Fig 1 Young athletes receive instruction on proper football techniques, including shoulder tackling and blocking, in the Heads Up Football program.
Courtesy of USA Football.


Published 6/1/2017
Terry Stanton

Safety Program May Help "Turn the Tables on Concussion"

Protocol enlists coaches and trainers to emphasize proper tackling and blocking techniques in high school football players
A study involving more than 2,500 high school football players in South Carolina found that those on teams that had participated in the USA Football Heads Up safety program had concussion rates 33 percent lower than those on teams that had not.

The study was presented at the Game Changers Paper Session at the AAOS Annual Meeting in San Diego by John M. Tokish, MD.

Heads Up Football provides school teams with a curriculum for football safety, including certification of coaches, appointment of a player safety coach, instruction in blocking and tackling techniques to reduce risk of concussion and other injuries, concussion recognition and response protocol, and other health and safety measures such as heat preparedness and hydration, proper equipment fit, and cardiac event preparedness. The Heads Up coaching uses shoulder tackling and blocking progressions and drills to teach players to play with their heads and eyes up and reduce helmet contact.

The study followed 1,818 players from 14 South Carolina high schools in the Greenville County School District who had received Heads Up training and who had at least one coach (designated as "player safety coach") and an athletic trainer, and 696 players from schools that had not participated in Heads Up training—comprising private schools within the district and public schools in neighboring counties. Random monitoring for proper coaching instruction was performed three times during the season at each trained school to ensure compliance with program guidelines. Concussion cumulative incidence and incidence rate ratios were calculated with 95 percent confidence intervals to determine program effectiveness.

Among all players, 117 sustained concussions; of these, 75 were players on Heads Up teams and 42 were those on non–Heads Up teams. The Heads Up rate of 4.1 concussions per 100 players was 33 percent lower than the 6.0/100 rate on the non–Heads Up teams. The Heads Up players resolved their concussions and returned to full participation 27 percent faster than athletes in the non–Heads Up group (time loss: 18.2 ±10.6 days versus 24.8 ±15.3 days).

The number of concussions in the entire cohort was higher in games (n= 61) versus practice (n = 56), but this difference was not significant. The concussion rate in games trended toward higher in the non–Heads Up cohort.

A collaborative effort
Dr. Tokish said the study was the first proof-of-concept evaluation for the athletic trainers' network that was established in South Carolina among Greenville Health System, the Greenville County School District, the Steadman Hawkins Clinic of the Carolinas, and the Center of Effectiveness Research in Orthopaedics (CEROrtho).

Ellen Shanley, PhD, PT, OCS, the lead investigator for the study and the CEROrtho director for Athletic Injury Research, Prevention, and Education, explained that the project came about when the Greenville School District—the largest in South Carolina, with 101 schools and 76,000 students—expressed interest in providing Heads Up training to its football coaches. "The athletic director for the county was interested in making sure that the coaches were following through with the training and that the results could be monitored," she said. "We designed the study to evaluate both the implementation and the results of the training and had a built-in comparison group in the schools that were not involved in the training."

During the study period, football players in both groups were monitored beginning on the first day of practice throughout the 2015 competitive football season. The Heads Up–trained player safety coach educated all other football coaches within the organization as well as parents and players on all aspects of player safety, including tackling, blocking techniques, and concussion awareness. The player safety coach also directed all contact tackling and blocking drills to ensure use of proper Heads Up techniques during football practices. The program was implemented at all levels of football at the trained schools from the first day of preseason practice through the last official game during the scholastic season. Control schools and athletes did not participate in any special training or additional focus on concussion recognition or blocking/tackling technique.

Concussion injuries, including the date, circumstances of injury, treating medical provider, time loss, and demographic data within the Athletic Trainer System (ATS), were monitored and then documented by the athletic trainer. ATS is a software system that functions as a tracking tool for athlete participation and injuries including circumstances, treatment, and recovery, as well as serving as an electronic medical record for trainers. ATS also serves as an electronic medical record for trainers.

Each concussed athlete was referred to a board certified sports medicine physician or orthopaedic surgeon within the school system for evaluation, diagnosis, and follow-up care. The physician documented the concussion using a combination of history and symptom reports, physical examination, and appropriate imaging, complemented by neurocognitive and balance assessments. A "football-related concussion injury" was defined as "any type of traumatic brain injury caused by a contact injury or rapid movement of the head causing the head and brain to move rapidly back and forth that occurred during any scholastic sport team-sponsored activity."

The collaborative effort included more than 50 schools with athletic trainers employed by Greenville Health Systems. "Many of our physicians and staff have children who play in the school system, and several of us coach," Dr. Tokish said. "We felt like we had a unique opportunity with our outcomes engine to be able to ask and answer large-scale questions. The Greenville County school system should be credited with instituting the Heads Up program within their teams, providing Dr. Shanley and me the opportunity to study it."

An appreciable difference
Dr. Tokish said that while he and Dr. Shanley had hypothesized that the Heads Up teams would show a relative reduced concussion rate, they were surprised by both the magnitude (33 percent) of the difference between participating and nonparticipating schools and by the 27 percent faster return to play rate of injured players in the Heads Up schools.

The authors describe this study as the first to prospectively explore the effects of Heads Up training on the incidence and recovery from concussion in high school football. Asked to comment on the implications of their findings for orthopaedic surgeons and other physicians and personnel involved with school football teams, Dr. Shanley said, "I would agree that these findings need to be confirmed with additional study. However, I believe that these results confirm the belief that prevention programs focused on limiting contact hours and maximizing techniques that emphasize safe participation can reduce the number and impact of injuries in football. Physicians and healthcare providers can help design and advocate for the implementation of techniques to reduce the impact of injuries."

Dr. Tokish noted that the study findings—which he described as "fresh and not yet well known"—might draw resistance or challenges from some. "Any injury prevention program is going to bring controversy: There is a cost to implementation, both financially and in terms of time that would normally be spent on practice," he said. "We feel very confident in our data, and feel like it justifies the commitment to implementing this program. Certainly, more study is necessary, and refinements to the program will come, but this is a good start toward turning the tables on concussion. Perhaps most exciting for us is that it validated our 'engine' and will allow us to study large-scale questions in other areas.

"We believe that team physicians, coaches, athletic trainers, and players should be familiar with proper tackling techniques," he continued. "We believe that these should be implemented when players are as young as possible so that kids will be taught from the beginning the benefits of proper tackling techniques.

"I happen to coach my young son's team, and our program teaches these techniques to all levels, beginning with the age 8-and-under group," he added. "We hope that the emphasis we place on these techniques will result in proper tackling becoming second nature as they grow."

Dr. Tokish also said that this study suggests other avenues to be explored. "There are many other variables that can be studied in this population. We are interested in looking at the effect that these injuries have on academic performance and the time it takes to 'return to play' in the classroom. We also will look at the mechanisms we might have in place that can allow us to test equipment, as well as the effect of prolonged exposure to the Heads Up program."

For now, Dr. Shanley said, "The biggest challenge for us in our education programs is helping parents, players, and coaches to understand the process of recovering from concussion and safe reintegration into academics, daily schedules and activities, and athletics."

Co-authors with Dr. Shanley and Dr. Tokish are John M. Brooks, PhD; R. G. Gilliland, ATC; Michael J. Kissenberth, MD; Darryl Nance; and John Thorpe, ATC.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at

Bottom Line

  • The USA Football Heads Up program educates coaches and athletic trainers on teaching proper technique for blocking and tackling, as well as on cardiac arrest awareness and response training, concussion recognition, heat and hydration preparedness, and equipment fitting.
  • The study sought to evaluate the effect of the Heads Up program on concussion rates in high school football players in South Carolina.
  • In a comparison of school teams that had or had not participated in Heads Up training, players on Heads Up teams had 33 percent lower concussion rates and 27 percent faster return to play rates.
  • This prospective study was the first to evaluate the effectiveness of the Heads Up program in high school players.