Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997

Lessons for Improving Safety

Robert C. Cantu, MD; Frederick O. Mueller, PhD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 8 - AUGUST 1999

In Brief: The prohibition of 'spearing' in football and the rules regarding water depth and the racing dive in swimming are examples of how data on deaths and catastrophic injuries can be used to help promote the safety of young athletes. Other preventive measures supported by research include anchoring movable soccer goals to prevent tipping, improved training for high school wrestling coaches, increased awareness of pathogenic weight control in wrestling and gymnastics, rules against pushing or checking from behind in ice hockey, protective helmets for batting-practice pitchers in baseball, and barriers around the discus circle in track and field.

Football has been associated with high numbers of injuries (1-4), but those resulting in permanent disability and death declined dramatically after the early 1970s. In fact, there were 36 fatalities in high school and college football in 1968 and none in 1990. Research by the American Football Coaches Association (AFCA) and the National Collegiate Athletic Association (NCAA) contributed to this decline by providing data to support rule changes that promoted safety in football.

Nevertheless, catastrophic injuries and fatalities still occur in high school and college football and many other sports. Research in these areas has continued through the National Center for Catastrophic Sports Injury (National Center) at the University of North Carolina in Chapel Hill, which publishes data regarding catastrophic injuries and deaths in a variety of high school (grades 9 through 12) and college fall, winter, and spring sports. A summary of these data, beginning in fall 1982 and presented here, forms the basis for recommendations to promote the safety of young athletes.

Background

Data collection. The National Center compiles data through the assistance of coaches, athletic trainers, athletic directors, executive officers of state and national athletic organizations, a national newspaper clipping service, and professional associates of the researchers. After notification of a possible catastrophic sports injury, the National Center contacts the injured player's coach, athletic director, or athletic trainer by telephone, personal letter, and questionnaire. The data collected include demographics, the type and mechanism of injury, the sports equipment involved, and the immediate and subsequent medical care. Autopsy reports are used when available. Data collection is supported by the AFCA, the NCAA, and the National Federation of State High School Associations (NFSH).

Definitions. The National Center uses the following definitions in its research: a catastrophic injury is either nonfatal (resulting in permanent severe functional brain or spinal cord disability) or serious (involving transient brain or spinal cord disability). An example of a serious catastrophic injury is a fractured cervical vertebra with no permanent paralysis, whereas such an injury with quadriplegia is a nonfatal catastrophic injury. Fatalities are either direct (resulting directly from performing the specific activities of a sport) or indirect (caused by systemic failure as a result of exertion while participating in a sport). The deaths of Hank Gathers and Reggie Lewis from cardiac arrhythmia are examples of indirect deaths.

Fall Sports Summary

High school. From the fall of 1982 through the fall of 1996, high school fall sports (table 1) resulted in 387 direct fatalities and catastrophic injuries; 374 (97%) were related to football. Indirect fatalities totaled 115, of which 89 (77%) were related to football.

Table 1. Fall Sports Fatalities and Catastrophic and Serious Injuries in US High Schools and Colleges, 1982-1996
Sport	Total Number of Participants (Percent Male/Female)	Total Fatalities (and Rate per 100,000 Participants)		Total Direct Injuries (and Rate per 100,000 Participants)		Total Direct Fatalities and Injuries (and Rate per 100,000 Participants)
		Direct*	Indirect**	Nonfatal***	Serious****
High School
Cross-country	4,063,203 (59/41)	0	10 (0.25)	1 (0.02)	0	1 (0.02)
Football	21,302,466 (99/1)	61 (0.29)	89 (0.42)	147 (0.69)	166 (0.78)	374 (1.76)
Soccer	5,263,083 (64/36)	4 (0.08)	16 (0.30)	2 (0.04)	6 (0.11)	12 (0.23)
Total	30,628,752 (88/12)	65 (0.21)	115 (0.38)	150 (0.49)	172 (0.56)	387 (1.26)
College
Cross-country	262,050 (56/44)	0	1 (0.38)	0	0	0
Football	1,250,000 (100/0)	5 (0.40)	24 (1.92)	21 (1.68)	62 (4.88)	88 (6.96)
Soccer	331,212 (67/33)	0	2 (0.60)	0	1 (0.30)	1 (0.30)
Total	1,843,262 (88/12)	5 (0.27)	27 (1.47)	21 (1.14)	63 (3.42)	89 (4.84)
Overall	32,472,014	70 (0.22)	142 (0.43)	171 (0.53)	235 (0.72)	476 (1.47)
*Caused by performing the activities of a sport. **Caused by systemic failure as a result of exertion while participating in a sport. ***Resulting in permanent severe functional spinal cord disability. ****Resulting in transient functional spinal cord disability.

While football had the highest number of direct fatalities and catastrophic injuries among fall sports, the incidence of each of these per 100,000 football players was still less than 1.

College. During the same period, there were 89 direct fatalities and catastrophic injuries in college sports, and 88 (99%) occurred in football. Twenty-four (89%) of 27 indirect fatalities were football-related. Despite these figures, football-related direct fatalities were still fewer than 1 per 100,000 participants. However, the rate is 1.68 for nonfatal injuries and 4.88 for serious injuries.

Indirect fatality rates per 100,000 athletes were less than 1 in cross-country and soccer but higher in football (0.38, 0.60, and 1.92, respectively).

Winter Sports Summary

High school. High school winter sports (table 2) led to 70 direct deaths and catastrophic injuries; 33 (47%) were related to wrestling and 12 (17%) to gymnastics. Basketball accounted for most of the indirect fatalities, 54 (74%) of 73.

Table 2. Winter Sports Fatalities and Catastrophic and Serious Injuries, US High Schools and Colleges, 1982-1997
Sport	Total Number of Participants (Percent Male/Female)	Total Fatalities (and Rate per 100,000 Participants)		Total Direct Injuries (and Rate per 100,000 Participants)		Total Direct Fatalities and Injuries (and Rate per 100,000 Participants)
		Direct*	Indirect*	Nonfatal*	Serious*
High School
Basketball	13,878,343 (56/44)	0	54 (0.39)	2 (0.01)	5 (0.04)	7 (0.05)
Gymnastics	486,597 (14/86)	1 (0.21)	0	7 (1.44)	4 (0.82)	12 ( 2.46)
Ice hockey	354,135 (98/2)	2 (0.56)	2 (0.56)	4 (1.13)	5 (1.41)	11 (3.11)
Swimming	2,556,181 (46/54)	0	4 (0.16)	4 (0.16)	3 (0.12)	7 (0.27)
Wrestling	3,556,640 (99/1)	2 (0.06)	13 (0.37)	20 (0.56)	11 (0.31)	33 (0.93)
Total	20,831,896 (62/38)	5 (0.02)	73 (0.35)	37 (0.18)	28 (0.13)	70 (0.34)
College
Basketball	367,225 (54/46)	0	12 (3.27)	1 (0.27)	2 (0.54)	3 (0.81)
Gymnastics	34,543 (33/67)	0	0	5 (14.49)	1 (2.90)	6 (17.39)
Ice hockey	60,603 (96/4)	0	1 (1.65)	4 (6.60)	3 (4.95)	7 (11.55)
Swimming	234,566 (50/50)	0	4 (1.70)	1 (0.43)	0	1 (0.43)
Wrestling	108,673 (100/0)	0	0	1 (0.92)	0	1 (0.92)
Total	805,610 (61/39)	0	17 (2.11)	12 (1.49)	6 (0.74)	18 (2.23)
Overall	21,637,506	5 (0.02)	90 (0.42)	49 (0.23)	34 (0.16)	88 (0.41)
*See table 1 footnotes for definitions.

Although wrestling accounted for the greatest number of direct fatalities and nonfatal and serious injuries, the rates were less than 1 in 100,000 participants. Corresponding rates for basketball and swimming were also low (0.05 and 0.27, respectively), while ice hockey and gymnastics had the highest rates (3.11 and 2.46, respectively).

College. College winter sports caused 18 direct fatalities and catastrophic injuries; 7 (39%) of these occurred in ice hockey and 6 (33%) in gymnastics. There were 17 indirect fatalities, and 12 (71%) were basketball related.

College rates of direct fatalities and catastrophic injuries per 100,000 participants ranged from 0.43 in swimming to 17.39 in gymnastics. Indirect fatality rates ranged from 0 in wrestling and gymnastics to 3.27 in basketball.

Spring Sports Summary

High school. From 1983 through 1997, 68 direct deaths and catastrophic injuries were reported in high school spring sports (table 3); 39 (57%) were reported in track and field and 28 (41%) in baseball. Sixteen of 23 direct fatalities (70%) occurred in track and field.

Table 3. Spring Sports Fatalities and Catastrophic and Serious Injuries, US High Schools and Colleges, 1983-1997
Sport	Total Number of Participants (Percent Male/Female)	Total Fatalities (and Rate per 100,000 Participants)		Total Direct Injuries (and Rate per 100,000 Participants)		Total Direct Fatalities and Injuries (and Rate per 100,000 Participants)
		Direct*	Indirect*	Nonfatal*	Serious*
High School
Baseball	6,279,333 (99/1)	6 (0.10)	7 (0.11)	11 (0.18)	11 (0.18)	28 (0.45)
Lacrosse	442,785 (66/34)	1 (0.23)	2 (0.45)	0	0	1 (0.23)
Track and field	12,684,649 (56/44)	16 (0.13)	19 (0.15)	10 (0.08)	13 (0.10)	39 (0.31)
Tennis	3,951,505 (51/49)	0	1 (0.03)	0	0	0
Total	23,358,272 (67/33)	23 (0.10)	29 (0.12)	21 (0.09)	24 (0.10)	68 (0.29)
College
Baseball	319,679 (100/0)	2 (0.63)	2 (0.63)	1 (0.31)	1 (0.31)	4 (1.25)
Lacrosse	121,114 (61/39)	0	1 (0.83)	2 (1.65)	2 (1.65)	4 (3.30)
Track and field	836,624 (60/40)	2 (0.24)	1 (0.12)	2 (0.24)	3 (0.36)	7 (0.84)
Tennis	227,035 (51/49)	0	2 (0.88)	0	0	0
Total	1,504,452 (67/33)	4 (0.27)	6 (0.40)	5 (0.33)	6 (0.40)	15 (1.0)
Overall	24,862,724	27 (0.11)	35 (0.14)	26 (0.10)	30 (0.12)	83 (0.33)
							*See table 1 footnotes for definitions.

The 29 indirect fatalities included 19 (66%) in track and field and 7 (24% )in baseball; four of these involved female track athletes. Direct and indirect fatality and catastrophic injury rates were less than 1 per 100,000 participants in all spring sports.

College. College spring sports had 15 direct fatalities and catastrophic injuries during this period. Track accounted for 7 (47%) of these. The 6 indirect fatalities included 2 each in tennis and baseball and 1 each in track and field and lacrosse.

The rates of direct and indirect fatalities and of nonfatal and serious catastrophic injuries were less than 1 per 100,000 participants in all college spring sports except lacrosse.

Sport-Specific Injury Prevention

These trends provide the background for considering sport-specific and general recommendations to help reduce deaths and catastrophic injuries in scholastic sports. Fatalities and catastrophic injuries in female athletes, especially cheerleaders, deserve particular attention (see "Catastrophic Injuries in Female Athletes: Cheerleading Leads the List," below).

Football. The number of high school and college football fatalities and nonfatal catastrophic injuries decreased dramatically after 1976. Between 1982 and 1997, the numbers fluctuated but remained much lower than in the 1960s and early 1970s (figure 1: not shown), and deaths reached a historic low of zero in 1990. The improvement has been significant, but further steps are needed. These should emphasize the preventive measures that have already been successful:

• Continued enforcement of the ban on initial contact with the head in blocking and tackling, along with coaching in the proper skills of blocking and tackling;
• Ongoing research on helmet safety, continuing the effort that led to the establishment of a helmet standard by the National Operating Committee on Standards for Athletic Equipment; and
• Improved medical care for injured athletes, including hiring of athletic trainers and the writing of emergency plans for catastrophic injuries at all high schools and colleges.

Soccer. Since 1979, 18 children have died and 14 have been seriously injured when movable soccer goals have fallen on them, according to the US Consumer Product Safety Commission (CPSC). Safety measures include anchoring the goals, warning players to avoid climbing on them, and using proper moving, maintenance, and storage techniques. Guidelines for movable soccer goal safety are available from the CPSC at http://www.cpsc.gov.70/00/CPSC_Pubs/Rec_Sfy/4326.txt.

Wrestling. High school and college wrestling caused 34 direct fatalities and catastrophic injuries between 1982 and 1997. Since only 1 of these occurred at the college level, continued research should focus on high school wrestling. High school coaches should be well-versed in the skills of the sport as well as proper conditioning techniques and safety measures; physical education teachers also need training in wrestling skills. Physical education classes should include full-speed wrestling only if sufficient time is available to teach conditioning and skills.

Another important issue is improper weight reduction, which can lead to serious injury or death. During the 1997-1998 season, three college wrestlers died while trying to make weight. Major rule changes resulted, but wrestling coaches need to be aware of the dangers of pathogenic weight-control behaviors.

Gymnastics. Since male and female gymnasts have high injury rates in high school and college, injury mechanisms and preventive measures should be investigated further at both levels. Participation in both high school and college programs has decreased dramatically and will probably continue to, given the growing role of private clubs in competitive gymnastics.

Ice hockey. The absolute number of ice hockey injuries is low, but the fatality and catastrophic injury rates per 100,000 participants are higher than in many other sports. Catastrophic injuries in ice hockey usually occur when an athlete is struck from behind or falls and hits the crown of his or her head on the boards, resulting in fractured cervical vertebrae and paralysis.

Tator et al (5), who did an extensive survey on catastrophic injuries in Canadian ice hockey, recommended the following:

• Enforce current rules and consider new rules against pushing or checking from behind;
• Develop conditioning programs to help players strengthen their neck muscles;
• Teach players about the risk of neck injury; and
• Continue epidemiologic research.

Swimming. All catastrophic injuries in swimming occurred when swimmers struck their head on the pool bottom while doing a racing dive in the shallow end. After the swimming community was made aware of this fact, rules were changed.

Rules to ensure that swimmers have adequate depth when entering the water were created by the NFSH's Swimming and Diving Rules Committee in the early 1990s. If water depth is

• less than 3 1/2 ft, swimmers must start in the water;
• 3 1/2 to 4 ft, swimmers may start from platforms no higher than 18 in. above the water; and
• 4 or more feet, swimmers may start from platforms up to 30 in. above the water.

In addition, starting platforms must be securely attached to the pool deck and wall; if they are not, in-water starts are required.

These rules have reduced direct fatalities and injuries. In fact, no direct fatality or catastrophic injury has occurred in high school swimming for 7 years or in college swimming for 14 years.

Baseball. From 1983 to 1997, high school baseball caused 28 direct fatalities and catastrophic injuries. Most of these injuries occurred during a head-first slide or when a player was struck with a thrown or batted ball. If the head-first slide is to be allowed in high school, coaches must teach players the safest ways to execute this maneuver. Further, batting-practice pitchers should always wear a helmet.

Track and field. From 1983 through 1997, high school track and field resulted in 16 direct fatalities and 23 catastrophic injuries. The pole vault was associated with 13 (81%) of the direct fatalities, 7 (70%) of the 10 permanent injuries, and 6 (46%) of the 13 serious injuries. All of these occurred when the vaulter bounced or landed out of the pit area.

Three deaths in high school pole vaulting occurred in 1983 and prompted measures by the NFSH. Beginning with the 1987 season, the pole vault landing area had to include a common cover or pad extending over all of the pit. In 1991, additional recommendations called for stabilizing the pole-vault standards so they could not fall into the pit, padding the standards, removing all hazards from the pit area, and controlling traffic along the approach.

Being struck by a thrown discus, shot put, or javelin resulted in 10 direct fatalities or catastrophic injuries in high school athletes from 1983 to 1997. Safety precautions during practice and competition must be used to eliminate these needless accidents. One step in this direction was the 1993 NFSH rule requiring that the back and sides of the discus circle be fenced off.

Lacrosse. Only one direct death (and no catastrophic injuries) occurred in high school lacrosse in the 15 years of this study. That fatality occurred when a player struck an opponent with the top of his helmet, an illegal move.

Direct catastrophic injury rates are higher in college lacrosse than in other college spring sports, but the number of lacrosse players is so low that even one injury increases the rate dramatically.

General Prevention Recommendations

Besides these sport-specific considerations, the data collected by the National Center suggest the following general safety recommendations: All athletes should be required to undergo a preparticipation physical examination (see "The Preparticipation Physical Evaluation: Steps Toward Consensus and Uniformity," page 29). All schools should provide teams with a qualified trainer; accessible, written emergency procedures; and excellent and safe facilities and equipment. Coaches should be well trained in physical conditioning, the skills of their sport, and the risks of injury and be able to teach these effectively to young athletes. Game officials must enforce rules strictly, and coaches should support officials' efforts to conduct safe competitions. In addition, continued sports-related research will provide the injury data and analysis necessary to formulate changes in rules, facilities, and equipment that can help prevent tragedies.

References

1. Mueller FO, Schindler RD: Annual Survey of Football Injury Research 1931-1987. Mission, KS, National Collegiate Athletic Association and American Football Coaches Association, 1987
2. Mueller FO, Cantu RC: Catastrophic injuries and fatalities in high school and college sports, fall 1982-spring 1988. Med Sci Sports Exerc 1990;22(6):737-741
3. National Federation of State High School Associations: 1985-1986 Handbook. Kansas City, MO, 1986
4. Schneider RC: Serious and fatal neurosurgical football injuries. Clin Neurosurg 1964;12:226-236
5. Tator CH, Edmonds VE, Lapczak L, et al: Spine injuries in ice hockey players, 1966-1987. Can J Surg 1991;34(1):63-69

Catastrophic Injuries in Female Athletes: Cheerleading Leads the List

From 1982 through 1997, 60 direct fatalities and catastrophic injuries and 25 indirect fatalities occurred among high school and college female athletes, including cheerleaders (table A). Cheerleading, in fact, accounted for 34 (57%) of the direct fatalities and catastrophic injuries. A major factor in these injuries was the change in cheerleading activity, which now involves gymnastic-type stunts such as front and back flips, dives from mini-trampolines, and pyramid building.

Table A. Fatalities and Catastrophic and Serious Injuries in US Female Student- Athletes, 1982-1997
	Direct Fatalities* and Catastrophic Injuries**		Indirect Fatalities***
High School	Cheerleading	18	Basketball	8
	Gymnastics	9	Swimming	5
	Track	3	Track	4
	Swimming	2	Cheerleading	3
	Basketball	2	Soccer	1
	Softball	2	Cross country	1
	Field hockey	2	Volleyball	1
	Volleyball	1
	Total	39		23
College	Cheerleading	16	Tennis	1
	Gymnastics	2	Basketball	1
	Field hockey	1
	Downhill skiing	1
	Lacrosse	1
	Total	21		2
*Caused by performing the activities of a sport. **Resulting in transient or permanent severe functional spinal cord disability. ***Caused by systemic failure as a result of exertion while participating in a sport.

Many state high school associations have responded to these changes and the increase in injuries by banning stunts such as pyramid building and the tossing of cheerleaders. Others have designated cheerleading as a sport. The American Association of Cheerleading Coaches and Advisors implemented a Safety Certification Program, which has certified over 500 coaches and been adopted by some states and some college conferences.

Safety initiatives have resulted in a number of recommendations, including the following:

• Coaches should supervise all practices and be safety certified;
• Cheerleaders should have a preparticipation exam, be trained in gymnastics, spotting, and conditioning, and participate only in stunts that they have mastered;
• Stunts should be limited; eg, pyramids should be limited to two levels and performed on mats;
• Emergency procedures should be written and available; and
• Cheerleaders who have signs of head trauma should receive immediate medical attention and return to cheerleading only with permission from a physician.

Dr Cantu is the chief of the Neurosurgery Service at Emerson Hospital in Concord, Massachusetts. He is the medical director and Dr Mueller the director of the National Center for Catastrophic Sports Injury Research in Chapel Hill, North Carolina. Dr Cantu is a fellow of the American College of Sports Medicine and an editorial board member of The Physician and Sportsmedicine. Address correspondence to Robert C. Cantu, MD, Neurological Surgery Inc, John Cuming Bldg, Suite 820, 131 Old Road to Nine Acre Corner, Concord, MA 01742.