Officials need to understand rules better too.

Last night, I was discussing rules with a youth football coach regarding an incident that occurred during his game earlier in the day. It should come as no surprise that the rule in question is on illegal helmet contact. The coach was upset when a running back lowered his shoulders so low to the ground while carrying the ball that there was no chance that he could initiate contact with anything except his head. The contact was made with the face mask like a battering ram and the defender was basically run over. When the coach asked for an explanation as to why no foul was called, he was told there was no "helmet to helmet" rule in high school and below by the official.

 

This is consistent with a discussion that I had a couple of weeks ago with a high school coach who was very concerned over what he was being taught at a recent clinic. He was told by a college running backs coach that the ball carrier should lower his shoulders as low as he could to initiate the head-on contact against a potential tackler. This is nothing new, but the coach was told that if the running back could get so low that his back was parallel to the ground while holding the ball with two hands, then obliviously, the head would be the part that hits first in many situations. "That is how we get around the rule. Many officials won't call the penalty against the running back. It's very clever." was how the collegiate coach explained it to the high school coach.

"Clever" is hardly the word I would choose the describe it. What ever happened to the stiff arm or trying to juke or dance around the tackle? Why do we feel the need to turn a running back into a battering ram?  I agree that most officials will not have the guts to call this, especially if contact is made with the face mask and not the crown of the helmet, but do the biomechanics of the head and neck injury change simply because the person is carrying a football in his arms?  I wouldn't expect many people to think that to be the case.

The cold reality is that this hit IS defined in the high school rule book as a butt block. This rule can be found on page 31 of the 2011 National Federation of High Schools Rule book for football.  This rule is clear as to its intention to eliminate contact using the head first.


Rule 2 (Definitions), Section 20 (Helmet Contact - Illegal) states:
"Article 1...Illegal helmet contact is an act of initiating contact with the helmet against an opponent.  There are several types of illegal helmet contact:
    a. Butt Blocking is an act by an offensive or defensive player who initiates contact against an opponent who is not a runner with the front of his helmet. [face mask makes contact first]
    b. Face tackling is an act by a defensive player who initiates contact with a runner with the front of his helmet. [face mask makes contact first]
    c. Spearing is an act by an offensive or defensive player who initiates contact against any opponent with the top of his helmet."

The definition of illegal helmet contact is actually more inclusive in high school than just "helmet to helmet."  This rule includes initiating contact with the helmet to ANY part of the opponent.  While the official was technically right that the phrase "helmet to helmet" does not appear in this part of the rule book, it is a perversion of the high school rule by omission to make this statement.  However, the "helmet to helmet" clause DOES appear later in the rule book.

The NFHS rule book further defines the penalties associated with these definitions in Rule 9 (Conduct of Players and Others.) In Section 4, Article 3, part i, the definitions of illegal helmet contact are defined as fouls.  This rule states:

"i. [No player or nonplayer shall] initiate illegal helmet contact. (butt block, face tackle, or spear.)
NOTE: Illegal helmet contact may be considered a flagrant act.  Acts considered to be flagrant include, but are not limited to:
    1. illegal helmet contact against an opponent lying on the ground,
    2. illegal helmet contact against an opponent being held up by other players, and/or
    3. illegal helmet to helmet contact against a defenseless opponent." (pg. 69)

The penalties associated with the foul are defined as being a 15 yard penalty for illegal helmet contact AND "Disqualification also if any foul is flagrant." (pg. 70)

In this case (any many like it) not only has the official completely disregarded the definition of the helmet contact rule as defined in rules 2 and 9, but he also ignores the definition of the flagrant foul in rule 9 and the necessitated ejection for committing that foul.  This HAS TO STOP!  The rules clearly state that the this is illegal and it must be penalized.  Officials are there to enforce the rules.  They are not there to pick and choose which rules they choose to enforce.  There are serious safety concerns for the players when they choose to not enforce the rules.

For those of you who would like to see the rule book first hand, here is a pdf file that I have compiled that will allow you to share this rule with others and promote the safety of our youth.  The file contains has the rule quoted from the book first so that it is easier to read, then the scanned excerpts of the rule are included.  (I cropped out rules that did not apply to the illegal head contact from the pages to make it easier to understand.)

And of course,  a few videos that show the dangers of what can happen.
Brutal Football Hit - Helmet to Helmet
RB Helmet Hit
Pee-Wee Football Player gets Leveled

Sports mTBI myths and the history of helmets

It seems with two days in full swing it has been harder than expected to get this post written and a week has passed too quickly.  Shortly before my last post, Dustin Fink of the concussion blog posted a great resource that he had found regarding the myths of TBIs written by Don Brady and Flo Brady that include a lot of other false ideas commonly perpetuated about TBIs.  All of these myths are compiled into one pdf file for easy reading.


However, I believe that there is one myth that was left out of the document.  The idea that a better designed helmet will prevent all concussions is one that continues to be thrown around at an irritating rate.  This is the myth that has even driven many in Congress to pass laws to require better headgear for football and other sports.  A waste of time on Congress's part, to be sure.  Of course helmet manufacturers are going to continue to pursue better helmets.  If they want to remain in business, the competition amongst the manufacturers is going to drive this without any government interference.

The problem isn't looking for the ideal helmet.  The problem exists in the anatomy of the human head. The brain is not fixed to the inside of the skull, but instead, it is suspended in cerebral spinal fluid.  It is floating inside the skull in fluid.  Sudden accelerations and decelerations of the head will cause the brain to shift inside the skull and collide with its interior wall.

The best analogy that I've seen for this is the comparison to a raw egg.  It doesn't matter how much padding I add to the exterior of the egg to prevent the shell from cracking.  If I shake the egg hard enough, the yolk will collide with the interior of the shell and eventually become beaten inside the shell.

The truth of the matter is that helmets were originally designed to reduce the incidence of skull fractures, not TBIs.  When in 1905, the Chicago Tribune ran the headline "18 FOOTBALL PLAYERS DEAD AND 159 SERIOUSLY INJURED!" President Theodore Roosevelt proclaimed that football needed to change the rules or be banned.  This led to the changes requiring helmets be used.  Unfortunately, as helmet technology improved, players began to develop a false sense of security and started using their helmets as weapons.  This included three kinds of hits.  Butt blocking (leading with the head and making initial contact with the facemask to anybody except the ball carrier), face tackling (a butt block to the ball carrier), and spearing (leading with the crown of the helmet to make contact rather than the facemask) were all made illegal in 1976 due to the rapidly increasing number of neck fractures and head injuries.  Spearing has been called consistently since that time, however butt blocking and face tackling have not.  Further compounding the problem is the ESPN highlight reel that glorifies those hits from Saturday and Sunday games.  This has quickly filtered down to lower level games as well and we see kids from elementary school to high school trying to make the same "highlight reel hits".  This is what has led to the recent, rapid rise in mTBIs in the football and other collision sports.

This is not to say that creating a better helmet is a futile effort and should be abandoned.  Any helmet improvements that can reduce the risk should be pursued and implemented.  However, we need to realize that the risk is still present in football and other sports and that there is no "concussion-proof helmet."  The effort to reduce these injuries in football have to be from many angles including rules enforcement and sportsmanship as well as improving helmet design.

Time for a review.

This is a simple fact that seems to elude many emergency departments (ED) today.  This fallacy needs to be buried six feet under and please, skip the eulogy, because it is better off dead. The fallacy that I am referring to is the notion that a CT scan or an MRI is sensitive to the presence of a mild traumatic brain injury (mTBI).  These two scans are simply taking pictures of the structures in body.  They save us from being forced to do exploratory surgery to see what is going on inside the body.  They are NOT sensitive to changes at the cellular level and detecting the ions that cross the cell membranes and create the symptoms that we refer to as mTBI or concussion.

This is VERY WELL documented and researched. (see Brady and Brady, The Concussion Blog, and Sports Concussion) However, it doesn't seem to matter to many EDs as they continue to tell patients "The CT came back negative and they do not have a concussion."

Currently, a new. much more expensive type of MRI is being researched as to its effectiveness in diagnosing mTBIs.  This is a functional MRI or fMRI.  This looks at the brain in a much different way than a more common MRI and shows some promise.  However, the expense in conducting this fMRI is incredibly high and cost prohibitive for most hospitals to perform.  At the moment, it is only used in research.

This is not to say that the CT Scans and/or MRIs are not useful.  By no means should they be skipped.  These diagnostic measures do detect hematomas and other issues, more serious and often life threatening issues in the brain that can result from the same hit that created the mTBI.  We must rule out any of the more severe conditions before we move on to treat the injury.

The only way to properly diagnose a mTBI is through a very long interview where a comprehensive set of questions about the patient's symptoms are asked, memory and cognitive functions are tested, and balance is issues are addressed.  This exam is often very tedious and takes a long time to conduct.  However, the information that is gained from the exam is invaluable in making the correct the diagnosis.

To compound the issue, EDs often instruct the athlete that they can return to play "in a of couple days."  This is impossible due to current standards of practice requirements.  There needs to be at least 5 days of slow progression before we can think about return to play.  There needs to be a lot of follow up work, and in this case, at least one neurocognitive test performed and another trip to the physician for clearance before this can happen.  Also, none of these steps can be implemented until the athlete is symptom free.

I am hoping beyond all reasonable sanity that we can get the proper people educated about this quickly and end this issue.

This insanity needs to end!

In the latest updates, there have now been 4 young athletes and 1 coach that have passed away this in VERY young season. Three of these deaths have been attributed to heat illnesses and the other two are still awaiting autopsy results. Furthermore, one more athlete in Ohio in critical condition at the moment?

THESE HEAT ILLNESS DEATHS ARE PREVENTABLE!!!!

If this season's deaths don't finally push the envelope far enough to get certified athletic trainers at every school, then I wonder if anything ever will. Recently, a lot of events have occurred to push this issue to the very front of the line. There have been continuous discussions about the dangers that TBIs (see the concussion blog for more information) and heat illnesses present, a recent collegiate lawsuit involving sickle cell trait, and another high school lawsuit over heat illness deaths. I don't want to imagine what else needs to happen for this to finally get done. We need to take this momentum now and push this issue to the front. If we continue to wait, the liability of running an athletics program could become cost prohibitive regardless of the presence of a certified athletic trainer.

Virginia Tech Helmet Study

Early in my hiatus, (meaning late May) a Virginia Tech study was released that rated the various helmets on their efficacy at preventing TBIs.  The response to this study was not surprising, especially from the manufacturers.  The newest Riddell Helmets and a lot of the Schutt models raked highly on the list.  Meanwhile, the older Riddell VSR4 was amongst the worst rated.  Ridell almost immediately recommended that the VSR4 helmet be taken out of use and that they be replaced with the newer models. How noble of Riddell considering this means replacing helmets with new ones.  I certainly support Riddell's decision to push for new helmets, but it doesn't exactly hurt Riddell either.  It looks even better when you consider the very large numbers of VSR4 helmets that are still in use.

The Adams helmets were ranked very low on the scale designed by the researchers.  Since Adams did not have any helmets that really scored well, they decided to attack the methodology of the research and defend their current products.  Once again, this should surprise nobody.

The issue that I have with this whole thing is that helmets were NEVER designed to prevent TBIs.  They were designed to prevent skull fractures.  TBIs occur when the brain slams against the inside of the skull.  Since the brain is suspended in cerebral spinal fluid, no helmet is going to prevent the brain from moving when the head is violently shaken.  The best way I have heard this described is an analogy of a padded raw egg.  It doesn't matter how much padding you put on the egg to prevent the shell from cracking, if you shake the egg hard enough, you will scramble the yolk inside.

While I applaud the manufacturers for their efforts in creating a better helmet, the manufacturers really need to quit telling everybody that their helmet will prevent TBIs.  They won't.  They may be able to decrease the severity or the frequency a little, but until we can figure out how to slow the decelerational forces during collisions, I don't see helmets changing the rate of TBIs very much.

Almost time to start again

With just over two weeks to go until we start our school seasons again, I find myself with mixed emotions.  I always enjoy getting back to see the kids this year and I will get to do it knowing that I have finally finished the Masters degree that I have spent the last four years working on.  (Yes, I took my time.) However, there are other factors this year that are really making it hard to get excited about this year and I have to work a little harder to prevent them from ruining an exciting time of the year.

The big announcement that I alluded to in an earlier post has not been forgotten about.  It is nearly ready.  I am hoping that this new program I have developed will be an outstanding resource for many of my colleagues.

Finally, before I start back into some new material for posts, I figured I would review former posts and clean up anything that has been left hanging.

In March, I posted a review of the concussion testing software for the iPod Touch, iPhone, and iPad platforms.  I had been praising the software but for one big glitch.  I couldn't buy the software to run on my iPod Touch 2nd generation.  I was told I was not the only person having that issue and that the problem was being addressed.  The initial conversations about the problems were encouraging, but quickly fell off and the problem still remains on the iPod Touch.

I have been able to run the program without any issues from my iPad, but I don't really want to carry my iPad onto the sidelines of a Friday night football field.  I simply can't watch the iPad all night and it would grow legs far too easily.  The software also has not been modified from the iPod version to take full advantage of the iPad's graphics capabilities yet.

Because of these reasons, I cannot give the software a full five star rating that I would like.  The software does exactly was it is supposed to do otherwise and is of a high quality, but it is not completely refined yet.  In light of the fact that there are now at least two other competing pieces of software on iTunes, I would think that perfecting your product would be the best option.  Again, I wish there was more to report on this software as well, but unfortunately, after four months of waiting, there has been little done.

A little less active this summer

Over the next couple of months, I will need to focus on finishing my last three classes for my Masters degree.  The fun part of this is the major project that I am working on for the degree will be important for treating injuries with middle and high school students.  More information will be forthcoming as it gets closer to being ready for implementation.