Pediatrics Group Declines To Endorse Outright Ban On Tackle Football


Brooke de Lench, Lindsey Barton Straus

On October 18, 2015 the American Academy of Pediatrics issued a much-awaited Policy Statement on Tackling in Youth Football, joining those calling for limits in the number of contact practices, but declining to make a clear recommendation in favor of delaying the age at which tackling is introduced. The AAP likewise refused to support those calling for an outright ban on tackling in football for athletes below age 18, unwilling to recommend at this time such a fundamental change in the way the game is played.

Writing for the AAP's Council on Sports Medicine and Fitness, William P. Meehan, III, Director of The Micheli Center for Sports Injury Prevention at Boston Children's Hospital, MomsTEAM concussion expert emeritus, and featured in MomsTEAM's PBS documentary, The Smartest Team: Making High School Football Saferand co-lead author, Gregory Landry, a professor of pediatric and adolescent primary care sports medicine at the University of Wisconsin School of Medicine and Public Health, recognized that head and neck injuries in football have been a topic of "intense interest recently in both the public media and the medical literature."

They acknowledged that safety concerns - especially about the risk of concussions and catastrophic injuries - have led to a drop in football participation, while recognizing that the potential for adverse long-term health consequences from multiple concussions and repeated subconcussive blows to the head had prompted calls for limits on the number of full-contact practices, a delay in the age in which tackling is introduced, and even for an outright ban on football at below college.

Noting that the effect of subconcussive blows on long-term cognitive function, the incidence of chronic traumatic encephalopathy (CTE), and other health outcomes remains "unclear," and that further research was needed, the group nevertheless endorsed efforts to reduce the number of impacts to the head in football because, "Repetitive trauma to the head is of no clear benefit to the game of football or the health of football players." 

The AAP saw in a delay in the age at which tackling is introduced both benefits (a likely decrease in risk of injury) and potential risks (once tackling was introduced, athletes lacking tackling experience might be exposed to an increased risk of injury). The group therefore said no "informed recommendation" could be made until further investigation into the effects of delaying the introduction of tackling until a certain age could be made.  

If organizations decided to delay the introduction of tackling, the statement said such change would need to be accompanied by a concentrated effort by coaches to teach proper tackling technique as well as the teaching of skills necessary to evade tackles and absorb hits.  "It is unclear," said the statement, "whether such techniques and the neuromuscular control necessary for performing them can be adequately learned in the absence of contact."  (For a 2011 blog post by MomsTEAM's Brooke de Lench discussing the two sides of this debate, click here)

Outright tackle ban: a bridge too far 

Finally, the group was completely unwilling to go so far as to endorse removing tackling from football at the youth and high school level altogether.

Despite recognizing that doing so would likely lead to fewer injuries of every kind (e.g. overall injuries, severe injuries, catastrophic injuries, and concussions), the AAP decided not to endorse a complete ban on tackle football, largely because removing tackling from the game would lead to a "fundamental change in the way the game is played."  

The group thus left it to "participants" to "decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling."

Injuries associated with tackling 

Reviewing the medical literature, the AAP found that most injuries in tackle football were "minor" (e.g. contusions, strains to muscles and tendons, and ligament sprains), with with head and neck injuries accounting for a "relatively small proportion" of overall injuries.  

Available data suggested that both the overall incidence and severity of injuries increased  with age, with injuries at the youth level lower than for older players. Some studies suggested that the incidence of overall injuries in football were similar to other sports, said Meehan and Landry, but the incidence of serious injuries "appears to be greater" for football than any other team sport.  

Tackling accounted for a higher proportion of injuries resulting from contact, and tackling in particular, the most common player activity at the time of injury and at the time of severe injury.  

Although they characterized the risk of catastrophic injuries to the head and neck in football as "low", Meehan and Landry admitted  hat it was likely higher in football than in other sports and appeared to increase with age. The risk of catastrophic injury, such as quadriplegia, was found to be comparable to that in gymnastics and lower than in ice hockey; lower for youth players than high school players, and lower for high school players than those playing college football.

Severe and catastrophic injuries, particularly to the head and neck, including paralysis and brain bleeds, were associated with spear tackling, or leading with the crown of the helmeted head while tackling by defensive players. Such practices, while banned almost forty years ago "continue to be the predominant mechanism of injury causing quadriplegia," the group said, leading it to call for improved teaching of proper tackling technique and better enforcement of existing rules prohibiting the use of the helmet in tackling.

As for the risk in tackle football of second impact syndrome, the statement said that, while often associated with football, it has been observed in other sports such as ice hockey, boxing, and skiing.  Given its rarity, its incidence in football was, said the group, unknown. 

Eight recommendations

After reviewing the available medical literature, the AAP ended up making eight recommendations regarding tackling in youth football:

1. Strictly enforce rules against spearing. A significant number of concussions and catastrophic injuries occur because of improper and illegal contact, such as spear tackling. The AAP statement bemoaned what it said was a "culture of tolerance" of head first, illegal hits, and called for a change in that culture to one of "zero tolerance" emphasizing protecting the heads of the tackler and players being tackled. The statement calls for consideration of "stronger sanctions" for contact to the head, especially of a defenseless player, up to and including expulsion from the game.

2. Weigh risks against benefits in participation decision. Because removal of tackling from football would lead to a fundamental change in the way the game is played, the group said it was up to "participants" in football to decide whether the potential health risks of sustaining injuries are outweighed by the recreational benefits associated with proper tackling (although the statement does not enumerate what those benefits are, and suggesting that the athletes themselves, not their parents, to decide whether to play tackle football was curious, to say the least)(For two blog posts by MomsTEAM's Brooke de Lench saying that it was ultimately up to parents to decide whether to allow their child to play tackle football, click here and here) 

3. Offer non-contact forms of football. Nontackling leagues for young athletes who enjoy the game of football and want to be physically active but do not want to be exposed to the collisions currently associated with the game, says the AAP, should be considered by football leagues and organizations. This would allow athletes to choose to participate in football without tackling and its associated risks, even after the age at which tackling is introduced, the statement said (Note, however, that data comparing injury rates between tackle and flag football, presented at the 2015 American Academy of Pediatrics National Conference and Exhibition suggests that injury rates in flag football may actually be higher) 

4. Limit contact practices. Although stating that the effect of repetitive head impacts (RHI) on long-term cognitive function, incidence of CTE, and other health outcomes remained "unclear," and that further research is needed, Meehan and Landry saw "no clear benefit" in RHI to the game of football or the health of football players. To reduce the risk of any long-term health problems from RHI,  the AAP thus endorsed efforts being made at the high school and youth level to reduce the number of impacts to the head that occur during participation in football (which emerging research, including a paper presented at the 2015 AAP National Conference and Exhibition and a 2015 study in the Orthopaedic Journal of Sports Medicine suggests can reduce the risk of concussion)

5. Consider delay the age at which tackling is introduced.  Doing so, said the authors, would likely decrease the risk of injuries for the age levels at which tackling would be prohibited, but, once introduced, might expose athletes with no previous experience with tackling to collisions for the first time at an age at which speeds are faster, collision forces are greater, and injury risk is higher. Because such lack of experience with tackling and being tackled may lead to an increase in the number and severity of injuries once tackling is introduced, the AAP said that if rules banning tackling below a certain age were adopted, "they must be accompanied by coaches offering instruction in proper tackling technique as well as the teaching of the skills necessary to evade tackles and absorb being tackled."  


6. Promote neck strengthening.  Although recognizing that "definitive scientific evidence is lacking," the AAP endorsed strengthening of the cervical musculature as a way of reducing the risk of concussions in football by limiting the acceleration of the head after impact. Physical therapists, athletic trainers, or strength and conditioning specialists, with expertise in the strengthening and conditioning of pediatric athletes, are best qualified to help young football players achieve the neck strength that will help prevent injuries.


7. Staff games and practices with athletic trainers. Given their importance in the medical management of sport-related injuries and preliminary evidence suggesting an association between athletic trainers presence and a decreased incidence of sport-related injuries, efforts should be made by football teams to have athletic trainers at the sidelines during organized football games and practices.