IS THERE A FUTURE FOR FOOTBALL?

Historical Note

In 1905, there were 18 deaths and 159

documented serious injuries

attributed to the game of football.

In response President Theodore

Roosevelt convened representatives

from academic institutions and

formed a committee to revise the

rules of the game

The NCAA Century Series Part 1 : 1900–1939. The NCAA News,

The Roosevelt Rough Writer: The Newsletter for Volunteers in Part at

Sagamore Hill. 2005; 1

Rate of Concussion – high school athletes (per 1000 athlete-exposures)

Football 0.47Girls soccer 0.36Boys soccer 0.22Girls basketball 0.21Boys lacrosse 0.19Boys wrestling 0.18Boys basketball 0.07Girls softball 0.07Boys baseball 0.05Girls volleyball 0.05

Source: Journal of Athletic Training, December 2007

Football and long term cognitive

outcome

• CTE is a REAL pathologic entity which has been best

characterized in autopsy studies.

• Unfortunately, we still lack significant understanding of

important factors about susceptibility, pathophysiology,

clinical manifestations, modifying factors, and co-morbid

conditions

• “believers” vs. “deniers” is not a helpful construct!!

RESEARCH, RESEARCH, RESEARCH!

5

NFL MEDICAL RESEARCH EXPENDITURES 2013 - 2018

Since 2013 the NFL has directly contributed over $235 million to medical research and education involving all aspects of player health and safety.

• $60 million Head Health Initiative with GE (2013, 4 years)• $40 million for TBI imaging• $20 million for innovation challenges

• $30 million to independent government sponsored research (2013, 4 years)• $17 million through FNIH• $13 million unrestricted gifts to NIH-sponsored projects

• $40 million to independent scientific advisory board (2018)• $60 million to Engineering Roadmap (2016)• $45 million to USA Football “Heads Up” educational program (2015)

• $6 million grant to the University of Pittsburgh and University of Pittsburgh Medical Center (UPMC) for its “Prevalence of Brain Health versus Neurodegeneration in Professional Football Retirees” project.

• $14.5 million for “A Prospective, LONGitudinal and Translational Study for Former National Football League Players” at Boston Children’s Hospital and Harvard Medical School.

• A $9.4 million grant to “Surveillance in High Schools to Reduce Concussions in Youth” led by a group at the University of Calgary.

• $3.4 million for the project “Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI Longitudinal),” led by researchers at the University of California-San Francisco.

• $1.5 million to “The Spectrum of Concussion: Predictors of Clinical Recovery, Treatment and Rehabilitation, and Possible Long-Term Effects” led by a team at Spaulding Rehabilitation Hospital and Harvard Medical School.

FUNDING ANNOUNCED NOVEMBER 2018 (SAB)

What should we do until the data becomes more settled?

All of us know that the best

treatment is…

PREVENTION!!

Risk modification

Can we reduce the incidence and severity of head impacts in

football?

Risk reduction strategies

• Equipment

• style of play/rules

• training and teaching

• Supervision and medical

support

Injury

Engineering

Gameday

Data Analytics

EMR

UNC ATC

Video Review

Video Recon

Lab testing

GSIS

NGSHelmet Tracker

Schedule

Surface Officiating

Environmental

INJURY EVIDENCE PLATFORM

Confidential and Proprietary

270 263 265

244

212

279

250

291

2010 2011 2012 2013 2014 2015 2016 2017

Number of Concussions

16%

12

All time high of concussions in 2017 seasonFull season; 2010-2017

HOW CAN WE REVERSE THIS TREND?

•How can we IMMEDIATELY begin to

significantly reduce the number of

concussions suffered by NFL

players?

• What are the major causes of these

concussions?

• What steps could prevent these causes?

13

CONCUSSION REDUCTION STRATEGY

14

Injury Reduction Plan - Concussions

G O A L

Education

Reduction in concussion incidence in

the 2018 seasonRemove dangerous style of play

1

2

3

Increase number of players wearing better performing helmets

Decrease pre-season practice concussions

+ Enforcement+ Engineering

15

Video Review Method – Game Concussions

Review Presentation

Review of all available video

Sideline Video

EndzoneVideo

Broadcast Video

Replay #2

Replay #3

Replay #1

“All 22” Video

Live broadcast feed

NFL Films footage Broadcast Melt Reel Footage

Database Entry

(PHL, safety)

Impact Location

Primary Impact Source: Shoulder

Concussed Player:Collision Partner:

(MIN, wide receiver)

Activity: Tackled

Activity: Tackling

Video Review Database

0

5

10

15

20

25

30

35

40

45

50

Top Front Side(upper)

Side(lower)

Rear(upper)

Rear(lower)

Facemask(central)

Facemask(upperedge)

Facemask(sideedge)

Perc

enta

geHelmet Impact Location in All Impact Types (2015-2016 , n = 325)

All (n=325)

H2H (n=116)

H2B (n=92)

H2S (n=56)

H2G (n=61)

Side is the most common impact location

H2H Case: Rate of Rotation

20

STR

IKIN

G P

LAY

ER

NEC

K IN

JUR

Y R

ISK

STR

UC

K P

LAY

ER

CO

NC

USS

ION

RIS

KIncreased Lowering of Head

BaselineFacemask-to-Facemask

> 2 XBaseline

Risk

> 80 XBaseline

Risk

N A T I O N A L F O O T B A L L L E A G U E 2 0 1 8

Helmet Striking Helmet

21

N A T I O N A L F O O T B A L L L E A G U E 2 0 1 8

Helmet Striking Helmet

22

N A T I O N A L F O O T B A L L L E A G U E 2 0 1 8

Helmet Striking Helmet

23

24

Tackling Player Helmet Location

Biomechanics of Lowering the Head

Tackled Player Concussion Risk

Upper Body Alignment with Closing Velocity

Head-Spine-Torso Alignment

25

26

CONCUSSION INCIDENCE AND ANALYSIS

27

2828

INCIDENCE OF CONCUSSION

Number of concussions by year and season; 2012-2018

201 players

concussed in 2018

26% 13%No

change25%29% 29%

29

PRESEASON PRACTICES

30Confidential and Proprietary

Preseason Practice Concussions Did Not Decrease2010-2018

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9

Nu

mb

er

of

Co

ncu

ssio

ns

91

79

PS Practices

PS Overall

45 45

Year Timing in Preseason

Training Camp Rest of Preseason Total

2016 20 (77%) 6 (23%) 26

2017 31 (69%) 14 (31%) 45

2018 31 (69%) 14 (31%) 45

21% of concussions

occur in PS practice

31

• Preseason Practice Blocks ≈ 2/3

Concussions

• OL > 1/4 of Preseason Practice

Concussions

2018 PRESEASON PRACTICE CONCUSSIONS

31

• How can we practice OL in a safer manner?

64%

15%

27%29%

64%

15%

0%

10%

20%

30%

40%

50%

60%

70%

Blocks Tackles OL % All Concussions

Preseason Practice Concussions (Relative to Games)

Preseason Practice Games

32

HELMET CHOICE

33

Helmet Usage

2017 2018 17%

2%

42%

24%

41%

74%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2017 Reg WK17 2018 Reg WK17

Prohibited Not Top Group Top Group

(n=32)

2.45 2.55 2.65 2.75 2.85 2.95 3.05 3.15 3.25 3.35 3.45

2018 Helmet Combined Metric Score

2015 -2018 Helmet PerformanceHelmets with > 30,000 Plays

Bubble Size = Number of Plays

Laboratory PerformanceBetter Worse

On

-fie

ld P

erf

orm

ance

Bet

ter

Wo

rse

0.16

0.19

0.22

0

0.05

0.1

0.15

0.2

0.25

Green Yellow Prohibited

+ Risk 15%

Risk +38%

Helmet Poster Group

2015-2018 GAME CONCUSSIONS/1000 PLAYS

35

36

RULES: USE OF HELMET

• UOH Violations in 2018 confirm significant risk associated with lowering the head behavior

• We saw some positive change in LTH behavior on the field in 2018

• However, biomechanical and medical analysis of concussions (and all plays) reveals high risk LTH behavior still present

• Broader definition of UOH/LTH would capture larger percentage of concussion causing impacts

37

USE OF HELMET (UOH) AND LOWERING THE HEAD (LTH)

• Nearly 40% of H2H concussions result from player lowering the head to initiate contact

• Nearly 60% of player-to-player concussions result from some form of LTH behavior

• Dangerous LTH is a risky behavior that requires ongoing education and enforcement to further decrease injury rates and protect players

38

SUMMARY: USE OF HELMET AND LOWERING THE HEAD

Tackling39%

Tackled25%

Blocking17%

Blocked12%

Diving/Leaping4%

Other3%

Tackling Tackled Blocking Blocked Diving/Leaping Other

TacklingPlayer61%

TackledPlayer 39%

Blocking17%

Blocked12%

ConcussionsFrom Tackles

2018 ConcussionsTackling = 58

2018 ConcussionsTackled = 31

2018 ConcussionsTackles = 89

Tackles responsible for 64% Concussions despite only 17% of helmet impacts

ALL CONCUSSIONSGAMES 2015-2018

CONCUSSIONS FROM TACKLESGAMES 2015-2018

39

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

0 2 4 6 8 10 12 14

Inju

ry R

ate

Impact Closing Speed (m/s)

Injury Rate by Impact Closing Speed for Tackling Players2017 - 2018 Weighted Exposure (96 games) and BIOCORE Video Review with NGS

Definitive Impacts

Torso

Arm

Helmet

Lower Body

Shoulder

> 5X Injury Risk

Tackled Player Body Regions

TacklingPlayer Injured

TackledPlayer BodyRegions

1X

1X

3.7X

5.3X

5.0X

40

RULES: KICKOFF

41

42Confidential and Proprietary

Kickoffs: Trends in Returns vs. Missed-Time Injury RateRegular season games; 2012-2018

a Kickoff plays include all plays, not only returns; b Missed time injuries are defined differently between 2012-2014 and 2015-2018. In 2012-2014, these include

injuries that met the reportable injury definition. In 2015-2018, these are injuries that resulted in removal from participation and inability take full part in future football

activities following the injury. Missed time information may be updated throughout the season, therefore these data are subject to change; c Game injuries reported

during a fumble and those with unknown or missing play type are not included.

0

20

40

60

80

2012 2013 2014 2015 2016 2017 2018

0

2

4

6

8

10

% o

f To

tal K

icko

ff P

lays

Rate

of

Inju

ry p

er

100 P

lays

a,b

,c

% Returned

Missed Time

Injuries per 100

Kickoff Plays

Restriction of

wedge on KO

Returns

27% decrease in missed

time injuries

Year 2016 2017 2018

Total Kickoff Concussions 20 17 13

Rate on Total Kickoffs 0.76 0.67 0.49

Kickoff Return Concussions 17 13 11

Rate on Kickoff Returns 1.64 1.25 1.13

PUNTS/BLINDSIDE BLOCKS

43

44Confidential and Proprietary

Injury Rate by Play Type: Injuries Resulting in ≥8 Days Misseda

Regular season games; 2012-2018

a Injuries resulting in ≥8 days missed are defined as any injury that resulted in removal from participation for ≥8 days following the initial onset. Open injuries at

the time of this analysis were assumed to have been removed from participation for ≥8 days. b Game injuries reported during a fumble and those with unknown

or missing play type are not included. (For ≥8 days missed: 2018: 93, 2017: 142, 2016: 157, 2015: 106, 2014: 258, 2013: 114, 2012: 38). c All kickoffs, not only

returns, are included in denominator.

0

1

2

3

4

2012 2013 2014 2015 2016 2017 2018

Rate

of

Inju

ries p

er

100 P

lays

Kickoff Punt Run Pass Field Goal Extra Pointc

Punt

Kickoff

Play Typeb

2018 Regular Season

Game Injuries

N % Injuries

Punt 70 10%

Kickoffc 45 7%

Run 246 36%

Pass 320 46%

Field Goal 6 <1%

Extra Point 2 <1%

➢ Average time missed on punt plays is

higher than other plays, including

run/pass

➢ More games loss injuries on punts than

other plays

• 63% of concussions from blocks in punts are caused by Blindside blocks

• 40% of other serious injuries (>8 days lost) from blocks that knocked players out of games on punts were caused by blindside blocks

• Blindside blocks cause concussion and other major injuries on other plays as well –usually on special teams or turnovers

• Removing the blindside block will decrease injuries and concussions, especially on special teams plays

45

BLINDSIDE BLOCKS AND OTHER INJURIES

Preview/Summary:

• Carter (#55) is injured when a blindsided player collides with him.

• A total of four players are involved in a collision resulting from the blindside block.

46

VIDEO EXAMPLE 2: BLINDSIDE BLOCK LEADING TO FIBULA FRACTURE

Video Source: Biocore Video Review Database

Blocker

Christopher Carter #55 (WAS, DL)---(2017-Reg-Week14)--- Fibula Fracture/Distal

Injured Blocked

• The first year of the concussion reduction strategy was a success

• There is more that can be accomplished to decrease concussions in 2019

• Concussion savings in future years will be driven by rules changes, enforcement and education

• Lowering the head behavior increases concussion and injury risk even when the player is not completely parallel to the ground

47

KEY TAKEAWAYS

NFL AND NFLPA MOUTHGUARD SENSOR: DATA → POSITION-SPECIFIC HELMETS

Initial Deployment with 4 NFL Teams 2019 Season

>15,000 Events2130 Game Events56 Player-Games

2018-2019 UVA Pilot Study

48

OVERALL INJURIES AND LOWER EXTREMITY INJURY STRATEGY

49

LOWER EXTREMITY INJURY REDUCTION

50

0

9,000

18,000

ACL Tears(n=193)

LEX Strains(n=2248)

ShoulderInstability

(n=224)

High AnkleSprains(n=406)

AchillesRuptures

(n=56)

Ankle / LegFractures

(n=85)

ShoulderStrains(n=245)

Concussions(n=841)

Isolated MCLTears

(n=406)

IsolatedMeniscusInjuries(n=124)

Lateral AnkleSprains(n=588)

Estimated based on mean*

Reported

a Isolated injuries are those without concomitant ligamentous pathology.

* Return dates are missing for 12-50% of injuries; days missed is estimated by using the mean across all reported injuries. These estimates do not

take into account football-related and other non-injury related factors for return to play.

8 out of the 11 highest burden injuries are to the lower

extremity, leading to more than >57,500 days missed

per season & >3,000 games missed per season (est.)

Nu

mb

er

of

Da

ys

Mis

se

d*

• Similar to our concussion reduction plan, we will present a plan to reduce the highest burden lower extremity injuries:

• Hamstring/adductor strains

• ACL/knee ligament complex tears and sprains

• Ankle sprains and fractures

51

LOWER EXTREMITY (LEX) INJURY REDUCTION PLANS

• Hamstring/adductor strains

• Review of all injury data

• Need to access performance data (Catapult, Zebra, GPS, etc.)

• Correlate with training schedules and timing of injuries

• Hypothesis that acute on chronic loading is basic mechanism

• ACL/Knee ligament

• Create profile of all injury variables

• Review injury video and describe biomechanics

• Correlate with equipment and surface

• Look at relevant training factors

52

LEX INJURY REDUCTION

• Ankle sprains and fractures

• Foot scan project

• RFID tags in all cleats

• Allows for correlation of injury rates with each cleat style and pattern (similar to helmets)

• Surface committee

• In depth analysis of injury rates on different surfaces

• Better description and measurement of surface properties

• Interaction with turf manufacturers to improve new designs and maintenance

53

LEX INJURY REDUCTION

SUMMARY

54

Summary

• Sports related injuries can be significantly reduced by:

• Better equipment

• Data-driven changes in rules and style of play

• Teaching and supervision

• Consider benefits and risks of sports participation

• Need for continued well done research on long term

effects of all aspects of sports participation including

brain injury

56