Contact In Non-Contact Football / Why you still need an AT for flag and 7v7

There is a lot of contact in non-contact football. Which is why you need an athletic trainer on the sidelines for flag & 7-on-7 football.
Due to the public’s ongoing concern with head trauma in general, and concussions in particular, the popularity of non-tackle versions of football has grown dramatically over the last decade. In fact, participation in flag football at the youth level nearly equals that of tackle football, nationwide. The thought is that the elimination of blocking and tackling makes head contact and its consequences far less likely and injuries, overall, far less numerous.
Intuitively much safer than the tackle version of the game, flag and 7-on-7 practices and games experience injuries so infrequently that an athletic trainer need not be present. Right?
A CDC study published in Sports Health in 2021 would seem to suggest so – at least for youth players, ages 6-14. Employing mouthguard sensors, the researchers followed 477 tackle and 47 flag players over the course of a season. They found that the tackle players experienced nearly 15 times more head impacts than those playing flag. Furthermore, the intensity of the hits was far higher in the tackle version.
Case closed?
In the words of ESPN football analyst Lee Corso, “Not so fast, my friend.”
A study in the Orthopaedic Journal of Sports Medicine (OJSM), out of the University of Iowa in 2017, compared 3525 youth tackle football athletes with 269 playing flag during one season. Surprisingly, the overall injury rate was higher in flag with 5.77/1000 athletic exposures (AEs), with an AE being one athlete participating in one practice or one game. In tackle, the rate was 2.6/1000 AEs. The rate of severe injuries was slightly higher in tackle than flag but the difference was insignificant. Of most concern? The concussion rate in flag was nearly twice that in tackle.
The concussion rate in flag was nearly twice that in tackle.
Consider first that flag players generally do not wear helmets and other protective gear. Then, compare these injury rates in flag football to other sports.
A study published in the May 2024 issue of the OJSM found that high school football players suffered 3.96 injuries/1000 AEs. The injury rate for games was 12.62/1000 AEs and 2.05 for practices. The overall rate in girls’ soccer was 2.65 (5.84 games/1.20 practices). Boys’ wrestling had similar numbers (2.36 overall/3.99 games/1.79 practices). Boys’ soccer was safer overall and in games than girls’ but riskier in practices (1.78 overall/3.76 games/1.78 practices).
(Editor’s note: the OJSM retracted the study in November because it used data from the ongoing National Health School Sports-Related Injury Surveillance Study without permission. Nonetheless, the “retracted” study remains available online and the data is accurate.)
Nobody would argue against the necessity of having an athletic trainer on the sideline for a contest and on the premises during a practice for tackle football, soccer, or wrestling.
One might consider the 2017 OJSM study an outlier. However, a study in the Journal of Athletic Training (JAT) in 2023 also focused on flag football. Done by researchers at the University of Cincinnati, it looked at injury rates across three flag football tournaments involving 1939 athletes aged 6-12 in late 2021 and early 2022. The game-only injury rate among the participants? 5.1/1000 AEs. That is comparable to girls’ soccer and worse than wrestling and boys’ soccer. Nearly 32% of the injuries were to the head, neck, or face. Not surprising, given the absence of helmets and facemasks. However, there was only one concussion. The ankle and foot were next at nearly 20%. Across all injuries, three quarters were the result of the victim making contact with an opponent or the ground.
The American Academy of Pediatrics classifies flag football as a “limited-contact” sport. Perhaps, those determining that label have never attended a flag football contest.
A higher number of flag participants would have provided more confidence in the statistics from the 2017 OJSM study but there is no denying the rates identified in the JAT article.
Consequently, it should be no surprise that the National Federation of State High School Associations (NFHS) published an online commentary entitled “Consideration of Liability of Issues in 7-on-7 football” in 2020. The 7-on-7 version of the game is very similar to flag, with no blocking and tackling, but the flags are usually absent and the receiver is downed instead by a touch from a defender.
“Although no tackling is allowed,” wrote attorney Lee Green, “the incidental contact common in 7-on-7 results in many high-speed collisions as multiple athletes converge on the same spot to make a play and athletes routinely hit their heads hard on another player or the ground, along with sustaining the full range of injuries typical to football such as joint and ligament damage to the knees, ankles, hips and shoulders, in addition to suffering various broken bones.”
The incidental contact common in 7-on-7 results in many high-speed collisions
While blocking and tackling are prohibited in 7-on-7 games, high school players often wear helmets and/or protective soft shells on their heads, making them less fearful and full-speed collisions more likely.
In consideration of such dangers, Green recommended that all such contests be attended by personnel with, “the training to fulfill the wide range of duties owed to young athletes such as specific supervision, proper technique instruction, warnings, safe playing environment, protective athletic equipment, evaluation of players for injuries and incapacities, enforcement of proper return-to-action protocols following injuries, provision of immediate medical assistance, activation of emergency medical response plans, (emphasis added) matching and equating players for safe participation, and provision of safe transportation – duties regarding which school-employed coaches and athletic personnel receive extensive training and thus presumably have the sport-specific knowledge to safely administer the activity.”
Coming from the NFHS, such a pronouncement sets a standard of care for 7-on-7 practices and games. And it is impossible to meet that standard without an athletic trainer in attendance.
John Doherty is a licensed athletic trainer and physical therapist. This column reflects solely his opinion. Reach him at jdoherty@powershealth.org. Follow him on X (formerly Twitter) @JDohertyATCPT.
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