Football injury: a literature
review *
John J. Kos, DC, FCCS(C)t
1038 Portage Ave.
Winnipeg, Manitoba R3G OS2
A great deal of concern is recently being expressed
relative to the playing of tackle football by adolescent
Canadians. The purpose of this literature review is to try to
summarize the important data from the available world
literature. Very few Canadian statistics are available. Most
of the data comes from United States experience. Tackle
football injury is examined from various perspectives:
1. Equipment
2. Mechanisms of injury
3. Types of injury, with some emphasis on epiphyseal in-
jury
4. Prevention
5. Comparison with other sports
Although no "hard and fast" conclusion is drawn, the
paper tends to show that:
1. Football is dangerous
2. Football is damaging to many body systems
3. Prevention of injury is difficult under present condi-
tions
4. Alternate games, such as soccer and rugby seem to pro-
vide the same benefits with less catastrophic injuries
Introduction
The advisory committee on sport, fitness and posture
of The C.C.A. has, by definition, prevention as its main
concern. The members of my committee, Dr. Stewart
O'Brien and Dr. Tom Sawa and myself are acutely inter-
ested in the chiropractor's role in preventive methods for
the sustenance of life and health for Canadians. Preven-
tion in chiropractic practice covers a wide area - hypo-
kinetic disease, exercise therapeutics, spinal hygiene and
so on. Much needs to be said about all of these concerns.
However, I will try to give you an overview of sports in-
jury, particularly as it relates to football and particularly
as that sport affects adolescent players.
This paper would not have been possible without the
help of two students of the Canadian Memorial Chiroprac-
tic College, since graduated, who spent many tedious
hours doing literature research that provided the data base
for this literature review: Paul D. White, § and Donald
R. Findlay.4
* Originally presented at the Western Canadian chiropractic convention,
Winnipeg, Manitoba in June 1977. Updating as necessary has been done
by the author.
t Past-Chairman of Canadian Chiropractic Association Committee
on Sports, Fitness and Posture
-Member of Advisory Council on Sport and Fitness for the
Province of Manitoba
The Journal of the CCA / Volume 23 No. 3 / September 1979
FOOTBALL INJURIES
There is no team sport played anywhere in the world in
which the occurrence of injury is more frequent than in
American football. Canadian football follows a close sec-
ond in frequency of injury (this may be due to the absence
of downfield blocking and the fact that we have only three
downs). 1
Dr. Tony Martin, a chiropractor from Timmins, Ontario,
has successfully encouraged the Ontario Chiropractic
Association to pass a resolution urging the provincial
government to ban the sport of football in all high schools
in the province. He felt compelled to take this action when
he discovered that a high percentage of the children play-
ing football in Timmins were consulting him for injuries
sustained while participating in this sport2. The medical
director of The Toronto Rehabilitation Center recently
told The Canadian Family Physician Publication that he
would be in favor of substituting soccer for football3. Dr.
Roy Shepherd, a professor in the Department of Preven-
tive Medicine at the University of Toronto, said that he is
somewhat sympathetic to the banning of high school foot-
ball. He also stated that a study at the University of Toron-
to found a very high incidence of injuries among football
players. He said a player had more than an even chance of
getting injured in any given year and that these results
would probably hold true for high school football players
as well3. Others disagree and feel that serious injuries are
no more common in football than in other high school
sports. Cerney in An Encyclopedia of Athletic Injuries
states that high school boys who participate in a full season
of practice and play have a twenty percent chance of being
injured sometime during the season and an eight percent
chance of sustaining a serious injuryl. In the United States,
statistics indicate that 1.2 million people play football each
year and that there are 318,000 injuries requiring
emergency-room care, 30,000 of these due to head and
neck injuries. Injuries to the head and neck are by far the
most important. They have the potential to cause
catastrophe - death, severe paralysis and disability. They
also have the potential to disturb growth centers
(epiphyses) in children, as well as to cause mechanical
dysfunction in the motion segment at various levels which
in turn can result in disturbing syndromes such as occipital
neuralgia, cervical migraine, radiculopathy, myelopathy,
and Barre Lieou syndrome. These of course can occur im-
mediately after injuries or many years post-traumatically.
§ BSc (University of Western Ontario), DC (CMCC
t BSc (University of Calgary), DC (CMCC)
89
Football injury
While it is true that all contact sports render the cervical
spine vulnerable to injury, fooball is not only a contact
sport, it is a collision sport. Because of its calculated
violence and its popularity it is one of the major causes of
athletic injuries to the neck.
Just how much injury really results to the cervical spine
through football playing is difficult to assess, particularly
in Canada, because specific statistics are largely unavail-
able. Some authors feel that there is a reluctance on the
part of coaches and athletic administrators to publicize the
problem of injuries. Even players are sometimes adverse to
complain or to admit to injury. Sports injuries and ill-
nesses are not as subject to routine reporting nationally as
other health problems. A formal reporting system using
trained personnel is basic to hospitals and industry but not
to sport.
At the present time there are attempts being made to
develop a National Athletic Injury Illness Reporting
System (NAIIRS) in Canada. NAIIRS has been conceived
to serve as a practicable system for continuous collection
and interpretation of information on injuries and illness
incurred by male and female participants in a variety of
sports. It was designed to establish trend lines which would
demonstrate the incidence of these health problems and the
relative influence of a miriad of variables of preventive an
hazardous character.
The objective of NAIIRS thus is fourfold:
1. To provide a feasible and inexpensive mechanism for
continuous collection and retrieval of health problems
in sports.
2. To provide a service to institutions and agencies for
maintaining meaningful injury-illness records for a
variety of sports.
3. To maintain a repository of nationally uniform cur-
rent data for periodic epidemiologic analysis.
4. To serve as a resource to decision-makers and
qualified investigators for research-worthy informa-
tion.
However, we do have data from the United States and I
will discuss that. Schneider in Head and Neck Injuries In
Football gives some interesting statistics5.
90
You can see from these figures (Table 2) that in the so-
called sandlot type football in which no equipment is worn
and which uses rather loose rules, there was a relatively
low number of injuries; whereas, in professional football
where heavy equipment is worn and where there is a lot of
officiating, there were a relatively high number of injuries.
Yet it is a common among many people that sandlot foot-
ball causes the greatest number of fatalities because of the
lack of proper protection5.
In 1964, Alley reported on 300 head and neck injuries
and related them to poor conditioning, poor equipment
and spearing taught by coaches6.
In 1972, Dr. Carl Blyth of North Carolina, published a
40-year survey in which he catalogued 1029 fatalities7.
At the University of Massachusetts, careful study
covered a four-year period of every injury in football,
hockey, basketball and lacrosse. Football had no serious
challengers for top position of causing major injuries. The
statistics also showed that head, neck and knee injuries
were the most frequent8.
Some reports put the incidence of time-loss injury at 50
to 86 percent of the population at risk per season9. Fatality
rates have averaged 3 per 100,000 participants per year
from direct causes over a 43-year period, The over-
whelming majority of these of course is due to head and
neck injuries9.
Some statistics seem to suggest that these types of in-
juries are on the increase. Although all of these reports are
interesting, at present no real estimate can be made of the
true magnitude of the problem. Many catastrophic injuries
which are reported in news clippings somehow do not find
their way into the published data1O.
The development of the modern football helmet has pro-
tected the head so well that the players are able to use their
heads as offensive and defensive weapons. Consequently
their cervical spines are exposed to increased violence.
Available statistics seem also to suggest that the number of
injuries are increasing as improvements are being made in
football helmets1 1, 12, 13.
The head and neck injury problem of football is of suffi-
cient magnitude to warrant concern of all responsible in-
dividuals9. Let us not forget that spinal cord injury is one
of the most devastating accidents that man can endure.
Contribution of helmets, spring-loaded dummies and
shoes to the occurrence of injuries
James M. Robey of the Department of Physical Educa-
tion, University of North Carolina, reported in Medicine
and Science in Sports on the analysis of over 4,000 injuries
and their relationship to helmets. His analysis found12:
1. There was a causal association between injuries to the
wearer and the fit and condition of head-gear.
The Journal of the CCA / Volume 23 No. 3 / September 1979

2. Injuries to participants other than the wearer were also
contributed to in a significant way by the head-gear.
3. Standards are needed for the strict enforcement of
design and quality.
He also points out that there is a paucity of published in-
formation with regards to testing protective equipment.
Emphasis seems to be on sales promotion rather than
laboratory research or field testing. One manufacturer, for
example "tested" a new helmet prototype for football by
asking several professional and college players to wear
them.
His data also seemed to suggest:
1. Good and poor classification of helmets showed no
difference in injury rate if the crown suspension was
adequately adjusted.
2. When the helmet is too small or when the suspension is
improper, helmets of the combination suspension-
padded type are associated with higher injury rates.
3. Helmets that were too large but were padded and in
good condition were associated with low rates of in-
jury.
4. One might expect that in football being a collision
sport that the majority of injuries would be caused by
an individual colliding. However, the frequency of in-
juries due to a blow from an object is over twice as
large as collision with an object. The data also seems
to indicate that the helmet is the one piece of equip-
ment most often responsible for injury.
Those speaking in defense of the helmet often say that
"the hard-shelled helmet may cause a few bumps and
bruises but it must be hard and rigid to protect the head".
However, facts seem to show that while bruises are often
frequent other injuries are also often due to the helmet,
such as fractures, lacerations, dislocations and internal in-
juries12.
It is interesting to note that there is some evidence that a
soft outer covering on football head-gear might help pre-
vent injury in both the wearer and the opponent12.
Any consideration of the causal relationship of helmet
to injury must ultimately get back to the psychological
nature of man. The helmet is often used as a primary
assault weapon in playing techniques. This is often en-
couraged by coaches. Schneider in a five-year study im-
plicated the use of the head as a weapon as a primary cause
of head and neck injuries. One of the major concerns has
been the neck of the person using his head as the battering
ram. However, danger to the recipient of the blows is also
well documented. Blyth and Mueller in a study of 8,000
high school players clearly identified the helmet as the one
piece of equipment most often responsible for injuries
resulting from a blow from an object11.
In September, 1976, The Journal of the American
Medical Association reported some interesting cases of
serious injury resulting from collision with spring-loaded
football tackling and blocking dummies. The tackling
dummy is a spring-loaded device that travels 2.5 metres
towards the player on a suspended railing. It is made of
The Journal of the CCA / Volume 23 No. 3 / September 1979
Football injury
sponge rubber. However, the inner core consists of a steel
pipe. The impact force can be adjusted by varying the
loading spring. The player attacks the dummy after it has
been released. The author of this article believes that the
near-fatal and fatal injuries reported in a short period in a
relatively small geographical area warrant further in-
vestigation14.
Other pieces of equipment are also important in the pro-
duction and prevention of injuries. For example, properly
fitted shoes can make a great deal of difference to injuries
at the ankle joint. A small sole on a large foot will
predispose to supination and pronation injuries15.
Mechanisms of head and neck injuriesl1
When we analyze football injuries to the neck, five
mechanisms can be identified:
1. Extension
2. Flexion
3. Impaction
4. Lateral stretch
5. Congenital instability
Extension: Hyperextension of the neck can occur while
tackling or falling or when the face guard is grasped and
forced backward by an opponent. Upper cord damage can
occur without fracture or dislocation due to cord contu-
sion or vascular damage.
Flexion: Coaches and team physicians are in general agree-
ment that violent flexion is the most dangerous
mechanism. The most commonly involved area is C4 to
C6.
Impaction: When the head is driven downward the con-
dyles of the occiput may split the ring of C1 causing a Jef-
ferson fracture.
Lateral Flexion: The most common neck injury seen in col-
lege and professional football is the lateral neck sprain or
the so called "nerve pinch" in trainer's terminology. The
typical injury is a blow on the side of the head, with im-
mediate pain from the base of the neck to the head,
paresthesia of the whole arm and inability to move the ex-
tremity. Within a few minutes this set of sensations disap-
pears leaving a dull ache in the neck and shoulder of the af-
fected side. There is often diminished biceps or triceps
reflexes and patches of radial or ulnar numbness that
sometimes lasts for several months. Weakness of the
muscles in either the extensor-supinator or the flexor-
pronator groups is noted in more than half of the patients
and it persists in most of these for more than a year.
Associated with the neurological findings is limitation of
lateral flexion of the neck towards the affected sidel6.
In this case the lateral ligaments are sprained and the
lower cervical nerve roots are stretched, which may result
in swelling and fibrosis around the foramen and result in
nerve-root compression and impaired facet function. In
91
Football injury
three players, followed for over three years by Chrisman
and Snook16, extension-supination weakness and limita-
tion of motion were still present. In addition, spurring with
early osteoarthritis was noted on the x-rays. Analysis of
data also showed that short thick necks were less apt to be
injured. It is interesting that the report on impaired facet
function and limitation of movement reported by these
medical authors. There seems to be no indication that
chiropractic manipulative adjustments were used to try to
store normal joint function. Since there is no data, one has
to speculate as to whether these players would have suf-
fered deficit for so long a period had they had the benefit
of chiropractic spinal manipulative therapy.
Congenital instability: Children should be examined
carefully when associated with contact sports. Congenital
anomalies can be predisposing to serious injury.
In a book entitled Head and Neck Injuries In Football,
Richard Schneider, head of neurosurgery at the University
of Michigan, states that there is probably no better ex-
perimental or research laboratory for human trauma in the
world than the football fields. Football players may sus-
tain a serious or fatal injury in a game and the mechanism
is faithfully recorded by the photographic or television
camera. In this book he describes the mechanisms of injury
in broad categories using the terminology used by our
coaches, players, and trainers. I'll try to give you some of
the examples of these mechanisms5.
Piling on: Officials have tried to combat this deliberate,
vicious and brutal assault on key players.
Example: A professional halfback was tackled throwing
him out of the field of play. As he fell one of the opposing
players doubled up both arms into flexion raking the
downed player with his elbows hitting him in the left loin
with his left knee and striking his head with the right foot.
The ball carrier was not rendered unconscious but was
severely dazed, dizzy and he staggered markedly as he was
led from the field. He was later diagnosed as having suf-
fered concussion.
When the official fails to expel the offending player
from the game, this failure tends to evoke actions of
reprisal by the injured player and his team-mates.
Knee to head injury: This is responsible for the most
serious or fatal injuries in football. It is most frequently
the cause of fracture of the cervical spine on kick-offs and
punt returns. Failure to use proper head positioning while
tackling may result in a solid impact of the knee of the of-
fensive player against the head of the tackler.
Knee to face-guard: A blow of the ball carrier's knee to the
face-guard of the tackler may result in the posterior rim of
the helmet driving into the cervical spine. This can cause a
cervical fracture dislocation with immediate complete
transection of the cord and death.
Example: at the moment of contact a ball carrier jumped
into the air and his knee struck the face-guard of the
92
tackler snapping his head back. This resulted in a
dislocated vertebra in the neck which mangled the spinal
cord. One must remember that the face-guard protrudes
three and one-half inches from the base of the helmet. If
the chin-strap is done up properly, this will provide the
leverage for this type of injury.
Hyperextension injuries of the cervical spine can cause
vascular insufficienty to the brain stem and the cervical
spinal cord with or without cervical fracture-dislocation. A
player may exhibit the syndrome of acute central cervical
spinal cord injury without any signs of long tract sensory
impairment probably on the basis of vascular insufficien-
cy. This could be caused by trauma with spasm or more
likely by primary compression of the vertebral arteries by
the occipital condyles at the point where each vertebral
artery passes over the groove in the lamina of the first cer-
vical vertebra. Indirectly this would result in a relative in-
sufficiency of blood flow through the anterior spinal
artery. It should be noted that the direction of blood flow
from the prebasilar branches of the anterior spinal artery is
downward towards the T-R segment of the cord where
there is a zone of poor collateral circulation. The blood
supply to the cervical spinal cord is derived primarily from
the vertebral arteries with their prebasilar branches form-
ing the anterior spinal artery. Segmental vessels arise from
branches of the subclavian and other arteries in the neck.
The remainder of the thoracic cord is supplied by segmen-
tal vessels. The greatest radicular artery here enters the
cord between T-9 and T-12. The flow is both cephalad and
caudad.
Tackling by the face-guard: A fast-moving opponent
rushes in and grasps the face masks to make a tackle. If the
ball carrier has his feet well placed in the turf with long
cleats there is the peril of sustaining either a fracture of the
cervical spine or associated cervical spinal cord injury.
Clothes lining technique: The defensive player on rushing
into the ball carrier may merely hold his out-stretched arm
well extended so the ball carrier's neck is firmly struck
possibly directly over the carotid artery. This may result in
transient spasm and can result in permanent neurological
damage.
The karate blow technique: There is a tendency in football
to apply surreptitiously some of the karate principles on
the football field.
Head Butting: The teaching of head butting is one of the
most serious errors that can be made because the head and
neck can never be protected completely to withstand a
direct impact.
Example: a seventeen-year-old high school player lowered
his head and struck the on-coming player with the left tem-
poral region of his head and fell to the ground. He was
able to get to his feet but then suddenly vomited and fell to
the ground unconscious. He has sustained an extremely
severe contusion of the brain. Three years after his injury
he still walked with a poverty of movement and had mask-
ed facies, loss of associated movements, some partial
visual agnosia and marked retardation.
The Journal of the CCA / Volume 23 No. 3 / September 1979

Stick blocking or spearing: Probably the most single
devastating technique to arise as a result of protection af-
forded by the plastic helmet and the face-guard has been
stick blocking. Stick blocking consists of the defenseman's
face being planted directly on the numerals of the offensive
man's midsection. The term spearing refers to the techni-
que of a defensive man driving his head downward and
forward into an offensive opponent who is already
grounded.
To summarize mechanisms of injury one should note
that most injuries appear to occur during the act of tack-
ling and that flexion is the most dangerous mechanism.
Deliberate spearing of course is illegal and particularly
dangerous to the immature neck. Dislocation of the cer-
vical vertebrae may occur as a result of either hyperflexion
or hyperextension of the neck. It occurs most commonly
when the head makes initial contact with the opponent in
blocking or tackling, that is, spearing, face blocking, head
tackling or butting. Of course the common and serious
complication of cervical dislocation is injury to the spinal
cord with temporary or permanent quadriplegia or death.
Some studies suggest that more injuries occur in practice
than occur in games. However, this is reversed in profes-
sional football. It is also interesting to note that a report by
Hafner on New York State public high school football,
showed that a modified tackle football program produced
a relatively low injury ratel.
Cervical stenosis: Hinck et al,17 noted that individuals with
cervical stenosis often remained asymptomatic until a
precipitating complication develops. This could be spon-
dylosis, vertebral subluxation, or a hyperextension injury.
The measurement of the sagittal diameter is important in
detecting cervical stenosis. This is done by measuring from
the posterior surface of the adjacent vertebral body to the
nearest point on the ventral surface of the spinous process
where it joins the lamina. At C-3 the normal measurement
would be between 14.5 and 20 millimeters. Any smaller
measurements indicate stenosis. Students in this category
should be advised not to compete in collision sports.
All players with neck symptoms should be thoroughly
evaluated both clinically and radiographically to rule out
predisposing structural weakness particularly in the upper
cervical region of immature players. Isometric and
resistance exercises to develop neck strength are important.
In high school football one wonders if sufficient amounts
of time are taken to strengthen these muscle groups. Pro-
tective collars also should be worn. A lightweight sponge
rubber collar used to prevent extension in lateral flexion
could also be modified to extend anteriorly which would
aid in preventing extreme flexionl0.
Types of injuries
Brain injuries: There is probably no problem that the team
doctor sees more frequently on the sidelines than head in-
juries. Often times a head injury can occur without an im-
The Journal of the CCA / Volume 23 No. 3 / September 1979
Football injury
mediate indication that it has taken place. Injury to the
brain of course is the important consideration whether or
not a skull fracture has taken place. Skull fracture of
course, of itself, can be less important. When symptoms
persist after a concussion, brain injury has to be suspected.
There is a question as to whether players should continue
playing football at all after they have experienced one, two
or three concussions18. Many types of brain injuries can
occur, for example extradural hematomas with in-
tracerebral clot, subdural hematomas with intracerebral
clot, subdural hematoma unassociated with other lesions,
basilar artery thrombosis with pontine infarction, in-
tracranial hematoma of the posterior fossa13.
Concussion: Richard C. Schneider and Frederick Driss of
the University of Michigan writing in Medicine and Science
of Sports19 give us some interesting information relative to
cerebral concussions. (See Table 2)
They point out that the diagnosis of concussion has been
so confusing that the British neurosurgeons recently have
recommended abandoning its use. A definition developed
by the 1964 Congress of Neurological Surgeons reads:
"Brain concussion - a clinical syndrome characterized by
immediate and transient impairment of neuro-function,
such as alteration of consciousness, disturbance of vision,
equilibrium, etc, due to mechanical forces."
These authors feel that the football player who has sus-
tained a mild or first degree concussion usually may go
back into the game after a play or two, but should be
carefully watched for symptoms of fatigue and signs of
disorientation. The victim of second degree the player with
third degree concussion should be sent to hospital for
observation. Some authors feel that after three concus-
93
Football injury
sions in one football season the player should be
automatically removed from the sport permanently.
Others feel that players should be excluded permanently
after only one concussion when circumstances dictate.
Cerebral concussion which is transient and reversible
must be differentiated from a more severe injury such as
cerebral contusion. The initial symptoms of these condi-
tions may be identical. If there is a progression of the
symptoms, it suggests an expanding intracranial lesion
which demands hospitalization and a neurological con-
sultation. (See Table 3)
Progressive drowsiness after a lucid interval is an im-
portant sign of cerebral contusion.
Successful emergency treatment may depend on three
cardinal points:
1. Communication with the physician, the hospital, ambu-
lance etc.
2. Transportation a constantly availability during games.
3. Notification of the patient's status so that the hospital
can be alerted.
After such injuries a decision has to be made as to
whether or not the athlete should continue in football and
there is no test that can give definitive answer to this ques-
tion. For example, a normal electroencephalogram does
not exclude brain injury, and about fifteen per cent of all
supposedly normal individuals have an abnormal brain-
wave pattern.
Cord injury: Let me describe an incident of cord concus-
sion. The player's head and neck are forcibly thrown
backward as he falls to the ground diving for a fumbled
ball. He then experiences a feeling of numbness all over
and paralysis of all four extremities. Gradually senation
returns first in the feet, but profound weakness persists in
the arms. Subsequent x-rays reveal no fracture or disloca-
tion. Cranial nerves are intact. Biceps reflexes are depress-
ed and other deep reflexes are equal and active. No
pathological reflexes are present and there is little
tenderness over the cervical spine. By the next morning his
arms are almost completely normal and cervical stiffness is
apparent. This phenomenon can be due to squeezing of the
cord between the wrinkled ligamentum flavum posteriorly
and the vertebral body anteriorly. Also the partial vascular
94
insufficiency of the vertebral arteries can occur as they
pass through the cervical foramen and over the lamina of
C-1 13.
Other neck injuries: It seems obvious that the same
mechanisms that cause catastrophic injuries are instrumen-
tal in the production of less serious injuries that eventually
result in chronic disorders such as degenerative disc syn-
dromes, chronic traumatic arthritis, and neuromuscular
deficits. It is important to point out to coaches and team
doctors that symptoms that refer to the brachial plexus and
nerve roots are basically cervical spine injuries. Many of
these are called "stingers" by the trainers. Many are given
the diagnosis "jammed neck" and about half the diagnosis
"pinched nerve". As many as four to six neck injuries may
occur in a single practice session or game. With symptoms
of numbness, tingling, and muscular weakness due to
brachial plexus radiculopathy2O.
All injuries of this nature should be considered serious
unless proved otherwise and certainly any player if
rendered unconscious should be considered to have an
associated neck injury. Soft tissue injuries to the spine are
more common than fractures or dislocations. Careful
follow-up studies need to be done to disclose whether these
injuries to the soft tissues are responsible for disc
degenerations so commonly seen in young adults in our of-
fices.
X-ray is important in evaluating and examining the
spine. Criteria for evaluation often include disc space nar-
rowing, body compression, and/or angular displacement.
When freshmen recruits at the University of Iowa had
routine x-ray examinations, many showed evidence of
previous injury. And when a questionnaire was used to
study 430 high schools in Iowa where football is played
many players had a history of neck injury. When coaches
were similarly interviewed it was revealed that only about
one half of the injured players were seen by a doctor and
only eight per cent had x-rays of the cervical spine. This in-
dicates that athletes, coaches and physicians are not aware
of the severity of injury that can occur. It is difficult to
comprehend that many neck injuries are not recognized as
such, and often the radiating symptoms are not associated
with the neck. These facts were brought out by Feldick and
Albright in an article entitled "Football Survey Reveals
Missed Neck Injuries" which was published in The Physi-
cian In Sports Medicine in October of 197620. Dr. Feldick
is team physician at the University of Iowa and Dr.
Albright is associated with the Department of Orthopedic
Surgery at the University of Iowa.
We must remember that adolescents have immature
bony structures. End plates of the vertebrae do not close or
become mature until eighteen to twenty-one years of age.
Ligamentous and cartilaginous structures are immature.
The muscle strength of the neck is weak, therefore, if
adolescents are to play collision sports at all, pre-season
examination should include a through history and physical
examination since x-rays alone can miss problems that the
history and examinations may reveal.
The Journal of the CCA / Volume 23 No. 3 / September 1979

Injuries to other body sites:1 It has been estimated that
during a fourteen game season of professional football
there is a total of only ninety minutes in which the players
are engaged in action. Nevertheless during four seasons of
practice and play, fifty per cent of all squad members of
one leading professional team were injured seriously
enough to miss at least two weeks each season. In football
injuries take place to most areas of the body. The relative
distribution of such injuries in high school players is in-
dicated by the following table (Table 4) taken from the ex-
perience of Wisconsin high schools between 1963 and
19671.
Knee injuries are the most serious chronic disabling con-
ditionl. Shoulder girdle injuries cause apparently greater
acute disability. Abrasions to the hands, shins and nose are
common in footballI. Lacerations occur chiefly around the
eyebrows and chin as a result of contact with shoe cleats
and other protective pads'. Contusions are common on the
trunk, even under pads. Crushing injuries may cause deep
contusion and create painful and disabling myositis
ossificansl. Tackler's exostosis affects the anterior lateral
aspect of the humerus and is more common in high school
players2l. Contusions of the internal organs of the body
may produce serious or even fatal results. Even myocardial
infarction and precordial effusion have been reported as a
result of the helmet striking the sternuml.Rupture of
kidney, spleen and liver are occasionally reported. Muscle
strains are most common in the groin.1 Chronic strains of
tendons and ligaments occur most commonly in the cer-
vical, elbow and knee regionsl. These, of course, may be
accompanied by deposition of calcium in and around the
inflamed structures and by the occurence of bursitis and
chronic tendinitisl. Sprains occur in almost every joint of
the body in football. Anterior costochondral joints may
produce prolonged disabilities. In the knee, the combina-
tion of complete tear of the medial collateral ligaments,
tear of the medial meniscus, and complete rupture of the
anterior cruciate ligament have been termed the unhappy
triad by O'Donoghuel. Subluxation of the acromioclavi- 3. The possibility of permanent damage to bones and
cular joint is a common and painful football injury.
The Journal of the CCA / Volume 23 No. 3 / September 1979
Football injury
Posterior displacements of the clavicle in acromioclavi-
cular sprains is often not recognized and degenerative
changes can occur within the joint22.
The most common fractures in football are those of the
upper limbs, ribs, tibia, fibula and feet. Fractures of the
scapula, spine, pelvis and femur are less common. Skull
fractures are relatively infrequent in football since the ad-
vent of the hard shell helmet. Ninety per cent of the fatal
injuries now occurring in football are brain and cord in-
juries1.
Epiphyseal injuries in the growing athlete:
S. Schwab of the University of Saskatchewan, writing in
the CMA Journal, gives us some interesting information
ralative to epiphyses22.
"The epiphyseal plate is two to five times weaker than
the surrounding fibrous tissue in children and adolescents.
Consequently a force causing a ligamentous tear in adults
is likely to cause an epiphyseal plate injury in growing
children. The epiphyses and the epiphyseal plate are largely
responsible for longitudinal growth and circumferential
remodeling of the long bones in the growing body. All
physes are, at one time in their growth, . . . vulnerable to
injury; therefore physes that are more exposed to trauma
are more prone to injury. In contact sports such as foot-
ball, there is a repetitive trauma to both arms, legs [and the
spine]. Since the epiphyseal plate is two to five times
weaker than the surrounding fibrous tissue, an epiphyseal
disorder must be suspected in all injuries of the joints in
children. As the child grows older the epiphyseal plate
ossifies and thus becomes stronger. Most epiphyses are
closed by age twenty years.
"Interruption of growth of the epiphyseal plate is more
serious than a clean fracture in a fully ossified are a partly
because pain and deformity are less obvious at the time of
injury and therefore corrective measures may be delayed
until an irreparable defect has resulted." Physiologically,
epiphyses on the one hand help to correct a deformity and
reshape bone as growth occurs and on the other hand pro-
duce deformity by unequal growth after they are damaged.
Sound clinical judgment is therefore essential when ex-
amining these joints especially when radiographs appear
normal.
Here are some objections to the participation of athletes
in the young adolescent age-group in collision-type
athletics24.
1. There is increased likelihood of injury to the
undeveloped skeletal and muscular system.
2. The factor of immature judgement leading to more ex-
posure to trauma.
joints by early athletic participation.
95
Football injury
Larson writing in The Journal of The American Medial
Association states that a study of 1,338 athletic injuries
seen by four orthopedists revealed that high school
students appear to be the most vulnerable to athletic in-
juries24. While epiphyseal injury is a hazard in sports par-
ticipation, failure to recognize the injury and to provide
proper treatment is an additional hazard. If these injuries
are properly treated children do not have permanent defor-
mity.
Certain children are more susceptible to injury of the
epiphyses, for example, the obese Froehlich type or the tall
uncoordinated lanky child with poor muscular develop-
ment and relaxed ligaments. These children certainly
should not be participating in football24.
One problem when dealing with epiphyseal injury as
pointed by William Harsha, is the laissez-faire attitude of
many practitioners towards sprains25. Medical literature is
remarkably devoid of dissertations dealing with sprains
and their sequelae. And again I will stress that the strength
of the fibrous capsule is two to five times stronger than the
metaphyseal-epiphyseal junction. Therefore, all so-called
"sprains" around the weight-bearing joints in children
must be carefully checked for possible epiphyseal injury.
The weak part of the epiphysis is towards the metaphysis,
and this is where the cleavage usually occurs with separa-
tion. Harsha also points out that orthopedists who are in-
terested in athletic injuries frequently find that carefully
taken x-rays of so-called "sprains" in the child, particular-
ly about the ankle, do not show disruptions of ligamentous
structures but actual periosteal tears, together with partial
separations of the metaphyseal-epiphyseal junction, yet
without loss of anatomical position25.
Larson reported that football and basketball players
were reported to have the highest incidence of epiphyseal
in juries26. Epiphyseal injuries of the axial skeleton are
most likely to occur in contact sports such as football in
which there is excessive head tackling. Cervical epiphyses
are usually injured in these sports. The mechanism is
usually one of hyperflexion or hyperextension along with
rotation23.
Radiographs of epiphyseal injuries are often difficult to
interpret, consequently these injuries are often missed in
children26. Very careful diagnostic procedures including
the taking of an accurate history of the mechanism of in-
jury, visual observation, palpation of the injured area,
functional muscle test and bilateral radiographs in at least
two planes are necessary. Signs and symptoms to look for
are deformity, swelling and pain at the epiphyseal plate. If
the injury is not severe enough to produce deformity the
diagnostician must take careful note of the exact site of
pain. Pain will be present over the epiphyseal plate rather
than over the nearby fibrous structures. Significant distur-
bance of growth follows approximately ten percent of
epiphyseal plate injuries and minor growth disturbances
are seen after a high percentage of injuries23.
Harsha also states that they see large numbers of grow-
96 The Journal of the CCA / Volume 23 No. 3 / September 1979
ing children who have developed an asymmetrical plane at
the knee joint, for example. A careful history often reveals
a trauma to the knee that was passed off as a simple sprain.
He feels that the possibility that these sprains represent a
partial disruption of the metaphyseal-epiphyseal junction
must be considered. These areas may be devitalized tem-
porarily allowing the opposite side of the epiphyses to con-
tinue its growth. An irregular growth may take place and
this may predispose to future arthritic changes. He also
believes that all sprains of weight-bearing joints in children
must be considered to be severe injuries and he prefers to
immobilize them in plaster and to x-ray them periodically
during the entire growth period to detect any possible ir-
regularities in epiphyseal growth.
Salter writing in The Journal of Bone and Joint Surgery
gives us some additional interesting information27.
Each epiphysis has its own plate through which skeletal
growth occurs, and it is important that a distinction be
made between the epiphysis and the epiphyseal plate. Two
types of epiphyses exist in the extremities, namely pressure
epiphyses and traction epiphysis. Two types of epiphyses
exist in the extremities, namely pressure epiphyses and
traction epiphyses. Pressure epiphyses situated at the end
of long bones are subject to pressures transmitted through
the joint into which it enters. A traction epiphysis is the site
of origin or insertion of major muscles or muscle groups
and is therefore subjected to traction rather than to
pressure. The three main types of injuries are separation of
the epiphysis through its epiphyseal plate, fractures that
cross the epiphyseal plate and crushing injuries of the plate
itself27.
The crux of the problem is whether the blood supply is
interfered with. The cartilaginous epiphyseal plate is ob-
viously weaker than bone. Salter states that of all the in-
juries to the long bones during childhood approximately
fifteen per cent involve the epiphyseal plate. These injuries
are more frequent in boys than in girls, presumably
because of the more active physical life of boys. In general,
epiphyseal plates that provide the most growth are most
commonly separated by injury. If properly treated the
healing of the epiphyseal separation when there is no
vascular damage is very rapid and is complete in three
weeks27.
In fractures that cross the epiphyseal plate the gap
created in the epiphyseal plate fills with bone. Premature
closure of the plate and shortened extremity result.
Epiphyseal injury should be suspected clinically in any
child who shows evidence of fracture near the end of a long
bone, dislocation, ligamentous rupture, even severe
sprains of a joint. It must be remembered that an epiphysis
may be displaced at the moment of injury and then return
to its normal position, in which case clinical examination is
likely to be of considerable importance in recognizing the
nature of the injury. The best time to reduce an epiphyseal
injury is the day of the injury since reduction becomes pro-
gressively more difficult whith each day27.
 Football injury

Schwab states that the secret of treatment of epiphyseal be due to carelessness, ignorance, or a "don't give a
injury is prevention. She also states that children should damn" attitude on the part of coaches or trainers. It may
not be subjected to highly competitive organized sports; be due to the psychological composure of athletes possibly
nor should they be made to develop excessive muscle driven by too lofty aspirations or the zeal of parents to
strength by means of weight training until the epiphyses have superstar in the family.
become strong enough to withstand these forces23. This condition is of course completely preventable with
Rugby: There has been a growing belief that the armour knowledge of heat illness and knowledge of the limitations
with which we have clothed the present-day football player of physical tolerance and the provision of free access to
may be dangerous. For this reason, and because dif- water during practices.
ferences in the rules of various games can effect frequency
of injury, I would like to compare American football with Adult supervision31: Another factor which can be im-
rugby. plicated in the injury to young adults is the adult supervi-
The rugby player is prohibited from wearing protective sion of play. It's interesting to note that when adults are
clothing. Tackling as performed in rugby, proceeds in the not present youngsters who are not bound by rules tend to
direction of the player's forward motion. We have to com- create their own rules, and these tend to conform with their
pare that with the direct vertex or head-on tackling which physical abilities and their enjoyment of play. Left to their
is used in the United States and Canada. own, their activities are more varied. They change from
In an article by Scher entitled "Rugby Injuries to the one game to another more frequently according to their
moods.
Cervical Spinal Cord"28. He points out the following physical They don't usually force themselves beyond their
ability.
statistics. In Scotland during 1959 to 1965 only one fatal ing when he is tired In the natural state a child will stop play-
cord injury was recorded. In Ireland during 1959 to 1963 When adult or even when he's slightly injured.
there were two fatalities.In Wales during 1945 to 1964 supervision dominates or regulates com-
there were only two cord injuries. petitive pressures of winning enter into the scene as do
spartan attitudes towards injury. Unfortunately it is usual-
Walkden, honorary medical officer to the Rugby Foot- ly the better player who is most affected because the coach
ball Union, analyzed all injuries from 1964 to 1975 at and the team depend on him to win. He is the one who may
Twickenham29. The percentage of injuries was 10 per cent be returned to play most often before recovery is complete.
and of these only 1.7 per cent were severe. Of those 1.7 per It is interesting to note too that the injury rate for
cent, only 6.5 per cent comprised head injuries, and over peewee and midget divisions doesn't seem to be as great
half of these only involved over-night observation. because at that age they are fairly equally matched in
Scher analyzed twenty cord injuries as a result of rugby weight and maturity. They also don't hit hard enough to
and found that 40 per cent occurred during scrums28. He seriously injure, and youngsters at this age are not too
stated that these injuries were rare in South Africa. They receptive to deliberate techniques aimed at hurting each
usually occur when the scrum collapses and the rest of the other. This of course doesn't hold true for the high school
pack keep on pushing and the hooker is forced to the age group. High school players as well are going through a
ground with his head in flexion causing cervical disloca- period of rapid growth often and one finds more frequent-
tion. He also points out that the use of protective helmets ly the tall gangling type and the heavy froelich type which
would not protect the player against this type of injury and are especially prone to epiphyseal injury.
that to help reduce of prevent these injuries, rule changes To prevent injury, therefore, children should be match-
and strict action by referees would be the best preventive ed not only by age but weight and size should be taken into
method. consideration.
Walkden29 also points out that another step would be to
insure that no young teenagers be allowed to play with Equipment: Earlier in this paper I discussed helmets at
heavier opponents. some length. It is important that the equipment be proper-
ly fit, that it be chosen on the basis of proper protection
and that coaches insist that protective pieces of equipment
Prevention of Injuries such as the "horse collar" be worn. Good research is
necessary in this area. Example, in visual field studies done
Heat illness30: A significant number of deaths have occur- on a subject wearing several different designs of football
red during the past decade due to heat stroke in athletes. headgear and face guard combinations, efects of varying
Deaths from heat stroke in the football player may occur magnitude were demonstrated32. Another example is the
under conditions of extreme humidity or excessive addition of the face guard. This piece of equipment cer-
muscular work. Rules for the prevention of heat stroke tainly helps to protect the face but there is some question
have been well worked out and are widely understood. as to whether it causes increased tendency toward excessive
However, in spite of this heat stroke has killed about fifty hyperextension of the cervical spine at certain times.
players in the past ten years. In fact it ranks second among Playing surfaces are another consideration. Bramwell
reported causes of death in high school athletes. This may and Garrick of The University of Washington found that
The Journal of the CCA / Volume 23 No. 3 / September 1979 97
Football injury

injury rates for games played on synthetic surfaces were Coaching: Coaches must have skill, sufficient training and
significantly higher than those played on grass33. sensitivity to meet the demands of a young team. What is
the coach's attitude? Does he allow everyone an equal op-
Fitness: If injury is the occupational hazard of sport then portunity to play, does he feel that he must win at all
physical fitness and training are its opponents. This is pro- costs, does he play excessive pressure, does he use
bably one of the most important considerations in injury humiliating methods, does he allow players to play when
prevention. Physical exercise and training that are careful- injured, etc?34
ly graduated can develop muscles to a stage of actual
energy production more than three times the normal rate.
The aims of fitness training are to help the athlete become
agile to be able to perform movements with the greatest Summary and conclusions
ease and more importantly, to have complete control over
his entire body. Of course training develops speed, Please allow me now to summarize some of the things
strength, agility, skill, endurance, flexibility, balance and that have been said in this paper and possibly draw some
reaction time as well as controlling the body weight. It is conclusions.
obvious that all of these factors are important in the In introductory remarks I pointed out that there are
prevention of injury. Training must take place before the large number of injuries in football. There are many
season actually starts so that muscles possess sufficient deaths and many paralytic results. Football injuries seem
tone and strength to support joints and to protect them to be more prevalent than injuries in other sports par-
from stress and strain. ticularly among the more serious types of injuries. You
probably noticed that there is a lack of adequate statistical
information in Canada. For that reason I used American
Post-injury rules: Joel Adams writing in Clinical Or- figures extensively and you saw that the figures were
thopedics and Related Research mentions the rules that somewhat alarming. I might point out here too that just
they use in the San Bernardino School District as because we have incompleteness of information in this
follows31. country, this does not justify avoiding decision36. For ex-
ample, in relation to the prevention of deaths and serious
1. A player sustaining any injury is ruled out of the game injuries and long-term consequences.
until he has obtained medical clearance. We talked about helmets and how they contribute to in-
2. When there is head injury with even a momentary loss jury and how helmets are used now as assault weapons.
of consciousness, the player is automatically ruled out Some figures seem to indicate taht while they protect the
of the game for the remainer of the season. skull, the brain and neck are made more vulnerable.
3. No player partially recovered from an injury may return When we looked at the mechanics of the game, that is,
to play while still taped, bandaged or splint in any way. collision, the type of tackling and the attitude of
devastating the opponent, lends itself serious injury. We
He states that there is absolutely no excuse for allowing a also talked about common actions in the game such as pil-
youngster of this age to return to play unless he is com- ing on, knee to the head or face guard, tackling with face
pletely recovered from his injury. guard, clothes-lining, karate blow, head butting, stick
blocking. Again these seem to be part of football.
Dangerous plays: Grabbing of face masks, spearing and I reviewed for you brain injury, concussion, cord injury,
other deliberate infractions should not only be penalized neck injuries, etc. I also reviewed injuries to other body
but the player should also be ejected from the game. This sites and it was again easy to see that the body pays a heavy
type of action is the major cause of serious head and neck toll for football.
injuries, and deaths to young players, yet some coaches Epiphyseal injuries were covered at some length, par-
continue to teach and encourage this practice. Other rules ticularly because the subject offer seems to be avoided.
could be changed to improve the incidence of injury, for You saw that growth center can be damaged if one is under
example, punt returns are particularly dangerous, in pro- eighteen years of age and that this can lead to deformity.
fessional football special teams aptly named "suicide In my practice as a chiropractor, I see many young adults
squads" are sent in for these plays34. with degenerative cervical changes. Often they have a
history of trauma and often this trauma is related to the
playing of football.
Pre-participation physicals: These are often too cursory to I compared statistics for rugby injuries for you. It seems
uncover conditions that might lead to serious injury and apparent to me that that tough sport, which is played with
often children who should have been disqualified from very little protection, causes less catastrophic incidents
play are allowed to play. Earlier in this paper I mentioned than football.
some of the criteria that should be used in evaluating We reviewed preventive ideas and you have seen how
players35. attempts to prevent injury have at times back-fired, for
98 The Journal of the CCA / Volume 23 No. 3 / September 1979

example, the improvements in helmets and face guards
have resulted in other types of injuries. You have also seen
that the attitudes of players, parents, coaches and officials
are paramount. Because of the nature of the game poor
attitudes lead readily to catastrophe.
Every sport or activity, of course, has a calculated risk.
This could be defined as a comparison of the hazard of the
sport relative to the sport's purported benefit.
Let us look compare the calculated risks of football with
for example, soccer.
Soccer plays 24 men with very few substitutes. Football
has an offensive and defensive team who change frequent-
ly and there is also a number of extra players. In soccer
most players may run several miles in a single game. In
football only the ball carrier does any significant running.
Therefore, soccer is much more oriented toward car-
diovascular fitness (school children in this country have
been found to be deficient in this area. Fifty per cent of us
will die of heart disease).
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Football injury
In soccer all players are active for longer periods during
the course of the game. In football the play ends often and
after only ten or twenty seconds of play.
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In both of these sports the fields measure sixty-five by
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99