Direct Catastrophic Injuries in Sports
BARRY P. BODEN, M.D.
Catastrophic sports injuries are rare
but tragic events. Catastrophic
injuries are divided into two etiologic categories: direct and indirect. Direct injuries are those resulting
directly from participation in the skills of a sport, such as a collision in
football. Football is associated
with the greatest number of direct catastrophic injuries for all major team
sports in the
INTRODUCTION
In the United States approximately 10%
of all brain injuries and 7% of all new cases of paraplegia and quadriplegia are
related to athletic activities Information on catastrophic injuries in
athletes is collected by the
The CPSC operates a statistically
valid injury and review system known as the National Electronic Injury
Surveillance System (NEISS). The
NEISS estimates are calculated using data from a sample of hospitals that are
representative of emergency departments in the
EPIDEMIOLOGY
For all sports followed by the NCCSIR,
the total direct and indirect incidence of catastrophic injuries is 1 per
100,000 high school athletes and 4 per 100,000 college athletes (2). The combined fatality rate for direct and
indirect injuries in high school is 0.40 for every 100,000 high school athletes
and 1.42 for every 100,000 college participants (2). Football is associated with the greatest
number of direct catastrophic injuries for all major team sports. Pole vault, gymnastics, ice hockey, and
football have the highest incidence of direct catastrophic injuries per 100,000
male participants (2). Cheerleading
is associated with the highest number of direct catastrophic injuries for all
female sports (2).
DIRECT INJURIES
Football
Head Injury
Football is associated with the
highest number of severe head and neck injuries per year for all high school and
college sports (2). Head injuries are the most common direct cause of death
among football players, accounting for 69% (497 of 714 fatalities) of all
football fatalities from 1945 through 1999 (3).
The majority of fatalities were associated with subdural hematomas (86%)
and occurred in high school athletes (75%) during game situations (61%) (3). Most subdural hematomas occur from head to
head collisions with the player being tackled usually suffering the injury (Boden,
unpublished data, head inj). In an
unpublished study over one-third of athletes who sustained a subdural hematoma
were found to be playing with neurologic symptoms from a previous concussion or
head injury (Boden, unpublished data).
The greatest number of brain injury–related fatalities occurred during
the 5-year span from 1965 through 1969.
There has been a dramatic decrease in brain injury-related fatalities
over the subsequent 3 decades. A
major factor in the decline of head injuries since the 1960’s is improvement in
the helmet design and the establishment of safety standards by the National
Operating Committee on Standards for Athletic Equipment (NOCSAE). Improved medical care and technology are
also likely responsible for the decline in fatalities.
Nonfatal head injuries are extremely common in football with nearly 900 concussions being reported in the NFL between 1996 and 2001 (4). New data reveal that the vast majority of injuries occurred to the player being tackled (4). Often the concussed player was hit from the side on the lower half of the face by the crown of an opponent’s helmet. New football helmets with better padding around the ear and jaw are currently being tested (Fig. 1).
Fig. 1
Cervical Injury
While the incidence of head-related fatalities started to decline in the early 1970’s the number of cases of permanent cervical quadriplegia continued to rise. This is likely due to the improved helmets allowed tacklers to strike an opponent using the crown of the head with less fear of self-induced injury. Torg was instrumental in reducing the rate of quadriplegic events by demonstrating that spearing or tackling a player with the top of the head is the major cause of permanent cervical quadriplegia (Fig. 2).
Fig. 2
When the neck is flexed 30 degrees the cervical spine becomes straight
and the forces are transmitted directly to the spinal structures. In 1976, spearing was banned and the rate
of catastrophic cervical injuries dramatically dropped (Fig. 3) (6,7).
Cervical cord neurapraxia
(CCN) is an acute, transient neurologic episode associated with sensory changes
with or without motor weakness or complete paralysis in at least 2 extremities (8,9).
The prevalence has been estimated to be seven per 10,000 football
participants (6). Complete recovery
usually occurs within 10 to 15 minutes but may take longer. Cervical
stenosis is believed to be the primary causative factor predisposing to CCN. The hypothesized mechanism of injury is either hyperflexion or
hyperextention of the neck causing a pincer-type compression injury to the
spinal cord. New data reveals that axial forces to the cervical spinal cord without
spinal column disruption also may cause CCN (Boden, unpublished data-cervical)
An episode of CCN is not
an absolute contraindication to return to football. It is unlikely that athletes who
experience CCN are at risk for permanent neurologic sequelae with return to
play. Rather playing technique in which the
athlete employs the top of the head for tackling is the primary factor resulting
in cervical quadriplegia. The
overall risk of a recurrent CCN episode with return to football is just over 50%
and is correlated with the canal diameter size;
the smaller the canal diameter the greater the risk of recurrence (9).
Athletes with ligamentous instability, neurologic symptoms lasting more than 36
hours, multiple episodes, or MRI evidence of cord defect, cord edema, or minimal
functional reserve should not be allowed to return to contact sports (6).
The Pavlov-Torg ratio was
developed as a method to assess cervical spinal stenosis that eliminates the
need to correct for radiographic magnification (6). The ratio is measured as the diameter of
the spinal canal divided by the anteroposterior width of the vertebral body at
the midpoint on the lateral radiograph.
A ratio of less than 0.8 was proposed as indicating significant spinal stenosis.
The ratio has been found to have a high sensitivity for detecting significant
spinal stenosis but a poor positive predictive value.
In one study 40 of 124 (32%) professional football players had a ratio less than
0.8 (10). Many football players have
large vertebral bodies with normal canal dimensions which may bring the ratio
below 0.8 (11). Therefore, the ratio
is a poor screening tool for athletic participation.
“Functional” spinal stenosis defined as loss of CSF around the spinal
cord as documented by MRI or CT myelography is a more accurate method to
determine spinal stenosis (12).
There is currently no cost-effective tool to screen for athletes at risk for CCN;
however, all athletes who experience an episode of CCN should undergo
appropriate imaging studies to evaluate the risk of recurrence. Preparticipation physicals should
specifically query whether an athlete has had a previous head or neck injury so
that appropriate counseling and return to play decisions can be made.
Pole-Vaulting
Pole vaulting is a unique
sport in that athletes often land from heights ranging from 10 to 20 feet. Pole
vaulting has one of the highest rates of direct, catastrophic injuries per
100,000 participants for all sports monitored by the NCCSIR (13). The vast majority of catastrophic pole
vaulting injuries are head injuries in high school male athletes (13). The overall incidence of catastrophic
pole vault injuries is 2.0 per year, while the incidence of fatalities is 1.0
per year (13). This is a high number
since there are only approximately 25,000 to 50,000 high school pole vaulters
each year.
Three common mechanisms of
injury have been described (13). The most
common mechanism occurs when a pole vaulter lands with his body on the edge of
the landing pad and his head, whips off the pad, striking a surrounding hard
surface such as concrete or asphalt.
The second most common scenario occurs when the vaulter releases the pole
prematurely or does not have enough momentum and lands in the vault or planting
box. The third common mechanism
occurs when the vaulter completely misses the pad and lands directly on the
surrounding hard surface.
In response to the high catastrophic injury rate, both the NCAA and NFHS decided to increase the minimum pole vault landing pad size from 16′ x 12′ to 19′8″ x 16′5″ as of January 2003 (Fig. 4). Fig. 4
Because the majority of injuries are a result of athletes either completely or
partially missing the landing pad, this rule change has the potential to
significantly reduce the number of catastrophic injuries.
The rules committee also proposed enforcing a rule established in 1995 that any
hard or unyielding surfaces such as concrete, metal, wood, or asphalt around the
landing pad must be padded or cushioned.
A new rule has been adopted placing the crossbar farther back over the
landing pad in order to reduce the chance of an athlete landing in the vault or
planting box. A “coach’s box” or
painted square in the middle of the landing pad is also being promoted and
should help train athletes to instinctively land near the center of the landing
pad. Other safety measures include marking the
runway distances so athletes can better gauge their takeoff, and prohibiting the
practice of tapping or assisting the vaulter at takeoff. Pole vaulting is a complicated sport
requiring extensive training and knowledgeable coaching; therefore,
certification by coaches is encouraged.
The value of helmets in reducing head injuries in high school pole
vaulters is controversial. Without conclusive data as to their protective
effect, the use of helmets is optional for athletes at this time.
Cheerleading
Over the past 20 years
cheerleading has evolved into an activity demanding high levels of skill,
athleticism, and complex gymnastics maneuvers.
In 2002 cheerleading was one of the most popular organized sports
activities for women in high school.
Compared with other sports, cheerleading has a low overall incidence of
injuries, but a high risk of catastrophic injuries. At the college and high school levels
cheerleaders account for more than half of the catastrophic injuries that occur
in female athletes (2). College
athletes are more likely to sustain a catastrophic injury than their high school
counterparts, which is likely due to the increased complexity of stunts at the
college level (14). The NCCSIR
reports approximately two direct catastrophic cheerleading injuries per year or
0.6 per 100,000 cheerleaders (14). In
2000 the CPSC estimated a total of 1,258 head injuries and 1,814 neck injuries
in cheerleaders of all ages; 6 were recorded as skull fractures and 76 as
cervical fractures.
The most
common stunts resulting in catastrophic injury are the pyramid with the
cheerleader at the top of the pyramid most frequently injured, or the basket
toss (14). A basket toss is a stunt
where a cheerleader is thrown into the air, often between 6 and 20 feet, by
either three or four tossers (Fig. 5).
Less common mechanisms include advanced floor tumbling routines,
participating on a wet surface, or performing a mount. The majority of injuries occur when an
athlete lands on an indoor hard gym surface (14).
The NFHS and NCAA have attempted to reduce pyramid injuries by limiting the height and complexity of a pyramid, and specifying positions for spotters. Height restrictions on pyramids are limited to 2 levels in high school and 2.5 body lengths in college. The top cheerleaders are required to be supported by one or more individuals (base) who are in direct weight-bearing contact with the performing surface. Spotters must be present for each person extended above shoulder level. The suspended person is not allowed to be inverted (head below horizontal) or to rotate on the dismount. Limiting the total number of cheerleaders in a pyramid as well as the quick transitions between pyramids and other complex stunts may also help reduce injuries.
Safety measures have also been instituted for the basket toss such as limiting the basket toss to 4 throwers, starting the toss from the ground level (no flips), and having one of the throwers behind the top person during the toss. The top person (flyer) is trained to maintain a vertical position and not allow the head to drop backwards out of alignment with the torso or below a horizontal plane with the body. Other preventative measures that may reduce the incidence of basket toss injuries include evaluating the height thrown, using mandatory landing mats for complex stunts, and improving the skills of the spotters. Since several injuries have been reported during rainy weather, all stunts should be restricted when wet conditions are present. Floor tumbling routines can be prevented by proper supervision, progression to complex tumbling only when simple maneuvers are mastered, and spotters as necessary. Minitrampolines, springboards, or any apparatus used to propel a participant have been prohibited since the late 1980’s.
Cheerleading coaches need
to place equal time and attention on the technique and attentiveness of spotters
in practice compared with the athletes’ performing the stunts.
Coaches are encouraged to complete a
safety certification, especially for any teams that perform pyramids, basket
tosses, and/or tumbling. Pyramids
and basket tosses should be limited to experienced cheerleaders who have
mastered all other skills and should not be performed without qualified spotters
or landing mats.
Baseball
Similar to cheerleading,
baseball has a low rate of noncatastrophic injuries, but a relatively high
incidence of catastrophic injuries.
Head injuries constitute the majority of catastrophic injuries. There are approximately 2 direct
catastrophic injuries reported to the NCCSIR per year or 0.5 injuries per
100,000 participants (2,15).
The most common mechanism of catastrophic injury in baseball is a collision
either between fielders or a base runner and a fielder (15).
Proper training is the easiest way to prevent collisions between
fielders. When an outfielder and
infielder are racing for a ball, the outfielder should call off the infielder.
When two infielders are running for a pop-up, the pitcher should determine who
catches the ball. These drills should be reinforced in
practice sessions so they become instinctual in game situations.
Collisions between base runners and fielders often involve the catcher. A typical scenario is a base runner who
dives head-first into a catcher and sustains an axial compression cervical
injury (15). Baseball rules state
that the runner should avoid the fielder who has the right to the base path. Unfortunately this rule is not always
enforced when a base runner is racing toward home plate. Since the speed of head-first sliding has
been shown not to be statistically different from feet-first sliding, the author
believes that the head-first slide needs to be reassessed at the high school and
college levels (16). In Little
League baseball head-first sliding is not allowed at any base.
After collisions, a pitcher hit by a batted ball is the next most common injury
mechanism. The pitcher is vulnerable to injury due
to the proximity to the batter and from being propelled forward, often off
balance, toward the batted ball.
Many coaches and concerned parents perceive a problem from non-wood bats, such
as aluminum bats, and have demanded that regulations be placed on non-wood bats.
Due to their lighter weights, aluminum bats can be swung faster than wood bats
resulting in a higher ball exit velocity (17).
In response to the potential problem, the NCAA and the NFHS now require all high
school and college bats be labeled with a permanent certification mark
indicating that the ball exit speed ratio (BESR) cannot exceed 97 miles per hour
as set by the Baum Hitting Machine (BHM).
Other important, new regulations are that the thickest diameter of the bat
(barrel diameter) is restricted to 2 5/8 inches, and that each bat shall not
weigh more than three ounces less than the length of the bat (e.g. a
34-inch-long bat cannot weigh less than 31 ounces).
While these regulations show promise for reducing the number of injuries, the
author is not aware of any clinical studies confirming their effectiveness.
In addition to regulating the bat, there are several other potential measures to
protect pitchers. Protective screens
(L-screens) are recommended at all times during practice sessions. Unfortunately screens are not practical
during game situations.
Players and coaches should also be educated of the risk to pitchers and have the
option of wearing protective equipment.
Lastly, it has been hypothesized that decreases in the ball hardness and weight
may significantly reduce injury severity to players hit by a batted ball (18). The coefficient of restitution (COR), the
measure of rebound that a ball has off a hard surface, has been adopted as the
testing standard for baseballs. At
the high school and collegiate levels the COR of a baseball cannot exceed 0.555.
Another area of concern in baseball is commotio cordis or arrhythmia often associated with sudden death from low-impact blunt trauma to the chest in subjects with no preexisting cardiac disease (19). The condition occurs most commonly in baseball, but has also been reported in hockey, softball, lacrosse, and other sports. The proposed mechanism is impact just prior to the peak of the T wave on an EKG which induces ventricular fibrillation. Although the rate of rescue from commotio cordis was initially documented to be extremely low, more recent reports indicate that survival is possible with immediate resuscitative measures such as a precordial thump or with use of automatic external defibrillators (20,21). The pediatric population may be more susceptible to commotio cordis because of a thinner layer of soft tissue to the chest wall, increased compliance of the immature rib cage, and slower protective reflexes.
Preventive measures for commotio cordis have focused on chest
protectors and softer core baseballs (22,23).
Unfortunately neither has been shown to reduce the risk of arrhythmias
and may exacerbate the force to the chest.
Preventive strategies are currently limited to teaching youth baseball
players to turn their chest away from a wild pitch, a batted ball, or a thrown
ball. Analysis of the biomechanics
of commotio cordis and the effectiveness of resuscitative measures, especially
with automatic external defibrillators (AED), require further study.
Soccer
Injuries to the head, neck, and face in soccer account for between 5% and 15% of
all injuries. Most head and neck
injuries occur when two players collide, especially when jumping to head the
ball. Fatalities in soccer are usually
associated with either movable goalposts falling on a victim or player impact
with the goal post (24). The CPSC
identified at least 21 deaths over a 16-year period associated with movable
goalposts. Goalpost injuries in soccer can be
prevented by never allowing children to climb on the net or goal framework (Fig.
6). Soccer goalposts should be secured at all
times. During the off-season goals
should either be disassembled or placed in a safe storage area. Goals should be moved only by trained
personnel, and should be used only on flat fields. The use of padded goalposts may also
reduce the incidence of impact injuries with the goalposts (24).
Although catastrophic head injuries are
rare in soccer, the incidence of concussions is relatively high at the elite
college level with approximately one per team per season (25). It has been reported that male,
professional soccer players have a 50% risk of sustaining a concussion over a
10-year span (26). Most concussions
occur as a result of contact with an opposing player, especially head-to-head
collisions, not with the soccer ball (25).
There is no evidence that an isolated episode of heading a soccer ball can cause
any head injury; however, there is controversy over whether repetitive soccer
heading over a prolonged career can lead to neuropsychological deficits.
Until conclusive data shows that repetitive heading of a soccer ball causes no long-term damage, it has been recommended that children use smaller soccer balls to reduce head impact. Leather or water-soaked soccer balls add weight to the balls and should never be used. Proper heading techniques should also be employed: contact on the forehead with the neck muscles contracted. Soccer players should be trained to hit the ball, not to be hit by the ball. A long-term prospective study on the cumulative effects of heading a soccer ball is currently underway.
Wrestling
There are approximately 2 direct
catastrophic wrestling injuries per year at the high school and college levels
or 1 per 100,000 participants (27).
There is a trend toward more direct injuries in the low- and
middle-weight classes. Cervical fractures or major cervical ligament injuries
constitute the majority of direct catastrophic wrestling injuries (27). Most injuries occur in match
competitions, where intense, competitive situations place wrestlers at a higher
risk (27).
The position most
frequently associated with injury is the defensive posture during the takedown
maneuver, followed by the down position (kneeling), and the lying position (27).
There is no clear predominance of any one type of takedown hold that contributes
to wrestling injuries. The athlete is typically injured by one of three
scenarios: 1. The wrestler’s arms are in a hold such that he is unable to
prevent himself from landing on his head when thrown to the mat, 2. The wrestler
attempts a roll but is landed on by the full weight of his opponent, causing a
twisting, usually hyperflexion, neck injury, and 3. The wrestler lands on the
top of his head, sustaining an axial compression force to the cervical spine.
General prevention
strategies for direct catastrophic wrestling injuries rely on the referees and
coaches. Referees should strictly
enforce penalties for slams and gain more awareness of dangerous holds (27).
Stringent penalties for intentional slams or throws are encouraged.
The referee should have a low threshold of tolerance to stop the match
during potentially dangerous situations.
Coaches can prevent serious injuries by emphasizing safe, legal wrestling
techniques such as teaching wrestlers to keep their head up during any takedown
maneuver to prevent axial compression injuries to the cervical spine (27).
Proper rolling techniques, with avoidance of landing on the head, need to be
emphasized in practice sessions.
Ice Hockey
Although the number of catastrophic injuries in ice hockey is low compared with other sports, the incidence per 100,000 participants is high (2). Catastrophic accidents from collisions with goalposts were common before the advent of displaceable goalposts. The majority of recent catastrophic injuries are reported to occur to the cervical spine, especially between levels C-5 and C-7 (28). The most common mechanism of injury is checking from behind and being hurled horizontally into the boards (Fig 7). Contact with the boards typically occurs to the crown of the player’s head subjecting the neck to an axial load (28). Head and facial injuries are also common from collisions, fighting, or being hit by the puck or stick.
Fig. 7 
The frequency and severity of head and neck injuries may be reduced by enforcing
current rules against pushing or checking from behind, padding the boards, and
encouraging the use of helmets and face masks.
In a prospective analysis of facial protection in elite amateur ice
hockey players, it was documented that players wearing no protection were
injured twice as commonly as players wearing partial protection, and nearly
seven times higher than those wearing full protection (29). Eye injuries were nearly five times
greater for players with no facial protection compared with those wearing
partial protection. Although it has
been implicated that head and facial protection leads to an increased risk of
catastrophic spinal injuries, this has never been substantiated (29). Aggressive play and fighting in hockey
should also be discouraged and penalized appropriately. The “heads-up, don’t duck” program
teaches ice hockey players to avoid contact with the top of the head when taking
a check, giving a check, or sliding on the ice.
The Safety Toward Other Players (STOP) Program places the STOP patch on
the back of the jersey of amateur athletes as a visual reminder not to hit an
opponent from behind.
Swimming
Most catastrophic swimming injuries
are related to the racing dive into the shallow end of pools (2). The NFHS and NCAA have implemented rules
to prevent injuries during the racing dive.
At the high school level, swimmers must start the race in the water if
the water depth at the starting end is less than 3.5 ft. If the water depth is 3.5 ft. to less
than 4 ft. at the starting end, the swimmer may start in the water or from the
deck. If the water depth at the
starting end is 4 ft. or more the swimmer may start from a platform up to 30 in.
above the water surface. The NCAA
requires a minimum water depth of 4 ft. at the starting end of the pool. During practice sessions where platforms
may not be available, swimmers are advised to only dive into the deep end of the
pool or to jump into the water feet first.
INDIRECT INJURIES
Indirect or nontraumatic
catastrophic injuries and deaths in athletes have been identified to be
predominantly caused by cardiovascular conditions such as hypertrophic
cardiomyopathy (HCM), coronary artery anomalies, arrhythmogenic right
ventricular dysplasia, myocarditis and dysrhythmias (30). Noncardiac conditions that cause
catastrophic indirect injuries are heat illness, dehydration, exertional
hyponatremia, rhabdomyolysis, status asthmaticus, and electrocution caused by
lightning. It is recommended that a complete personal and family history and
physical examination be performed on all athletes prior to participation. Participation guidelines for different
cardiovascular conditions are summarized in Table 2 (31). Preparticipation physicals should also
specifically query whether an athlete has had a previous head or neck injury so
that appropriate counseling and return to play decisions can be made.
Conclusion
It has been clearly documented that
physical activity has numerous health-related benefits. Nonetheless, there is a low
risk of catastrophic injuries in certain organized sports especially football,
pole-vaulting, ice hockey, and cheerleading.
The cost to the injured athlete and to society can be tremendous. In addition to the decreased quality of
life for the patient, the lifetime cost for a complete quadriplegic individual
can easily surpass $2 million dollars (32).
It has been estimated that the annual aggregate cost of treatment of
spinal cord injuries due to sports in the
ACKNOWLEDGMENTS
The
author wishes to thank Frederick Mueller, Ph.D for sharing data from the NCCSIR.
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FIGURES
Figure 1 New football helmet which provides more protection to
the side of face.
Figure 2 Photograph of athlete spear-tackling with the top of
his head. (Reprinted with permission
from Torg, JS, Guille, JT, Jaffe, S: Current Concepts Review: Injuries to the
cervical spine in American football players. J Bone Joint Surg Am
2002;84:112-122.)
Figure 3 Graph depicting the decline in cervical quadriplegic
events after spear-tackling was banned. (Reprinted with permission from Torg,
JS, Guille, JT, Jaffe, S: Current Concepts Review: Injuries to the cervical
spine in American football players. J Bone Joint Surg Am 2002;84:112-122.)
Figure 4 Footprint of high school landing pad before (A) and
after (B) rule change requiring larger landing pad. Illustration also demonstrates
recommended coach’s box.
Figure 5 Illustration of a basket toss in cheerleading. (Reprinted with permission from Boden,
BP, Tacchetti, R, Mueller, FO: Catastrophic cheerleading injuries. Am J Sports
Med 2003;31:881-888.)
Figure 6 Warning sticker developed by CPSC to prevent children
from climbing on goalposts.
Figure 7 Illustration of ice hockey player checked from behind
(7A) and thrown into boards head
first (7B). (Reprinted with permission from Minkoff,J,
Varlotta, GP, Simonson, BG: Ice Hockey, eds Fu, FH, Stone, DA; Sports Injuries:
Mechanisms, Prevention, Treatment, p. 430, 1994.
Table 1. Sources of Information on
Sport Safety.
AACCA
American Association of Cheerleading Coaches and
Advisors
www.aacca.org
CPSC
Consumer Product Safety Commission
NCAA
The National Collegiate Athletic Association
NCCSIR
National Catastrophic Center Sports Injury Research
NCIPC
National
Centers for Disease Control and Prevention
NFHS
National Federation of
NOCSAE
National Operating Committee on Standards for Athletic Equipment
PVSCB
Pole Vault Safety Certification Board
Table 2. Guidelines on Restriction of Exercise for Cardiovascular Disease
Contraindications to
vigorous exercise
Hypertrophic cardiomyopathy
Idiopathic concentric left ventricular hypertrophy
Marfan’s syndrome
Coronary heart disease
Uncontrolled ventricular arrhythmia’s
Severe valvular heart disease (especially aortic stenosis and pulmonic stenosis)
Coarctation of the aorta
Acute myocarditis
Dilated cardiomyopathy
Congestive heart failure
Congenital anomalies of the coronary arteries
Cyanotic congenital heart disease
Pulmonary hypertension
Right ventricular cardiomyopathy
Ebstein’s anomaly of the tricuspid valve
Idiopathic long Q-T syndrome
Require close monitoring and
possible restriction
Uncontrolled hypertension
Uncontrolled atrial arrhythmia’s
Hemodynamic significant valvular heart disease (aortic insufficiency, mitral
stenosis, mitral
regurgitation)
Adapted from 26th
Table 3. Summary of Safety Measures for Sports
Football
Helmet improvements (NOCSAE standards)
Banning spear-tackling
Assess spinal stenosis before return to play after CCN episode
Pole Vault
Larger landing pad
Soft surrounding surfaces adjacent to landing pad
Moving crossbar closer to landing pad
Cheerleading
Limit height and complexity of pyramids
Maintain vertical position for flyer
Improving the skills of spotters
Baseball
Proper training to prevent collisions
Avoiding head-first sliding
Protecting pitchers (L-screens, bat and ball regulations)
External defibrillators for commotio cordis
Soccer
Goalpost safety (anchor properly, no climbing)
Proper heading technique
Smaller ball at youth level
Wrestling
Strict penalty for intentional slams
Heads-up technique
Ice
Hockey
Avoid checking from behind
Helmet and face masks
Swimming
Adhere to rules on racing dive
The author can be
contacted via eMail at
BBoden@theorthocenter.com
The Orthopaedic Center, P.A.
9711 Medical Center Drive, Suite 201
Rockville, Maryland 20850-3323
