Not only is football perhaps the most popular high school sport in the country every fall, but it is one of the highest risk of injury sports throughout the year. Regardless of playing organized sports for a school or team or played in the neighborhood with friends, injuries are commonplace. All positions are at risk for injury, and often the quarterback, wide receivers, running backs and safeties are at the forefront of concern. However, the players that are often overlooked are offensive and defensive linemen. These are the guys playing on the front lines of every play and make contact every single play of the game. While there are over 350,000 football related injuries nationwide, linemen have the highest risk of developing acute, chronic, or even season ending injuries during the season. Listed below are the injuries and conditions commonly diagnosed.
Concussions
Concussions occur when the head undergoes acute rotational forces from impact to the head and/or body that result in cognitive, vestibulo-ocular, as well as neurologic symptoms. Memory loss or loss of consciousness are not required to make a diagnosis of concussion. Players with concussion can present with memory loss, loss of balance, incoordination, headache, dizziness, and fatigue, with headache as the most common symptom. Symptoms can be provoked by too much cognitive or physical activity. Linemen are at increased risk of developing concussions due to multiple helmet to helmet hits that occur much more frequently than at other positions. Concussion recovery can be a long process involving being immediately pulled from the sport, possibly for the entire season, getting plenty of rest, eating a balanced diet, staying hydrated, and avoiding symptom triggers that over stimulate the brain. Too much stimulation slows the recovery process, which can be caused by prolonged screen time, vigorous exercise, and receiving a second impact injury. Prevention involves undergoing a preseason check up, wearing equipment with an appropriate snug fit (helmet and pads), rotating in and out of play often, and proper blocking and tackling techniques that involve leading with your hands, and keeping your head up.
Knee Injuries
In the heat of the play, with players moving in all directions can often lead to one player rolling into or twisting a lineman’s knee. Bone, ligament and cartilage injuries can result. The areas of the knee at highest risk to damage are the anterior cruciate ligament (ACL), medial and lateral collateral ligaments, medial and lateral menisci, in addition to the bones around the knee. The ligaments and cartilage hold the knee in place. Being hit in a certain direction can cause these ligaments to be stretched too far causing a sprain or complete tear. In younger athletes ligaments can even avulse a piece of bone, called an avulsion injury or fracture. Ligament injuries are assessed on the field or sideline with tests that assess their integrity by forcing the joint in different directions. A torn or sprained ligament will allow the knee to bend in directions that would normally be limited by the ligament. Acute treatment mostly involves conservative measures involving the player being removed from sport, followed by rest, ice, compression, elevation, and use of pain relievers such as ibuprofen or aspirin. Bracing is very helpful for sprains, which can promote a quicker return to play. Long-term treatment involves rehabilitation such as physical therapy to strengthen the muscles supporting the joint and hasten the healing process. If the ligament is completely torn, surgical repair to the damaged ligament is an option as well; the medial and lateral collateral ligaments rarely require surgical reconstruction, except when causing chronic pain and instability; Surgical reconstruction is almost always necessary in the setting of an ACL tear. Ligament and meniscus injuries can be confirmed with MRI, and in some settings with ultrasound for the MCL, LCL and peripheral meniscus tears.
Spondylolysis
This is a stress fracture of one of the “posterior element” bones of the vertebrae, with the specific location called the pars interarticularis. This is a relatively thin, flat, and more fragile part of the archway that surrounds and protects the spinal canal and cord. Damage can happen when the combination of compressive and extension forces are put on the, which is a common position for linemen when making contact and blocking an opponent. Repeating this motion multiple times and over a long period of time can lead to the development of a crack (or stress fracture) of the pars interarticularis. This often leads to back pain that doesn’t resolve with a little rest; and often returns pretty quickly after jumping back into sport after several days of feeling better. Adolescents are at risk of this injury because of the rapid growth that contributes to tight hamstrings and hip flexors. If this injury is not identified and treated appropriately, the pars interarticularis can separate entirely leading to a condition called spondylolisthesis, where the vertebrate above the damaged bone will slide forward. While magnetic resonance imaging (MRI) is the most efficient way to diagnose this condition, x-rays are often necessary to meet insurance requirements and can identify some fractures and definitely a spondylolisthesis. A bone scan is the traditional gold stand for diagnosis, but due to radiation exposure it is reserved for the rare case then a stress fracture is suspected but no identified on x-ray or MRI. (Note: MRI is about 95% accurate at identifying these injuries.) Computerized tomography (CT) can also be used, but uses radiation (x-ray) technology to look for the fracture, but cannot identify the early stress and inflammation in the bone like MRI. When first suspecting or being concerned for this injury, the athlete should removed from sport with initial treatment involving exercises that strength the core (neutral stabilization) and hips, working on flexibility of the hamstrings and hip flexors, which can best be achieved under the guidance of a physical therapist or athletic trainer. Evaluation with a sports medicine physician or orthopedic surgeon may be necessary to order imaging to confirm the diagnosis. When the stress fracture or injury is confirmed, some physicians treat in a hard plastic brace that neutralizes the spine. Not all of these injuries require bracing, and some physicians treat this condition without a brace. For patients who have persistent pain despite aggressive treatment, evaluation with an orthopedic or spine surgeon may be considered, having screws placed to reconnect the fracture site. Treatment for this injury unfortunately often requires months away from sport to allow the bones to heal, and strengthening the hips and core to prevent re-injury. When this injury is suspected, it is important to be seen by a physician who can assess for other causes of back pain, such as sacroiliitis, which can mimic the stress fracture injury.
Hypertension
Surprisingly, linemen are at higher risk of developing high blood pressure compared to other positions. Linemen are often selected for their strength, height, and weight, which unfortunately are linked to having a high body mass index (BMI). Increased BMI is a risk factor for developing high blood pressure, which increases the risk of conditions like heart disease, kidney failure and diabetes later in life. Players most of the time will show no symptoms of high blood pressure, which makes office evaluation very important, which is part of the pre-participation physical exam. Remember, hypertension is often called the “silent killer” because there are no distinct symptoms that would tell us to look for high blood pressure. Diagnosis can be made using a blood pressure cuff. However, if high blood pressure is found then it needs to be confirmed with repeat testing over the course of a few weeks, and may require ambulatory testing with a blood pressure monitor worn for a few days taking random pressures. When hypertension is confirmed an electrocardiogram (ECG) is performed to evaluate for any effects of increased heart strain, such as ventricle enlargement or thickening of the muscular walls. Treatment for high blood pressure in high school students can be complicated. Lifestyle changes with diet and exercise are first line treatments, that can contribute to lowering the pressure without need for medications. Prescription medications may be necessary if initial treatment is not enough.
By Jon Ferlmann & Jon Minor, MD
References
“How to Make Proper Contact with the Defender.” Football Tutorials, 31 July 2014, http://www.football-tutorials.com/make-proper-football-contact/.
Sipek, Sarah. “College Football Linemen at Increased Risk of Hypertension.”
Cardiovascular Business, 6 Dec. 2016, http://www.cardiovascularbusniness.com/topics/structural-heart/collegiate-football- lineman-increased-risk-high-bp.
Payne, Marissa. “Offensive Linemen Are the Football Players Most Likely to Play While Concussed, New Studies Show.” The Washington Post, WP Company, 17 Oct. 2014, http://www.washingtonpost.com/news/early-lead/wp/2014/10/17/offensive- linemen-are-the-football-players-most-likely-to-play-while-concussed-new-studies- show/?utm_term=.36625c8e042b.
Turbeville, Sean D, et al. “Risk Factors for injury in High School Players.” The American Journal of Sports Medicine, vol. 31, no.6, 2003, pp 975-980.
O’Kelley, Shannon, and Kelly Weaver. “Spondylolysis: Injury in Teen Athletes.” The Everett Clinic, Health Matters Radio, KRKO 1380am.
“How to Repair a Torn Knee Ligament.” Johns Hopkins Medicine Health Library, John Hopkins Medicine, 2017, http://www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopaedic/knee_ligam
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