The NFL’s Battle with Concussions and Severe Injuries

The NFL’s Battle with Concussions and Severe Injuries
The NFL’s Battle with Concussions and Severe Injuries
Photo: USA Today Sports Images

by Scott Kacsmar

The Tom Brady injury scare took the NFL news feed by storm on Wednesday. Fortunately for New England, it was nothing serious. Not as fortunate were the dozens of players who already suffered a significant injury, including Jeremy Maclin, Bryan Bulaga, Dennis Pitta, Michael Crabtree, Percy Harvin, Danario Alexander, Dan Koppen, Victor Butler, Jared Veldheer and Plaxico Burress. At least 55 players have had a season-ending injury already. (Actually, that number has likely increased by the time you read this.)

Did I mention we only just kicked off the second full week of preseason games?

Based on a research study by Dr. Jesse David of Edgeworth Economics on data from the NFL Players Association, there were 265 concussions in the 2012 season (from training camp through the Super Bowl) after 266 in 2011. Is one fewer concussion progress? The total was 270 in 2010.

Injury prevention, especially in regards to head injuries, has never been a bigger issue in the NFL than it is today. The league has taken new measures to ensure safety is the top priority, as a failure to do so could result in catastrophic losses for the business through lawsuits. Past transgressions have already resulted in over 4,500 former players suing the league for not doing enough to prevent head injuries.

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Clinton Portis is the latest to join the suit. He estimates he sustained 10 or more concussions in his career. The fact that many went undiagnosed is the major problem the NFL has to fix going forward. Limiting the number of concussions should not be the first goal as proper treatment for all concussions becomes the real objective.

Concussions and Kickoffs

A mild traumatic brain injury (MTBI), also known as a concussion, may be the key element of study for player injuries right now. The NFL’s rule change on moving kickoffs to the 35-yard line in 2011 was expected to cut back on the number, but we see overall that concussions are fairly consistent for the last three seasons, which is the time in which reporting them has become more common.

There’s no denying we have fewer concussions on kickoffs now, as the total went from 35 in 2010 to 20 in 2011, but this is more about the rise in touchbacks and lack of returns. While a player can still get a concussion on a touchback, it’s usually not going to provide as much violent contact as a real return.

Here is the data on kickoffs related to touchbacks and concussions going back to 2004. Please note the percentages are rough estimates as the concussions include the preseason and playoffs while the kickoff data is for the regular season only in each season. I should have realized this in a similar review I wrote a year ago. However, since the number of kickoffs have remained fairly consistent over time, using this estimate for each season is still reasonable.

NFL Kickoff Data: Touchbacks (TB) & Concussions (MTBIs)
Year Kickoffs Returns Pct. TB Pct. MTBIs Pct.
2004 2,453 2,155 87.9% 208 8.5% 30 1.39%
2005 2,439 2,137 87.6% 218 8.9% 36 1.68%
2006 2,427 2,037 83.9% 316 13.0% 27 1.33%
2007 2,515 2,074 82.5% 311 12.4% 34 1.64%
2008 2,576 2,114 82.1% 371 14.4% 34 1.61%
2009 2,484 2,004 80.7% 401 16.1% 30 1.50%
2010 2,539 2,033 80.1% 416 16.4% 35 1.72%
2011 2,572 1,375 53.5% 1,120 43.5% 20 1.45%
2012 2,620 1,395 53.2% 1,156 44.1% 26 1.86%

The 26 MTBIs on kickoffs gave last year the highest (estimated) rate per kick return since 2004. The rule change does not make for a safer kickoff, it just means fewer will be returned. There have been over 1,100 touchbacks in each of the last two seasons.

Some of the past concussion rates wre no doubt misleadingly low as players were less likely to have reported a concussion years ago. We will need more years of data with the new kickoff rule to study this better.

We did not receive data on which 2012 kickoffs included the 26 MTBIs. Seven happened in the preseason (including practices) and two were in the playoffs. Without the proper data to see which types of kickoffs resulted in the concussions, we will only speculate on the rise from 2011.

One could theorize kickoffs may be more dangerous now since some return specialists need these opportunities to earn their roster spot. It's a fair speculation to think they may be more willing to return a kick that’s eight yards deep in the end zone. When you do that, you better get to the 20 or a special teams coach will be in your ear for a bad decision. So what we have is a player running harder than ever to get out of his end zone and make something happen.

It is no coincidence the 2011 season had the highest kick return average (23.8) in NFL history and the 2012 season ranked third (23.6). (Stats at Pro-Football-Reference.

Kickoffs aside, the overall number of concussions remains in that 265-270 range. What has changed is the time missed from them. In 2012, players missed an average of 16 days after a MTBI. The average was as small as four days in the medieval times of 2005.

Clearly concussions are handled with more care now. Rookie wide receiver Ryan Swope recently retired after suffering the fifth concussion of his football career in Arizona’s OTAs. Not many players in the past would have ended their dream before it began, but concussions aren't meant to be taken lightly. Knees and triceps will heal, but the brain is serious business. The league and many retired players are learning that the hard way.

The Rise of Severe Injuries

Speaking of serious injuries, in 2012 players suffered 1,496 severe injuries -- measured by missing at least eight days or requiring surgery. That is the highest total in the study, which goes back to 2004, and the frequency of severe injuries only continues to rise.

Total injuries went down from a whopping 4,493 in 2011 to 3,126 in 2012. The big reason for 2011’s bloated number was the 3,113 minor injuries (fewer than eight days missed). With stricter rules in reporting injuries, teams followed suit. Fast forward to the next season and it’s only natural to see some slacking off in that department as minor injuries fell to 1,630 in 2012.

But the perplexing part here is trying to figure out why severe injuries continue to rise. Yes, the "bigger, faster, stronger" principle could be part of it as players get more freakishly athletic as time goes by. It may go deeper than just that though.

"Treatment is more extensive," said Dr. David, who has analyzed injury information for three seasons. "So what appears 'severe' (longer time out of the game; more surgery) is actually just longer treatment for injuries that actually are not objectively worse than they used to be." However, the number of ACL injuries, often a season-ending injury, is increasing.

The NFL would like to believe the game has been made safer through changes to equipment and rules and that the increase in severe injuries is the result of better treatment. So far, data analysis does not support that, but more changes are coming to the league.

New Protocol Should Lead to More Reported Concussions

From the Saints’ Bountygate scandal to the suicide of retired star Junior Seau, whose brain had chronic traumatic encephalopathy (CTE), the NFL certainly had to fix its image problem when it comes to knockout shots and headhunting.

The league is clearly not taking risks when it comes to safety with the head in focus. While players are now required to wear thigh and knee pads, a new type of Bane-like face mask that was gaining popularity with defenders like Robert Mathis was quickly banned this summer. NFL V.P. of officiating Dean Blandino cited some problems with the face mask: one was that it may actually encourage players to lead with their heads. Of course the NFL implemented the "Crown Rule" this offseason to further restrict players from using their helmet as a weapon. We also know now that when the helmet comes off, the play is whistled dead immediately.

The message is clear: Keep your heads up, players. However, we also know the action is played at rapid speed on the field and impact between these players will continue to cause injuries. Sometimes the head shot is unavoidable when an offensive player ducks at the incoming defender at the very last second before contact.

While making the number of concussions shrink would look good for the NFL, treating each case with a standardized procedure is the best approach. This season is the first time the league will use an independent neurotrama specialist instead of a team’s medical staff to oversee concussion protocol. So if Robert Griffin is feeling woozy after a hit this season, no one can blame coach Mike Shanahan for throwing him back to the wolves to serve Washington’s best interest.

Getting honest answers from players fighting to keep a job will be the next challenge. For example, Alex Smth’s tenure in San Francisco effectively came to an end after a concussion paved the way for Colin Kaepernick to lead the team to the Super Bowl. Think there may be some regret there by Smith, leaving one of the NFL’s most talented teams to head to the Chiefs?

There was a telling scene in the first episode of HBO’s Hard Knocks with the Cincinnati Bengals. Trainer Paul Sparling told wide receiver Marvin Jones he was done for the day of practice after getting his bell rung. As much as Jones pleaded he was good to go, Sparling told him he could not go back on the field because of the new NFL rules.

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How many players, especially those barely hanging onto a roster spot, will admit to any symptoms now? That’s why it will be important for players sustaining big hits to be checked as soon as possible by the independent specialist.

More concussion checks should undoubtedly lead to more recorded concussions. If more minor concussions are found, then that could decrease the average time missed from them. Hopefully catching things earlier will help prevent future problems.

This is just my personal opinion, but I always believed that NHL star Sidney Crosby had such a long recovery from "a concussion" because he suffered one in the 2011 Winter Classic that went undiagnosed and quickly picked up another concussion after crashing headfirst into the boards just four days later. Crosby would not play again for over 10 months.

That’s one of the scariest things about concussions that result from contact sports. Once you have one, you are more susceptible to the next one, which will take even longer to recover from. So let’s nip it in the bud.

Thus far it has been a rough preseason for severe injuries. The 2013 numbers could be frightening at first glance, but if concussions go up, just remember that’s not necessarily a bad thing assuming the players are getting better treatment.

However, the players cannot have it both ways. They cannot lie about symptoms like in the past and still want to sue the league for not having their best interest. If a player’s feeling dizzy, he should get checked out ASAP. That may not be the manliest thing to do in a sport that promotes grit and bravado, but if the goal is to play as long as possible, then it’s the only smart thing to do.

If a teammate cannot understand that, then maybe he’s already taken too many unchecked blows to the head.


29 comments, Last at 18 Sep 2013, 9:15pm

#1 by Shattenjager // Aug 16, 2013 - 3:46pm

Crosby most likely took so long recovering at least in part because he was being treated by a "neurological chiropractor" (i.e., a crackpot):

That's an under-reported major problem with sports injuries that will probably never receive any real attention: the pervasive use and allowance of "alternative" treatments in lieu of actual medicine.

Points: 0

#8 by Noahrk // Aug 16, 2013 - 8:13pm

As someone who hasn't seen a "straight" doctor, dentists excepted, in 20 years, I disagree. The scientific method is a fine thing and it has given us great (and also terrible) things, but it's not the only way to get results or to obtain knowledge. Not by a longshot.

The man with no sig

Points: 0

#11 by Noahrk // Aug 16, 2013 - 11:05pm

Not at all. I was thinking about inner states. That's why we were so cruel to animals once upon a time, we couldn't prove scientifically they had feelings or even that they could feel pain. Science didn't change, people changed: we developed more empathy. That is, a direct awareness -or knowledge-, of other beings' inner states. Very unscientific.

But what about health? Can health be proven? That is, is it a simple measurable quantity? Is Santonio Holmes truly not a 100% or is he faking it?

The funny thing is that since we can't get a fully rational grasp of these issues, we'll quickly forget about them and fall back to our science/not science paradigm. But reality is way more complex than that.

The man with no sig

Points: 0

#13 by RickD // Aug 16, 2013 - 11:45pm

Don't get too caught up on concepts of "proof." Proof has almost nothing to do with modern science. Science is about cataloguing observations and trying to figure out what theory fits best to what we see. It's not about proof.

A lot of older notions about what animals think or represent nothing more than the biases of humans. There's no scientific theory of thought that could state that animals neither think nor feel. And it's fairly easy to demonstrate that an animal can feel pain. There's no reason to think feelings or pain are higher brain functions present only in humans. Even the notion that humans are the only animals that use language has been under attack (I suspect it's actually been debunked but don't have the time to check right now.)

Knowledge based on observations isn't "unscientific". I don't know why you would think that. Quite the opposite. Any observation that can be described in an objective fashion is fit food for science.

The problem with "non-traditional" approaches to medicine is not that they cannot be judged scientifically, it's that they can be judged scientifically and most of them fail to show anything beyond a placebo effect.

OK, that's my over-generalization for the night.

Points: 0

#21 by Noahrk // Aug 17, 2013 - 2:29pm

I agree. The problem begins when not everybody shares the same experiences and observations. It creates a divide between those who have and those who haven't had them, with the latter often calling the first unscientific in whatever conclusions they reach.

With traditional medicine, being based on reason, you can have studies with total control over all variables. There are several problems with testing alternative medicine. Who are acceptable practitioners, for one thing? The fact that investigators are probably biased doesn't help matters. Even worse, I have to wonder if a respectable investigator, having found evidence in favor of some such practice, would have the courage to try and publish. And what major publication have the courage to actually publish him? With livelihoods and reputations at stake?

I trust science to test and study traditional medicine. For alternative medicine, I trust experience.

The man with no sig

Points: 0

#24 by akn // Aug 17, 2013 - 2:55pm

being based on reason

That's certainly a good place to start compared to any other alternative I can think of.

you can have studies with total control over all variables

As someone involved in clinical research, I can assure you that total control over all variables is never achieved. You mitigate and compensate for what you can't control, and do the best with the data you get.

Who are acceptable practitioners, for one thing?

That requires a licensing apparatus, and a licensing apparatus requires objective validation and regulation. As long as there is a lack of good evidence for alternative therapies, there will be no such thing as "acceptable practitioners."

The fact that investigators are probably biased doesn't help matters. Even worse, I have to wonder if a respectable investigator, having found evidence in favor of some such practice, would have the courage to try and publish. And what major publication have the courage to actually publish him? With livelihoods and reputations at stake?

Where is your evidence for bias? We treat patients on an evidence-based approach, not on personal opinions of what should work. If a well-designed, large-scale randomized controlled trial that withstood peer-reviewed scrutiny objectively showed the significant benefits of homeopathic therapy, I would start prescribing them tomorrow. Nature or the New England Journal of Medicine would jump at the opportunity to publish such a revolutionary result, and the researchers of said study would probably be candidates for the Nobel in Medicine.

Again, as long as the evidence was there, which has always been the problem with alternative approaches.

Points: 0

#15 by Shattenjager // Aug 17, 2013 - 1:36am

My favorite comedian, Tim Minchin, has a truly brilliant beat poem called "Storm" that includes:

"By definition”, I begin
“Alternative Medicine”, I continue
“Has either not been proved to work,
Or been proved not to work.
You know what they call “alternative medicine”
That's been proved to work?

Points: 0

#17 by Theo // Aug 17, 2013 - 11:13am

I love to hear your arguments for other methods so I can field test them myself, peer-review them and improve them and help you to make it ready for publication - with your agreement.

Points: 0

#23 by Noahrk // Aug 17, 2013 - 2:38pm

Well, if you're interested in chiropractors, I can point you to two, in particular, who work in the same office and who have treated me and other members of my family, as well as friends, with great success. One of them in particular has such a reputation that he's booked for months in advance. They diagnose with x-rays, too, so that's good for documentation. Trouble is, they're in Mexico!

The man with no sig

Points: 0

#9 by akn // Aug 16, 2013 - 9:05pm

I'm no fan of chiropractors or any other alternative approaches, but to be fair, they are mostly harmless, except when patients go to them in lieu of their doctors.

However, in the specific case of concussion, treatment is essentially rest, rest, and more rest (both physical and cognitive), combined with conservative symptom management when indicated. Unless Crosby was having his "human gyroscope" therapy every day, it wouldn't have really made a difference either way.

The biggest problem was his returning to play too early.

Points: 0

#25 by Aaron Brooks G… // Aug 17, 2013 - 9:57pm

Chiropractic treatments involve spinal loads in excess of static tolerance. Occasionally, you'll run across a case study where a chiropractor broke someone's neck. But then, I've seen paramedics do that, too.

Chiropractics are usually about as effective a sugar pill, occasionally as good as a PT, and sometimes a complete loony who believes the subluxation theory of disease. That latter group should be exterminated -- that's sub-humour levels of medical reality.

Points: 0

#28 by Noahrk // Aug 19, 2013 - 11:06am

I didn't say anything since I took on the role of alternative medicine fanboy in this thread, but I completely agree that there's nothing harmless about chiropratics, or for that matter, about any other treatment of any kind, alternative or not. One should approach any health issue assuming total responsibility for the choices one makes, because the doctor or practitioner sure aren't going to be ones who'll have to live with the consequences.

The man with no sig

Points: 0

#16 by Jerry // Aug 17, 2013 - 4:34am

Here's a Sports Illustrated article on Crosby's treatment. And here's what Micky Collins said at a press conference in September 2011:

"He started to skate, was doing well – we got to that 80-90 percent level of exertion, and as he increased his speed playing hockey, as he increased his turns, as he increased his motion, the symptoms started coming back again. At that point – and even with all of the rehab we had done – Dr. Carrick became involved. And Dr. Carrick is an expert in rehabbing these types of injuries and these types of symptoms. And Sid sought out Dr. Carrick and recently Sid has made exceptional progress toward improving and to becoming normal. At this point in time – (Tuesday), actually – I assessed Sid. I hadn’t assessed him for a while. I was able to assess him and do the testing that we do, and I can tell you that his data is the best we’ve seen."

Crosby went to see Carrick relatively late in the game, and his highly-respected conventional doctor seems to think it helped. Maybe there's nothing to chiropractic neurology, but it's wrong to blame it for the length of time it took Crosby to recover.

Points: 0

#20 by evenchunkiermonkey // Aug 17, 2013 - 2:16pm

Crosby would take an additional two months from that quote to return to a game, then end up back on the injured list 2 weeks later, spending an additional month+ recovering. If Crosby ignored the advice from actual physicians because of this chiropractor's advice then you could indeed blame the chiropractor. Also, maybe the Pens team doctor also sucks.

Points: 0

#2 by Dean // Aug 16, 2013 - 3:56pm

The number of reported concussions stayed essentially flat, but do we have any evidence to suggest any change in the number of unreported concussions?

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#3 by RickD // Aug 16, 2013 - 4:38pm

Yes, the increase in the number of reported concussions might be coincident with a decrease in the number of unreported concussions, and the total number of concussions might be decreasing.

This is the kind of statistical issue that we've seen in the past with rape, child abuse, and other types of under-reported issues.

I don't know how we can estimate the historical rate for reporting concussions. I think we have to reach a point where we presume the reporting rate is fixed, and then see if the number of reported concussions decreases.

Points: 0

#4 by Terri Bey (not verified) // Aug 16, 2013 - 4:46pm

Great job. I know being honest can cost a player his job, but his brain is nothing to fool around with.

Points: 0

#18 by George Visger (not verified) // Aug 17, 2013 - 11:52am

Great article. Bottom line is we need to change the culture of football from "blowing people up" to out scoring your opponent.

If not, more will end up like Jr, his cousin (my 49er room mate) and me.

ESPN OUTSIDE THE LINES: The Damage Done 020813

Channel 13 News Sacramento 10/29/12 Terry Tuatolo interview

George Visger
The Visger Group - Traumatic Brain Injury Consulting

SF 49ers 80 & 81
Survivor of 9 NFL Caused VP Shunt Brain Surgeries
Benefactor of ZERO NFL Benefits

Points: 0

#19 by clyde (not verified) // Aug 17, 2013 - 1:15pm

Hello George -

I suspect the game you describe - outscoring opponents - will net less than 50% of the profits the present game does. You see how popular CFL and Arena are...

Perhaps better model for future game is hitting + "adequate" financial and long-term health compensation for participants? We do, after all, have strategies for paying coal miners, prison guards, and firefighters.

Killing the game, I fear, will result in fewer monies to retirees, while a new TV package, complete with settled lawsuits and long-term labor peace, could result in a financial and medical windfall for those who need it most, if handled properly.


Points: 0

#26 by Aaron Brooks G… // Aug 17, 2013 - 9:59pm

There's no real hope of being able to track data back prior to 1997. Before then, the definition of concussion changes, and any like comparison is lost.

Points: 0

#27 by Scott Kacsmar // Aug 18, 2013 - 1:48pm

We can add Dustin Keller to the list. My lord, I feel bad for him.

Points: 0

#29 by Burns (not verified) // Sep 18, 2013 - 9:15pm

I am thinking about doing a study on NFL concussions. I was wondering where you got the statistics on NFL concussions from previous seasons. Thank you.

Points: 0

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