Concussion Prevention in Football: Building a Foundation

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In the past ten years, we have learned a lot about the links between football and concussions. The sport does have inherent risks that have been thoroughly discussed in other venues. However, it is still an incredibly popular sport at the professional and youth levels. As football continues to be played, progress must be made in order to ensure the safety of the players. Many of these initiatives are fairly new and require further study; but they are going to be the foundation on which we can improve and make football safer to play. These fall into three main categories of emphasis: 

  1. Focus on better preparation and gameplay technique 
  2. Improvements to the process of fitting players’ equipment and the equipment itself
  3. Changes to game rules and player attitudes

One of the most important developments that has come from the concussion links in football is the development of the Heads Up Program. Heads Up Football is a joint venture between most of the professional organizations with a stake in the future of football. This includes the NFL, major college football conferences, equipment manufacturers, broadcasting partners, and medical organizations like the American College of Sports Medicine. It is a comprehensive program geared towards making football safer; and emphasizes having coaches at all levels become certified through their teaching program. As the name implies, one of the pilot initiatives of this program is to teach the “heads up” tackling system. Football is a contact sport and the research has shown that improper tackling technique is one of the greatest risks to players. Think back to the most high-profile injury in professional football in the past 3 years. Steelers linebacker Ryan Shazier was nearly paralyzed on the field in front of a national television audience on what seemed like a fairly innocuous play, because he attempted to make a tackle with the crown of his head as the principle point of contact. The program teaches 5 steps to fundamental, effective tackling without using the head: 

  1. The breakdown position (proper set up with correct body leverage to advance on the target)
  2. Buzzing the feet (making sure to control your footwork and gain ground)
  3. Hit position (proper stance, and re-establishing leverage before contact) 
  4. The shoot (gaining power from the lower body and hips as you spring towards the opponent), 
  5. The rip (finishing the tackle)

Along with the namesake teaching of proper tackling technique, the tenets of Heads Up Football include:

  1. Recognition and response to concussions and symptomatic players
  2. Teaching the shoulder tackling system more commonly used in rugby
  3. Teaching heat preparedness and proper hydration for players
  4. How to properly fit players’ equipment. 

There is no helmet that can prevent a concussion. There was a school of thought at one point that it would be a silver bullet that could solve the problem. While that has thankfully been debunked, proper fit and function of the playing equipment is incredibly important to keeping the players safe. The Heads Up program has a publicly available video on the proper sizing and techniques for fitting players with helmets and shoulder pads that will be provided at the end of this post. While there is no helmet that will be able to prevent 100 percent of concussions, the standards for the production and testing of football helmets have improved dramatically over the past few years. The National Operating Committee on Standards for Athletic Equipment (NOCSAE) has established and constantly updates standards that football helmets must pass to be certified safe for use. Helmets are put through rigorous impact and crash testing the way that vehicles have been for years. The NFL and its’ Players Association have helped fund the testing of many of the commercially available models of football helmets and determined which are safe for play. The results apply across the board: Patriots quarterback Tom Brady’s preferred helmet throughout his career, the Riddell VSR-4, will be banned beginning in the 2019-2020 season along with 10 of the other lowest performing models of helmets. Taking steps to ensure player’s have properly fitting equipment that has passed rigorous inspection standards is a big step to making sure that a game with inherent risk is as safe as possible.

The final measure to discuss is how the reaction to concussion problems is leading to rule changes in football. Many of these changes have begun in the NCAA ranks and have shown promising results, leading to adaptation of similar policies at other levels. For example, there is ample research suggesting that kickoffs are the most dangerous play in the game regarding the incidence of head trauma. If you have been watching football in the past few years, you will notice that changes have been made to the setup of kickoffs to make them a less frequent part of the game. The starting line for kickoffs has been moved up in order to encourage more touchbacks and less active return plays. During the last season, the NCAA expanded that rule to allow returners to call for a fair catch anywhere short of their own 25-yard line and apply it as a touchback would be done in the endzone. The limitation of kickoff has shown promise in the short amount of time it has been implemented and researched. A study conducted with the Ivy League schools showed a 5-fold decrease in reported concussions with the changes to their kickoff rules (Wiebe et al). 

Along with changes to the kickoff, the biggest rule addition has been the “targeting” policies that began in the NCAA; and have now been similarly added to other levels of football. NCAA Rule 9, Section 4 states that “no player shall target and make forcible contact to the head or neck area of a defenseless player… with the helmet, forearm, fist, elbow or shoulder. Targeting means that a player takes aim at an opponent for purposes of attacking with forcible contact that goes beyond making a legal tackle, block, or playing the ball.” The rule continues to establish specific examples, along with what constitutes a defenseless player. This includes but is not limited to players in the act of or having just thrown a pass, any player in the process of establishing possession of the ball, and players who are on the ground or obviously not involved in the play. The penalties for targeting are quite severe: ejection from the game and possible suspension at all levels, and monetary fines at the professional level. 

The message is clear, and reasonable. The game is played at high speeds and involves plenty of split-second decisions; it will likely be impossible to limit head contact entirely. Anything that can be done to limit intentional contact to the head will continue to be encouraged, and it is essential to making football as safe as it can be. Making players think twice about the way they will engage with opponents, and the way they will deliver contact, is a positive step for the future of football. 

Check Out This Video for Proper Equipment Fitting: 

By Nasser Koucheki and Mo Mortazavi, MD


Wiebe, Douglas. “Fewer Concussions After Football Rule Change.” Medpage Today, JAMA, 1 Oct. 2018,

“NCAA Rule 9 – Conduct of Players and Others Subject to the Rules.” Ruletool, NCAA, 2019,

“Football Helmet Standards Overview.” National Operating Committee on Standards for Athletic Equipment, NOCSAE, May 2018,

“Helmet Laboratory Testing Performance Results.” NFL Play Smart, Play Safe, NFL/NFLPA, 2019,

“HEADS UP FOOTBALL: SAFETY IN ACTION.” Heads Up Football, USA Football, 

“Teaching Tackling-Updated.” Teaching Tackling-Updated, USA Football , 3 June 2014,

O’Malley, Nick. “Brady’s Helmet Banned for Good by NFL; QB Must Switch to New Model.”, Massachusetts Live, 12 Apr. 2019,