Football is one of the most popular sports for boys, with over 1 million youth players annually (NFHS News, 2019). However, participation involves unavoidable exposure and an inherent risk of injury, and injury rates in football are typically higher than in other sports (Kerr et al., 2018).
A variety of injuries have been documented among high school football players, and the proper management and care of the injured athlete is integral to ensuring a proper return to play and mitigating future injury.
Sprains and strains are common injuries in football, particularly to the ankle, knee and shoulder.
Symptoms: Variations in injury type and severity exist.
Injury picture: Lower extremity injuries are more common, and injuries can occur from contact or noncontact mechanisms. Ankle injuries are common in sports with rapid changes of direction, and are the most common injury in high school football (Shankar et al., 2007; Wiersma et al., 2018).
Knee injuries in football account for 15% of all high school injuries (Ingram et al., 2008). Knee sprains occur more commonly in games than practice, and the risk is 3.72 times greater in high school football compared to youth football (Clifton et al., 2017). The MCL is the most commonly injured ligament in high school football followed by the ACL.
Treatment and Return to Play: A program will be targeted to the underlying condition. Additionally, efforts should focus on developing an injury-prevention program.
Concussions in high school sports are common, and football has the highest overall concussion rate in high school sports.
Symptoms: A concussion is a change in mental status due to a traumatic impact. Players do not need to lose consciousness, and signs of a concussion include headache, dizziness, nausea, loss of balance, drowsiness, numbness/tingling, difficulty concentrating, and blurry vision.
Injury picture: The majority of concussions in high schools sports occur when contacting another player, and the majority of concussions are seen in linebackers and running backs (Kerr et al., 2019).
One recent study followed concussion rates for 20 high school sports from 2013 to 2018 (Kerr et al., 2019). IN this study they defined rates of concussion as concussions per athletic exposure, with athletic exposure being defined as a high school athlete participating in either a practice or game.
The overall concussion rate in high school athletics was 4.17 per 10,000 exposures. Football had the highest rate per 10,000 exposures at 10.4, followed by girls’ soccer at 8.19 and boys ice hockey at 7.69. Between 2013 and 2018, the rates of football concussions in practice have decreased, but concussion rates in games have increased 33.19 per 10,000 exposures to 39.07 per 10,000 exposures. Concussions tend to occur more often in the latter halves of games and practices across all sports.
Treatment and Return to Play: A concussion specialist can also help guide return-to-learn and return-to-sports decisions. Student athletes are students first and students recovering from a concussion may have a difficult time adjusting to normal school activities. Academic accommodations may be necessary.
Return-to-play guidelines are a gradual process to ensure the athletes safe return to activity. These protocols should be sport specific, and post-injury testing is done to ensure the brain has recovered. The athlete should return to play only when clearance is granted by a health care professional.
Overuse injury refers to a group of injuries classified by a gradual progression of symptoms. Some estimates suggest that more than 50% of youth sports injuries are overuse injuries (DiFiordi et al., 2014).
Symptoms: Overuse injuries typically present with gradual and progressive pain and/or tenderness over the affected area.
Injury picture: Overuse injuries make up a small percentage of overall football injuries in youth and high school athletes. In a large studies of youth football injuries, overuse injuries made 3.6% of injuries (Morris et al., 2017). In high school football, 2.8% of injuries were due to overuse conditions. The rate of injuries did not differ statistically between youth football and high school football.
The majority of overuse injuries occur in the lower extremity. In high school football athletes 62.5% of overuse injuries occur in the lower extremity.
Injuries include inflammation of the tendon, especially tendinopathies, or joint. Conditions such as patellofemoral pain syndrome or patella tendinopathy are common. Tendon related growth plate injury can often be misdiagnosed as tendinopathy. Growth plates in the lower extremity can remain open until age 16 years in males, and conditions such as Osgood-Schlatter and Sever diseases are common. Chronic muscle injuries are also common in high school athletes.
Treatment and Return to Play: Overuse injuries tend to occur when a player trains beyond the ability for the body to recover. While rest is often prescribed many players can continue to play through overuse injuries with appropriate modifications to workouts and changes to load management. A program will be targeted to the underlying condition, and may include a stretching and/or strengthening program, modifications to equipment.
Non-orthopedic conditions, such as heat illness, can occur form overextended playing time. Heat injuries are a major concern for youth football players, and more commonly occurs in August corresponding with the highest temperatures and humidity of the year. Intense physical activity can result in excessive sweating that depletes the body of salt and water.
A higher injury risk has been documented in previously injured football players. While most injuries do not prevent athletes from continuing to participate in competition and practice, unaddressed these injuries increase the risk for further injury and may be an indicator of a deficiency in training or strengthening.
Injury prevention strategies include:
If you have any concerns about football injuries or football injury prevention strategies call to schedule an evaluation at Boston Sports & Biologics (781) 591-7855.
Clifton DR, Onate JA, Schussler E, Djoko A, Dompier TP, Kerr ZY. Epidemiology of Knee Sprains in Youth, High School, and Collegiate
American Football Players. J Athl Train. 2017 May;52(5):464-473.
DiFiori JP, Benjamin HJ, Brenner JS, Gregory A, Jayanthi N, Landry GL, Luke A. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med. 2014 Feb;48(4):287-8.
Ingram JG, Fields SK, Yard EE, Comstock RD. Epidemiology of knee injuries among boys and girls in US high school athletics. Am J Sports Med. 2008 Jun;36(6):1116-22.
Kerr ZY, Chandran A, Nedimyer AK, Arakkal A, Pierpoint LA, Zuckerman SL. Concussion Incidence and Trends in 20 High School Sports. Pediatrics. 2019 Nov;144(5):e20192180.
Kerr ZY, Wilkerson GB, Caswell SV, Currie DW, Pierpoint LA, Wasserman EB, Knowles SB, Dompier TP, Comstock RD, Marshall SW. The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in United States High School Football (2005-2006 Through 2013-2014) and National Collegiate Athletic Association Football (2004-2005 Through 2013-2014). J Athl Train. 2018 Aug;53(8):738-751.
Morris K, Simon JE, Grooms DR, Starkey C, Dompier TP, Kerr ZY. The Epidemiology of Overuse Conditions in Youth Football and High School Football Players. J Athl Train. 2017 Oct;52(10):976-981.
NFHS News. Participation in High School Sports Registers First Decline in 30 Years. National Federation of State High School Association. Sept 5, 2019. Available at: https://www.nfhs.org/articles/participation-in-high-school-sports-registers-first-decline-in-30-years/. Accessed June 28, 2021
Shankar PR, Fields SK, Collins CL, Dick RW, Comstock RD. Epidemiology of high school and collegiate football injuries in the United States, 2005-2006. Am J Sports Med. 2007 Aug;35(8):1295-303.
Wiersma AJ, Brou L, Fields SK, Comstock RD, Kerr ZY. Epidemiologic comparison of ankle injuries presenting to US emergency departments versus high school and collegiate athletic training settings. Inj Epidemiol. 2018 Sep 3;5(1):33.
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