Improving Safety and Reducing Risk in Youth Contact Sports

 Vernon Williams
  4th-Mar-2018

Concussion – no matter who you are or where you go today – is a word that has been splashed across many sports and mainstream media headlines. As such, it is a word that has provoked a collective fear and doubt in the minds of the public – perhaps most especially among parents of young athletes participating in "contact sports."

And the medical community is weighing in. A recent editorial in the journal Clinical Orthopaedics and Related Research asks: "Do Orthopaedic Surgeons Belong on the Sidelines at American Football Games?" The authors answer that question with a collectively resounding "no." Their rationale is well-intended and varied – from the notion that concussions aren't the primary area of expertise for orthopedic surgeons to a physician's moral obligation to not engage in helping a sport continue if it has known risks. Though I'm not an orthopaedic surgeon, most of the associate colleagues in my practice are, and yet the tenor and tone of this piece alarmed me.

My concern with the editorial comes at a time when draft legislation in Maryland calls to prohibit participation in youth/little league and Pop Warner football for anyone under the age of 14. In California, the United States Fight League – a youth martial arts program that includes grappling and limited contact striking – delegation is having great difficulty finding physicians to provide participation physicals for the participants due to health care provider concerns about the morality of youth combat sports. In this particular case, the physicians may not realize that youth pankration does not involve head strikes (this is a penalty) and all participants wear protective headgear. In fact, early evidence (based on the documentation of all participation injuries) indicates it's a safe sport with minimal, nuisance-type strains and sprains, and no significant concussive/head injury risk. But a fear of being seen as endorsing a sport that could be perceived – whether it's actually true or not – as posing even a remote neurological risk has become unpalatable for many in the medical community.

Here's the rub: The risk of concussion, sub-concussive injury and/or long-term associated consequences is not limited to participation in the sport of football or combat sports. A number of other sport and recreational activities also involve increased, but unquantifiable, risk. In attempting to force participation prohibitions on football or other assumed "dangerous" sports, are we as a medical community missing the larger and more important opportunity to improve safety for all individuals in all sports and activities with associated neurological risk? I believe we are, and this is what concerns me.

In addition, I believe there are some unintended but significant consequences of prohibition policies, especially for individuals in lower socio-economic and underserved communities. It's a widely held belief that the opportunity to participate in sport and athletic activities represents significant benefits for participants. The potential impact (were football and/or other sports with risk of concussive injury to disappear) on childhood obesity, behavioral problems, academic progress and success, and exposure to less desirable alternative "activities" with risk of brain injury is not known and may represent more danger to participants than the neurological risk. And will such a blanket prohibition policy impact different categories of people in different ways?

As doctors, we must consider public health principles – and yes, we do have a societal responsibility to protect and promote health in the population as a whole. But to date, there is insufficient evidence to justify an all-out prohibition policy on football and other contact or combat sports. Yes, there are studies and research to suggest a potential risk of participation in football (as well as other sports), but there is also high-level evidence that participation during youth doesn't confer excessive or increased long-term risk. Furthermore, many of the safety provisions in effect now weren't present before. So the fact remains that we're still learning about risk of participation, which individuals may be at highest risk and how to quantify said risk. We must also continue to be vigilant to the risks of unintended consequences. Much has been said about what contact, collision and other sports-related injuries may do to an individual who participates. We should also consider what participation in sport can do for our youth. To truly help our youth athletes right now, our attention and effort should be focused on improving safety and reducing risk, rather than prohibiting participation.

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