When Minnesota Viking Pro Bowl offensive lineman Korey Stringer died of exertional heat stroke (EHS) on August 1, 2001, the country took notice. However, he was just one of four football players who died as the result of heat-related illness in a two-week span that summer.  The others were Eraste Autin of the University of Florida (July 25), Travis Stowers of Clinton Central High School in Michigantown, IN (also on August 1), and Rashidi Wheeler of Northwestern University (August 3).

97% of the victims since 2000 have been linemen and over one third of the incidents resulted from “punishment” runs or drills.

While Autin was a fullback and Wheeler was a safety, these tragedies almost always victimize linemen like Stowers and Stringer.

In the wake of those 1995 fatalities, the lawsuits followed.

Clinton Central’s attorney contacted me regarding the Stowers case and asked if I would serve as an expert witness for her defense team. I responded by asking her a series of questions regarding the accuracy of several allegations made against Clinton Central staff in published stories. After she answered, “Yes, but …” to every one of my queries, I told her I did not think I would be much help.

Remarkably, the jury found in favor of Clinton Central at trial. However, the verdict was partially reversed on appeal in 2006 and the school district and Stowers’ parents agreed to a financial settlement shortly thereafter, rather than go through another trial.

Stringer’s widow didn’t settle with the NFL until 2009 – and not with equipment manufacturer Riddell until 2011 – for an undisclosed amount and a promise from the League to create a heat illness prevention program.

A portion of the NFL settlement was used a year later to start the Korey Stringer Institute (KSI) at the University of Connecticut.  KSI, partnering with the NFL and the National Athletic Trainers’ Association – among others, works to prevent sudden death in sports and focuses particularly on EHS.

Consequently, over the last 15 years, athletic trainers nationwide have learned how to take rectal temperatures – the only accurate method of diagnosing EHS — and to cool first and transport second. Only recently, though, are EMS units beginning to accept that practice, finally closing the “knowledge-to-practice” gap.

However, all concerned – particularly the athletes – would be better off if these episodes of EHS were avoided altogether. As well as cold water immersion works, it is no help if cardiac arrest becomes part of the scenario.

An “Exertional Heat Stroke” instructional sheet (Heat Stroke Warning Signs for Football) is among the resources offered on the Go4 website. In addition to listing signs and symptoms and providing a protocol for on-site treatment, it offers prevention advice regarding hydration, lightweight uniforms, what to do between games, and the use of sunscreen.

Meanwhile, coaches and administrators should know the limits that are dictated by wet bulb globe temperature (WBGT) readings.

Furthermore, coaches and athletic trainers should be fully aware of who their players are with sickle cell trait.

Despite all these guardrails, though, of supposed best practices in prevention, recognition, and treatment, football players keep dying in the heat each year. Through the end of July, two high school football players had already died of heat-related illness while a third had been hospitalized in an intensive care unit. All three were linemen.

Considering the something they had in common, something is missing in our prevention practices.

Getting prevention practices in line

In June of last year, Sports Health published a study entitled “Preventing Exertional Heat Stroke in Football: Time for a Paradigm Shift.” Lead author Scott Anderson, the retired University of Oklahoma head athletic trainer, was joined by 14 other sports medicine experts from across the country, including two from the National Federation of State High School Associations (NFHS) based in Indianapolis.

High metabolic heat loads that can outstrip the surface area for cooling, along with high body fat stores that tend to retain heat.

Citing ample research, including his own published and ongoing work, Anderson reported a particularly sobering set of statistics. Despite multiple rule changes from the NCAA and NFHS intended to improve heat safety, the incidence of fatal exertional heat stroke (EHS) has risen from two per season nationwide to three since the year 2000. In 2021 alone, there were nine. Furthermore, 97% of the victims since 2000 have been linemen and over one third of the incidents resulted from “punishment” runs or drills. Notably, no such deaths occurred in games.

Consequently, Anderson and his co-authors believe the strategies adopted over the past two decades are not working. “Because these improvements have not ended EHS deaths,” they wrote, “it is time to shift the prevention paradigm.”

They explained, “A lineman has a ‘heat stroke habitus’: a large body with a high percentage of lean muscle mass generating high metabolic heat loads that can outstrip the surface area for cooling, along with high body fat stores that tend to retain heat.”

Another Sports Health study, out of the University of Georgia, published online at the end of July came to a similar conclusion regarding linemen and heat. Reviewing 309 cases of non-fatal exertional heat illnesses among high school football players in Georgia, the authors found that “the lineman group had over 2.5 to 3 times greater risk of sustaining heat syncope/heat exhaustion than the backs and specialists groups.”

“the lineman group had over 2.5 to 3 times greater risk of sustaining heat syncope/heat exhaustion than the backs and specialists groups.”

To protect linemen, Anderson advocates training them for the way they play in a contest. Then, they hardly ever sprint. Thus, the commentary recommends excluding linemen from “high intensity, large volume workouts, timed mile runs, or sustained sprinting for distances within the first two weeks” of practice.

Rather than the five-day acclimatization period common in high school, the article actually recommends a four-week duration for linemen. During that time:

1) All training and conditioning should be position specific.

2) Physical activity should be modified per the heat load.

3) Understand that some players have a “do-or-die” mentality that supersedes their personal safety.

4) Never use physical exertion as punishment, even beyond the acclimatization period.

5) Eliminate conditioning tests, serial sprints, and any reckless drills that are inappropriate for linemen.

6) Consider air-conditioned venues for linemen during hot practices.

“The current training of linemen errs by including sustained aerobic intensity (e.g., serial sprinting) that is neither wise nor required for how linemen play the game,” Anderson and company concluded. “This is a recipe for disaster in the heat…. Until we change the football culture to train players for position-specific demands, the tragic EHS deaths of linemen will continue.”

“The current training of linemen errs by including sustained aerobic intensity (e.g., serial sprinting) that is neither wise nor required for how linemen play the game,”

The commonly accepted “knowledge-to-practice” gap is 17 years. Traditionalists among football coaches will resist this “paradigm shift” that Anderson advocates, helping to keep the gap in place. Athletic trainers need to lead on this issue and to stand firm in order to shorten significantly the gap and to put an end to EHS fatalities.

John Doherty is a licensed athletic trainer and physical therapist. He is the vice president of therapy services, sports medicine, and occupational health at Powers Health in Northwest Indiana. This column reflects solely his opinion. Reach him at jdoherty@powershealth.org. Follow him on X (formerly Twitter) @JDohertyATCPT.