High school and college football have approximately 12 fatalities annually with indirect systemic causes being twice as common as direct blunt trauma. The most common causes are cardiac failure, brain injury, and heat illness. The incidence of fatalities is much higher at the college level for most injuries other than brain injuries, which were only slightly more common at the college level. The risk of SCT, heat-related, and cardiac deaths increased during the second decade of the study, indicating these conditions require a greater emphasis on diagnosis, treatment, and prevention.

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Background: The incidence of nontraumatic fatalities in high school (HS) and National Collegiate Athletic Association (NCAA) football players has continued at a constant rate since the 1960s. Purpose: To describe the causes of nontraumatic fatalities in HS and NCAA football players and provide prevention strategies. Study Design: Descriptive epidemiology study. Methods: We reviewed 187 fatalities in HS and NCAA nontraumatic football players catalogued by the National Registry of Catastrophic Sports Injuries during a 20-year period between July 1998 and June 2018. Results: The majority (n = 162; 86.6%) of fatalities occurred during a practice or conditioning session. Most fatalities, when timing was known, (n = 126; 70.6%) occurred outside of the regular playing season, with the highest incidence in the August preseason (n = 64; 34.2%). All documented conditioning sessions were supervised by a coach (n = 92) or strength and conditioning coach (n = 40). The exercise regimen at the time of the fatality involved high-intensity aerobic training in 94.7%. Punishment was identified as the intent in 36 fatalities. The average body mass index of the athletes was 32.6 kg/m2. For athletes who died due to exertional heat stroke, the average body mass index was 36.4 kg/m2, and 97.1% were linemen. Conclusion: Most nontraumatic fatalities in HS and NCAA football players occurred during coach-supervised conditioning sessions. The primary cause of exertion-related fatalities was high-intensity aerobic workouts that might have been intended as punishment and/or excess repetitions. Exertion-related fatalities are potentially preventable by applying standards in workout design, holding coaches accountable, and ensuring compliance with the athlete’s health and current welfare policies.

Background: Football has the highest number of nontraumatic fatalities of any sport in the United States. Purpose: To compare the incidence of nontraumatic fatalities with that of traumatic fatalities, describe the epidemiology of nontraumatic fatalities in high school (HS) and college football players, and determine the effectiveness of National Collegiate Athletic Association (NCAA) policies to reduce exertional heat stroke (EHS) and exertional sickling (ES) with sickle cell trait (SCT) fatalities in athletes. Study Design: Descriptive epidemiology study. Methods: We retrospectively reviewed 20 academic years (1998-2018) of HS and college nontraumatic fatalities in football players using the National Registry of Catastrophic Sports Injuries (NRCSI). EHS and ES with SCT fatality rates were compared before and after the implementation of the NCAA football out-of-season model (bylaw 17.10.2.4 [2003]) and NCAA Division I SCT screening (bylaw 17.1.5.1 [2010]), respectively. Additionally, we compiled incidence trends for HS and college traumatic and nontraumatic fatalities in football players for the years 1960 through 2018 based on NRCSI data and previously published reports. Results: The risk (odds ratio) of traumatic fatalities in football players in the 2010s was 0.19 (95% CI, 0.13-0.26; P < .0001) lower in HS and 0.29 (95% CI, 0.29-0.72; P = .0078) lower in college compared with that in the 1960s. In contrast, the risk of nontraumatic fatalities in football players in the 2010s was 0.7 (95% CI, 0.50-0.98; P = .0353) in HS and 0.9 (95% CI, 0.46-1.72; P = .7413) in college compared with that in the 1960s. Since 2000, the risk of nontraumatic fatalities has been 1.89 (95% CI, 1.42-2.51; P < .001) and 4.22 (95% CI, 2.04-8.73; P < .001) higher than the risk of traumatic fatalities at the HS and college levels, respectively. During the 20 years studied, there were 187 nontraumatic fatalities (average, 9.4 per year). The causes of death were sudden cardiac arrest (57.7%), EHS (23.6%), ES with SCT (12.1%), asthma (4.9%), and hyponatremia (1.6%). The risk of a nontraumatic fatality was 4.1 (95% CI, 2.8-5.9; P < .0001) higher in NCAA compared with HS athletes. There was no difference in the risk of an EHS fatality in NCAA athletes (0.86 [95% CI, 0.17-4.25]; P = .85) after implementation in 2003 of the NCAA football out-of-season model. The risk of an ES with SCT fatality in Division I athletes was significantly lower after the 2010 NCAA SCT screening bylaw was implemented (0.12 [95% CI, 0.02-0.95]; P = .04). Conclusion: Since the 1960s, the risk of nontraumatic fatalities has declined minimally compared with the reduction in the risk of traumatic fatalities. Current HS and college nontraumatic fatality rates are significantly higher than rates of traumatic fatalities. The 2003 NCAA out-of-season model has failed to significantly reduce EHS fatalities. The 2010 NCAA SCT screening bylaw has effectively prevented ES with SCT fatalities in NCAA Division I football.

Objectives: Football is associated with the highest number of fatalities of any high school (HS) or college sport. In contrast to the annual number of traumatic fatalities in football, which has declined 4-fold since the 1960’s, the annual number of non-traumatic fatalities has stayed constant with current rates that are 2 to 3 times higher than traumatic fatalities. The purpose of this study was to describe the epidemiology and causes of non-traumatic fatalities in HS and college football players, to determine the effectiveness of the NCAA policies to reduce heat and sickle cell trait (SCT) fatalities, and to provide prevention strategies. Methods: We retrospectively reviewed non-traumatic football fatalities identified over a 20 year period from July 1998 through June 2018. Information was obtained from extensive internet searches, as well as depositions, investigative, autopsy, media, and freedom of information reports. Heat and SCT fatality rates were compared pre and post implementation of the NCAA football acclimatization model (2003) and SCT screening (2010) policies, respectively. Results: There were 187 (150 H.S., 37 college) non-traumatic fatalities (avg. 9/yr.). The most common causes of fatalities were cardiac (98, 52%), heat (44, 24%), SCT (23, 12%), and asthma (10, 5%). The majority of fatalities (127, 68%) occurred outside of the regular season months of September through December with the most common month for fatalities being August (61, 33%). Most (163, 87%) of the fatalities occurred during a practice or conditioning session (heat=100%, SCT=100%, asthma=90%, cardiac=77%). Hallmarks of exertion-related fatalities were: 1. conditioning sessions supervised by the football coach or strength and conditioning coach, 2. irrationally intense workouts and/or punishment drills, and 3. an inadequate medical response. The average annual rate of heat-related fatalities remained unchanged at the collegiate level pre (0.4) and post (0.4) implementation of the NCAA football acclimatization model in 2003. The average annual number of SCT deaths in collegiate football declined 58% (0.83 to 0.25) after the 2010 NCAA SCT screening policies were implemented. At the HS level, where there are no SCT guidelines, the number of SCT fatalities increased 400% (0.25/yr. to 1.0/yr.) since 2010. Conclusion: Most non-traumatic fatalities in HS and college football athletes do not occur while playing the game of football, but rather during conditioning sessions which are often associated with overexertion and/or punishment drills by coaches, especially strength and conditioning coaches. The football acclimatization model implemented by the NCAA in 2003 has failed at reducing exertional heat-related fatalities at the collegiate level. SCT screening policies adopted by the NCAA in 2010 have been effective at reducing fatalities in college athletes and similar guidelines should be mandated at the HS level. Conditioning related fatalities are preventable by establishing standards in workout design, holding coaches and strength and conditioning coaches accountable, ensuring compliance with current policies, and allowing athletic health care providers complete authority over medical decisions.