When Georgia public high schools were asked several years ago to devise a policy to govern sports activities during periods of high heat and humidity, one school's proposal stood out: It pledged to scale back workouts when the heat index reached 140.
Those who understood the heat index, the combined effects of air temperature and humidity, weren't sure whether to be appalled or amused. "If you hit a heat index of 140," said Bud Cooper, a sports medicine researcher at the University of Georgia who examined all the proposed policies, "you'd basically be sitting in the Sahara Desert."
The policy reflected an old-school, "no pain, no gain" philosophy, a view that athletes need to be pushed to their physical limits — or beyond them — if they and their teams are to realize their full potential.
In some places, state, school and sports officials are recognizing that the zeal of coaches, players, and parents for athletic accomplishment must be subordinated to safety. Increasingly, they are adopting measures to protect student athletes from serious, even catastrophic injuries or illnesses that can be the consequence of a blinkered focus on competitiveness.
Since 2009, every state and the District of Columbia have enacted laws mandating that athletes who of high school age or younger be removed from games or practices when it is suspected they have sustained concussions. This year, Mississippi became the final state to do so. Such laws also set the process for determining when an athlete with a concussion can safely resume sports activities.
In addition, some states and state athletic associations now require that schools have on hand automated external defibrillators for the treatment of sudden cardiac arrest, a leading cause of death in young athletes. A number of Southern states have adopted stringent rules to avoid heat-related illnesses and deaths. And some school systems or individual schools have implemented policies to try to prevent overuse injuries — injuries caused by the repetition of the same motion, such as pitching a baseball or softball.
But no state has enacted the provision that many of those involved in sports medicine believe would be the single most important step to keep student athletes safe: a requirement that every high school employ at least one full-time athletic trainer.
According to the Korey Stringer Institute, a research center at the University of Connecticut concerned with the safety of student athletes, only 39 percent of public high schools in the U.S. have full-time athletic trainers on staff. Many schools do have nurses, but they usually leave at the close of the school day, just as games and practices begin.
"Without question, all of these policies on heat, concussion, and so forth, they all make sense," said Doug Casa, the institute's chief operating officer and a leader in the study of heat illnesses in athletics. "As we move toward having more policies in place to protect these kids, the most important thing you can do is have an athletic trainer on staff."
The Korey Stringer Institute was named for a Minnesota Vikings offensive lineman who died of heat stroke during summer training camp in 2001. Stringer's high-profile death brought attention to the issue of heat-related illnesses experienced by athletes, but it took more than a decade before policies started filtering down to the high school level. Even then, they were mainly in the South with a couple of outliers, including New Jersey and Connecticut, in other regions of the country.
The guidelines were not the result of legislation, but rather were adopted by state athletic associations that oversee scholastic athletics. There is no national sports association presides over all high school sports as the NCAA governs collegiate athletics.
In 2011, Ralph Sweargin, then head of the Georgia High School Association, decided to address heat-related deaths in football in his state. At the time, Georgia had the most heat-related football deaths in the country, with six between 1980 and 2009, according to data from the National Center for Catastrophic Sport Injury Research Center at the University of North Carolina.
Two more heat-related football deaths occurred in the summer of 2011, including that of Don'Terio J. Searcy, a 16-year old lineman at Fitzgerald High School near the Florida border. Meanwhile, Georgia schools kept changing their calendars to open schools ever earlier, which meant football practices began in mid-July, the dead of summer.
Up to that point, the Georgia High School Association had let individual schools devise their own health policies. Sweargin concluded that approach didn't work, and that his association needed a policy that would govern all the schools, from the mountains in the north to the swamps in the south. But Sweargin, who retired as GHSA chief last spring, came to another conclusion as well. "I was really concerned we weren't making data-driven decisions, but relying on best guesses and assumptions and copying what other people were doing."
So Sweargin commissioned a team of sports medicine researchers at the University of Georgia, including Bud Cooper, to conduct a three-year study on the impact of heat on high school football players.
Their study of 25 Georgia high schools found that players were particularly prone to heat-related illnesses in the first days of practice. That was especially true of linemen, who tend to have higher ratios of body fat and whose bodies needed more time to acclimate to the heat. Clearly, Cooper said, one essential part of any new policy had to be a graduated start to football activities to allow players to get used to the hot weather.
Cooper said his team, which had previously conducted a heat-related study for the NCAA, knew that the use of the heat index to determine heat policy was not sufficient because it ignored an important factor: the "radiant temperature," or the temperature on the ground. Certain surfaces, like concrete or a football field, retain and intensify the heat on the ground. That is why the military, the NCAA, and other organizations use a device called the Wet Bulb Globe Temperature (WBGT) calculator, an instrument resembling a car battery that measures temperature, humidity and radiant temperature.
Following the recommendations of the research team, the new GHSA policy, implemented in 2012, requires all high schools to use a WGBT calculator. When WBGT readings reach a certain level, football coaches are required to take specific actions to relieve heat stress. For example, a reading above 82 requires coaches to provide at least three breaks an hour of four minutes or longer. Higher readings require more steps, such as shortening practice sessions and allowing players to wear shorts instead of football pants. For readings above 92, outdoor practices are prohibited.
The GHSA has now commissioned Cooper's team to conduct another three-year study to gauge the impact of the new policy.
While Southern states have taken the lead in adopting statewide heat policies, Bud Cooper insists that Northern states neglect doing so at their own peril — or the peril of their athletes. Temperatures in the North are also high when football players begin practicing. If athletes aren't acclimated to those higher temperatures, they can be at risk. He pointed out that Korey Stringer died of heat stroke in Minnesota, on a day the heat index hit 110.
Concussions and extreme heat have drawn the most attention in high school sports, but they are not the only dangers to young athletes. According to the National Conference of State Legislators, at least 17 states have laws either requiring or urging some or all schools to have automatic external defibrillators on hand. That's a good step, said Judy Pulice of the National Athletic Trainers' Association, but many of those laws do not require the devices be brought out to athletic fields. "A lot of time, after 3 pm. the AED is locked up in the principal's office," she said.
Overuse injuries also are receiving more attention. The increasing number of student athletes specializing in particular sports –– playing them year round to the exclusion of others –– risk serious injury from overused joints and muscles. For pitchers, there are elbow and shoulder injuries, including tears or ruptures in the ulnar collateral ligament in the elbow. In soccer, players are subject to knee and growth plate injuries. In volleyball and swimming, it's often the shoulder.
Jeffrey Dugas, an orthopedic surgeon at the Andrews Sports Medicine and Orthopaedic Center in Birmingham, Alabama, and medical director of the USA Federation for Sports Cheering, the national governing body for cheerleading, said that between 1999 and 2004, there was a tenfold increase in the number of patients with UCL injuries. Since then, he said, the number has increased another sevenfold. (John Di Fiori, chief of sports medicine at UCLA said he doesn't doubt those statistics but cautions that overuse injuries weren't classified that way until recently, so there is no firm data confirming an upward trend.)
"We all have a natural human competitiveness," Dugas said. "Parents and coaches and athletes are pushing so the kids are better, faster and stronger. That's human nature, but there needs to be controls on that."
States have largely left it to individual schools and school districts to adopt policies regarding overuse. Many limit the number of pitches baseball and softball pitchers are allowed to throw. Some schools try to mandate training breaks in the calendar in some sports to provide recuperation time for the athletes. But many athletes play their sports outside of school on travel or recreation league teams.
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