Because American football is a full-contact sport, head injuries are relatively common. According to the San Francisco Spine Institute at
Seton Medical Center in
Daly City, California, up to 1.5 million young men participate in football annually, and there are an estimated 1.2 million football-related injuries per year. An estimated 51% of injuries occur during training sessions, while 49% occur elsewhere. Injuries are nearly 5 times more likely to happen during contact training sessions than in controlled, non-contact sessions. Older players are at the most risk for injuries, while teams with experienced coaches and more assistant coaches are less likely to experience injuries. 50% of injuries occur in the lower extremities (with knee injuries alone counting for roughly 36% of all injuries) and 30% occur in the upper extremities. According to the NFL Physicians Society, the most common injuries in football are "concussions, blunt injuries to the chest such as
cardiac contusions,
pulmonary contusions,
broken ribs,
abdominal injuries,
splenic lacerations and kidney injuries." Concussions are particularly concerning, as repeated concussions may increase a person's risk in later life for
chronic traumatic encephalopathy (CTE) and mental health issues such as
dementia,
Parkinson's disease, and
depression. Concussions are often caused by
helmet-to-helmet collisions, impact against the ground or other players' knees, and upper-body contact between opposing players. However, helmets have prevented more serious injuries such as
skull fractures.
Cervical spine injuries can be catastrophic, but have sharply declined since the mid-1970s due to rule changes and improved workout regimes, equipment, and coaching.
Steroid use has been linked to an increased risk for
musculoskeletal injuries among players.
Human growth hormone (HGH) is used by some players to improve performance, recover from injuries, decrease aging, and to lose weight. Although none of these uses are scientifically proven or legal, HGH places users at risk for adverse side effects such as onset of
diabetes and negatively impacting joints and organs such as the
heart. However, there have been no studies of HGH use or the baseline levels of the hormone in NFL athletes. NFL players are routinely subject to drug tests in accordance with the NFL's two substance policies. Players found using performance-enhancing drugs, including
anabolic steroids, can face suspension and other penalties. As of 2014, the league does not test for HGH use among players.
National Football League An injury report section is common in the sports sections of American
newspapers, detailing injuries for each team and the amount of time each injured player is expected to be out. The injury report was created to prevent
gamblers from gaining inside information about injuries from players, and as a result, NFL teams must report on the status of injured players on a set schedule during the season. The standard severity descriptions are "out" (will not play in the upcoming game); "doubtful" (25% chance of playing); "questionable" (50% chance of playing); or "probable" (75% chance of playing). Teams have been known to downplay, exaggerate or overly detail their teams' injuries in an attempt to confuse or mislead upcoming opponents. Injured players may be placed on one of several injured lists, including the
Physically Unable to Perform (PUP) list. If a player is injured in an event outside of a game or team practice, or during collegiate practice prior to being drafted, he is eligible for the
Nonfootball Injury list. Players who have sustained major injuries and are not expected to play for the rest of the season may be placed on the
Injured Reserve (IR) list. These players do not count towards the teams' roster limit. Aside from concussions, orthopedic injuries are among the most common in the National Football League. These injuries consist of trauma such as tears in the achilles, anterior cruciate ligament (ACL), and patellar tendon. A study was done by the
Feinberg School of Medicine and
Northwestern University, where they studied the "return to play rate" (RTP) for given orthopedic procedures done based on a given injury. They found that out of 559 NFL players, the most difficult injuries for NFL players to return to play in were patellar tendon tears (50.0 %) and achilles tears (72.5%).
College and high school football According to the College Football Assistance Fund, over 20,000 injuries occur from college football each year. The
National Collegiate Athletic Association (NCAA) maintains an injury list similar to that used by the NFL – injured players are listed as "Out", "Doubtful", "Questionable", or "Probable", but suspended players are also included on the list. College players are limited to four years of eligibility, but can receive a
medical redshirt that lets them play another year if they have suffered a season-ending injury and have not played in more than 30% of the season's games.
Brain injury In 1994, the NFL established the Mild Traumatic Brain Injury Committee (MTBI), which was later replaced by the Head, Neck and Spine Committee, to study concussions and brain injuries in professional football players. The committee and its leadership, including Ira Casson and Elliot Pellman, were criticized by former players for stating that there is not enough research to determine if
concussions lead to permanent
brain injury. Pellman, who served as chairman of the committee from 1994 to 2007, received a large amount of criticism because he did not have a background in
neurology and the research he published on brain injuries disagreed with the findings of independent scientists. In 2009, an NFL-commissioned report showed increased incidence of diagnosis of
memory loss and
dementia among retired professional football players when compared to the general population. The study also indicated that these symptoms were related to the effects of concussions. However, the NFL and the report's own researchers questioned the reliability of some of the data-gathering methods employed by the study, including the fact that the study was conducted by phone. The same year, the committee acknowledged for the first time that concussions can lead to long-term brain injuries. A Congressional hearing in October 2009, as well as pressure from the
National Football League Players Association (NFLPA), led to an overhaul of the concussion policy in November and December of that year. NFL commissioner
Roger Goodell addressed the issue of head injuries in professional football during a talk held on November 15, 2012, at the
Harvard School of Public Health. In the talk, he highlighted the NFL's efforts to reduce head injuries by enacting measures such as penalizing hits to the head, better assessing concussions on the sideline, and removing players from the game after they have been diagnosed or suspected of having sustained a concussion. He also discussed the need for increased research on brain injuries and long-term disorders, and called for a culture change in the league, saying that players need to be more willing to acknowledge their injuries to medical staff. In September 2012 the league pledged a $30 million donation to the
National Institutes of Health to research the connection between brain injuries and long-term mental health issues. Beginning in 2012 the NFL was the subject of several lawsuits initiated by former players who alleged that the league withheld information and misled players about the potential long-term impacts of head injuries. Six of the lawsuits were approved to be tried together. Concussions are also an issue in non-professional football. In a 2010 study by
Purdue University and
Indiana University, an estimated 43,000 to 67,000 football players suffer a concussion every season. However, because many injuries go unreported, the true number may exceed 100,000. The study, "Detected Cognitive Impairment in High School Football Players Without Clinically Diagnosed Concussion", was published in 2013 in the
Journal of Neurotrauma and observed 21 high school players throughout a season; it determined that even players who would not be diagnosed with a concussion based on their symptoms can display notable impairments via MRIs and verbal or cognitive testing, indicating that the current tests used on the sideline to assess concussions may not be adequate. A 2013 study by the
National Academy of Sciences found that concussion rates in college football exceed those in any other sport, and that high school players have twice the risk of sustaining a concussion as collegiate players. The study found that, as reported by athletic trainers, college football players sustain 6.3 concussions for every 10,000 athletic exposures (meaning an individual practice or game), and the rate for high school football players is 11.2. The high school concussion figure is nearly double that of the next-highest sport,
lacrosse. The study, funded by a $75,000 donation from the NFL to the Centers for Disease Control Foundation, also found that there is no evidence that newer helmet technology decreases the risk for concussions. According to 2017 study on brains of deceased gridiron football players, 99% of tested brains of
NFL players, 88% of
CFL players, 64% of semi-professional players, 91% of
college football players, and 21% of
high school football players had various stages of
CTE.
Catastrophic injuries and fatalities Catastrophic injuries are not common in American football. According to the National Center for Catastrophic Sport Injury Research, there were 468 non-fatal injuries resulting in permanent neurological damage across all high school sports in the United States from 1982 to 2011. In football, catastrophic injuries are rare but are devastating when they occur. The rate of catastrophic head injuries has remained low since the introduction of the modern football helmet in the 1970s, but rates of injury are much higher at the high school level than the college level. A 2007 study found that, in high school and college football, there are an average of 7.23 catastrophic head injuries per year: there were 0.67 injuries per 100,000 high school players and 0.21 injuries per 100,000 college players. Over a 13-year period from September 1989 to June 2002, there were 94 players who sustained catastrophic head injuries—8 of these players died as a result of the injury, 46 sustained permanent neurological damage, and 36 made a full recovery. 56% of these players had a history of head injuries, 71% of them occurring in the same season as their catastrophic injury, and most of the catastrophic injuries resulted from being tackled or making a tackle. The study recommended that players exhibiting neurological symptoms should be strongly discouraged from returning to play. The medical costs for catastrophic injuries can be extremely high—a 2011 estimate from the National Spinal Cord Injury Statistical Center notes that first-year costs of someone who has high tetraplegia, an injury that causes partial or full loss of use in all limbs, is
USD $1,044,097, with subsequent years costing $181,328. Many high schools across the United States require students to have an insurance policy, while others offer supplementary insurance to help offset the cost; some schools also request that
boosters help families pay for these policies. Fatalities in football are rare. A 2013 study of high school and college football players split fatalities into two types: direct fatalities, defined as those caused by "trauma from participation in a sport resulting in a brain injury, cervical fracture, or intra-abdominal injury" and indirect fatalities, defined as those resulting from external factors such as "
cardiac failure,
heat illness,
sickle cell trait [SCT],
asthma, or
pulmonary embolism". The study found that, on average, there are 4 direct fatalities and 8.2 indirect fatalities among high school and college players per year, making indirect fatalities more than twice as common as direct fatalities. ==Effects on post-career life==