blunt trauma to the chest in individuals with no preexisting cardiac disease. The condition occurs most frequently in baseball, but has also been reported in lacrosse, softball, football, rugby, and other sports1.

#3. Conditioning for Football Linemen Should Be Separate from Skill Players

Exertional heat stroke (EHS) is a persistent problem across all sports, but most frequent in football1. There are several important risk factors for football EHS fatalities, the greatest being overexertion of linemen during conditioning/training sessions (Table 1)3. This usually involves high intensity drills, exertion as punishment, serial sprints, or conditioning tests3, all with no consideration of body habitus (obesity), baseline fitness level, or demands of position played3. Linemen are the at-risk population and constitute the vast majority of football deaths3. Disappointedly, common scenarios involve coaches pushing players to complete excessive conditioning and ‘toughness’ drills, despite athletes demonstrating signs of a medical crisis3.

Heat and humidity are important risk factors and a critical component in prevention strategy. However, the focus should be on the population at risk (linemen) and exertion intensity, which is the primary determinant of heat production and subsequent fatalities3. EHS is 100% preventable by tailoring training/conditioning to be position specific and dependent on game demands (Table 1). Exercise programs should be developed based on established principles of exercise science, body composition/BMI, or a 50/30/20/10% reduction (based on prior maximum training volume) of conditioning at the start of training periods4. Most importantly, linemen should receive separate training programs and not be expected to condition with the rest of the team. EHS is recognized by a slow demise over several minutes to hours with deteriorating mental status and rectal temperature greater than 104ºF. Treatment should include early recognition, withdrawal from activity, immediate initiation of the emergency response, and rapid cooling, which is best accomplished with cold-water immersion.

Key Prevention Strategies for Exertional Heat Stroke in Football1:

  • Conditioning programs should be based on exercise science.
  • Conditioning programs should be developed with a healthcare expert or exercise physiologist.
  • Conditioning should be consistent with game demands for each position.
  • Conditioning should be reduced during preseason or return from injury or illness.
  • Punishment drills are never acceptable.
  • Exercise levels should range from 50-85% of maximum level.
  • Linemen should train separately from skill players.
  • Linemen should avoid serial sprints.
  • Linemen should avoid performance tests (timed mile, etc.).
  • Exercise should be adjusted to heat, humidity, and altitude.

#4. Identify SCT Status, Educate, and Tailor Precautions

Sickle cell trait (SCT) is an inherited condition, not a disease. Athletes with SCT should not be excluded from participating in sports. The primary concern for athletes who have SCT, and their coaches and health care providers, is complications associated with intense exertion, which can be fatal. This threat has killed 27 youth, high school and collegiate male and female athletes in football, basketball, track and baseball in the past 2 decades. Although predominant in African Americans, SCT may be present in any population. SCT status should be confirmed prior to the start of the season during the PPE. Athletes with unknown SCT status, should be tested for the condition during the PPE. SCT status should be communicated to athletics health care professionals and coaches. In addition, athletes, health care professionals and coaches should be educated regarding signs and symptoms of a SCT crisis or exertional sickling (ES), settings of risk, and tailored precautions.

ES is caused by sustained, intense exercise, such as sprinting, and/or drills demanding successive bouts of maximal exertion, all with little or no rest intervals3. Common symptoms of ES are muscle pain, especially “cramping” in the legs or low back, shortness of breath, low back pain and/or leg pain and weakness.

ES can be a medical emergency. An athlete complaining of or exhibiting symptoms should be withdrawn from activity and monitored. If symptoms persist, the EAP should be engaged and the athlete referred for immediate care and supplementary oxygen.

Best Practices for Prevention of SCT Crises:

  • Allow SCT athletes to set their own pace
  • Engage in a slow and gradual progression of training
  • Allow adequate rest and recovery between repetitions, especially high intensity drills
  • Avoid performance or conditioning tests
  • Avoid all-out exertion beyond 2-3 minutes without a rest period
  • Discontinue activity if athlete starts to struggle, especially cramping or shortness of breath
  • Report any symptoms of distress to an athletic trainer or coach and provide prompt medical care
  • Stay well hydrated, especially in hot and/or humid conditions
  • Reduce activity in very hot or humid conditions or altitude jumps
  • Have ready access to supplemental oxygen
  • Control asthma to reduce risk of exertional sickling
  • Decrease activity sharply during any illness, especially with fever, vomiting, or diarrhea

#5. Keep the Head Out of Football

Structural brain injury (SBI) is distinguished from concussion by the presence of a brain bleed and often leads to permanent brain injury and fatality. The number of football fatalities from SBI decreased significantly starting in the 1970s likely due to football helmet improvements reducing skull fractures and advances in game-day medical coverage and treatment for major brain injuries. The majority of SBIs occur due to helmet-to-helmet contact during games, with a disproportionate number occurring in special teams’ players. Many athletes with a SBI sustained a prior concussion, especially within the same season as the catastrophic event5. In response to the risk of SBI after incomplete recovery from a concussion, the Lystedt Law was developed in 2009, and requires any youth athlete demonstrating concussion symptoms to be examined and cleared by a licensed health care provider before return to play. Additional factors that may contribute to SBI are abnormalities that predispose to brain bleeds, excessive use of non-steroidals, or failure to enforce rules of play designed to reduce risk6.

#6. Always Play Heads-Up Football (Avoid Spear Tackling)

Quadriplegic events in football are caused by tackling or blocking with the head down and contact on the top of the head (spear tackling)7. The 1976 ban on spear tackling7 significantly reduced quadriplegia injuries from an average of 30 to 6 cases per year8. The key to further prevention is renewed educational efforts (e.g., teaching proper tackling techniques) and rules enforcement. In response to the disproportionate number of catastrophic cervical8 and brain5 injuries during special team plays, numerous kickoff rule changes have been instituted to reduce the number of kickoff returns and injuries. All athletes suspected of having a severe cervical spine injury should undergo cervical spine immobilization, spine boarding, and transfer to an emergency room1.

#7. Enlarge the Minimum Dimensions of the Pole Vault Landing Pad

Prior to 2003, pole vaulting had the highest rate of traumatic catastrophic injury and the second highest number of fatalities across sports9. The primary injury mechanism was the vaulter’s body missing the landing pad with the head striking the surrounding hard surface (asphalt or concrete). The second most common mechanism was the vaulter landing in or around the vault box (area where pole is planted). Therefore, track and field organizations mandated a new rule in 2003 requiring a 68% increase in the minimum landing pad dimensions (Fig. 1) behind the vault box. This rule change eliminated almost all pole vault fatalities.

Despite the dramatic reduction in fatalities, the number of catastrophic injuries from athletes landing in the vault box area has persisted. Therefore, new plant boxes have been developed to improve shock absorption, reduce pole abrasion, and ensure the front lip is flush or lower than the runway.

Figure 1. New improved and enlarged minimum dimensions for pole vault landing pads

#8. Limit the Height of Pyramids and Use Mats for the Basket Toss and Advanced Stunts

The majority of catastrophic cheerleading injuries result from pyramid and basket toss maneuvers. Top pyramid location and poor flyer (thrown athlete) spotting were the largest risk factors. Half of the injuries occurred indoors on hard gym surfaces without a soft landing mat10. Therefore, in the early 1990s, the height of pyramids was restricted to 2 body levels in high school and 2.5 body lengths in college. After the rise of basket toss injuries in the early 2000s, the governing bodies banned (2006) performing the basket toss on any hardwood court unless it was on a mat (minimum thickness 1⅜”) and during halftime or postgame (banned during high-risk quick time-outs) in an area free of obstruction. Since the 2006 rule changes, there has been a substantial reduction in the number of catastrophic basket toss cheerleading injuries.

#9. Hockey: Never Check from Behind Near the Boards

The majority of catastrophic ice hockey injuries occur to the cervical spine in males during games11. Checking from behind, with the injured athlete’s head down, may cause contact at the top of the head against the boards. This is the most common ice hockey mechanism resulting in neurologic injury. In 1994 a worldwide ban on checking from behind was implemented. Since the rule changes and educational efforts, the number of severe spinal injuries has declined substantially11. Head and facial injuries, especially eye injuries, are common in ice hockey and can be easily prevented with proper facial protection (shields and masks). You can download “Play Heads Up Hockey” educational materials from USA Hockey for player training.

#10. Utilize Sequential or Uncontested Scrums

Worldwide rugby has the highest proportion of spinal cord injury caused by one sport1. Cervical spine injuries occur most frequently during the scrum, when the opposing sides of players come forcibly together (engagement). The front row players, especially the central player (hooker), suffer the most injuries as their arms are linked together, often forcing initial contact with the top of the head. With improper engagement or the hooker employing the head as a weapon (i.e., looking down during contact), quadriplegia may result. New internationally mandated (2007) rugby rules require a sequential scrum engagement with a “crouch, touch, pause, and engage” maneuver. Front row players are prohibited from being more than an arm’s length away from the opponent (touching shoulder) before engagement and should engage separately from the pack. Uncontested scrums are another method to avoid cervical spine injuries in rugby. Assessment of the scrum rule changes and educational efforts reveals a marked reduction of catastrophic cervical spine injuries.


Although catastrophic sports injuries will never be 100% preventable, it has been extremely rewarding to know that tremendous strides have occurred at significantly reducing these tragic events. Rule and policy changes have dramatically reduced traumatic catastrophic injuries in football, pole vaulting, cheerleading, ice hockey and other sports; however, further efforts are necessary to decrease cardiac and heat-related catastrophic injuries. Education and compliance with the 10 principles described in this article should allow for further reduction of catastrophic injuries.


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2. Boden BP, Breit I, Beachler JA, Williams A, Mueller FO. Fatalities in high school and college football players. The American journal of sports medicine. 2013 May;41(5):1108-16.

3. Boden BP, Fine KM, Spencer TA, Breit I, Anderson SA. Nontraumatic Exertional Fatalities in Football Players, Part 2: Excess in Conditioning Kills. Orthopaedic journal of sports medicine. 2020 Aug;8(8):2325967120943491.

4. Boden BP, Ahmed AE, Fine KM, Craven MJ, Deuster PA. Baseline Aerobic Fitness in High School and College Football Players: Critical for Prescribing Safe Exercise Regimens. Sports health. 2022 Jul-Aug;14(4):490-9.

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7. Torg JS, Guille JT, Jaffe S. Injuries to the cervical spine in American football players. The Journal of bone and joint surgery American volume. 2002 Jan;84-a(1):112-22.

8. Boden BP, Tacchetti RL, Cantu RC, Knowles SB, Mueller FO. Catastrophic cervical spine injuries in high school and college football players. The American journal of sports medicine. 2006 Aug;34(8):1223-32.

9. Boden BP, Pasquina P, Johnson J, Mueller FO. Catastrophic injuries in pole-vaulters. The American journal of sports medicine. 2001 Jan-Feb;29(1):50-4.

10. Boden BP, Tacchetti R, Mueller FO. Catastrophic cheerleading injuries. The American journal of sports medicine. 2003 Nov-Dec;31(6):881-8.

11. Tator CH, Provvidenza C, Cassidy JD. Update and Overview of Spinal Injuries in Canadian Ice Hockey, 1943 to 2011: The Continuing Need for Injury Prevention and Education. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2016 May;26(3):232-8.

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