Turn up hydration / Turn down hazards

For athletic trainers covering summer tournaments, the primary goal should be the preventing exertional heat illness, especially if the competition is planned for a field with an artificial surface. Artificial surfaces at mid-day may get to 120 degrees Fahrenheit or higher, even if the surrounding temperature is in the comfortable 70s.
There are multiple strategies available to combat heat illness, including the avoidance of the sun when it is at its strongest, between 10:00 a.m. and 4:00 p.m.
However, since most flag football tournaments take place during those hours, you need to have a WBGT device, a hydration schedule for all participants based on WBGT readings and associated heat alert levels as well as pre-determined limits—regardless of time of day—agreed upon with tournament organizers.
Green
When the alert level is green, normal activities are allowed but there should still be three, 3-minute fluid breaks per hour. Once the alert level reaches yellow, the length of those breaks should be increased to four minutes.
Orange
If at the orange level, activities should be limited to no more than two hours and the number of hourly 4-minute breaks should be increased to four.
Red
Weather conditions sufficient to cause a red alert should prompt organizers to seriously consider cancelling any outdoor event because the risk for heat illness is now high. At this point, the humidity is generally at a level where sweat is unable to evaporate (the primary way the body cools itself). Consequently, energy created by contracting muscles will cause the core temperature to keep climbing. If activity is allowed, it should be limited to one hour that includes four, 4-minute breaks.
Black
A WBGT high enough to trigger a black alert means no outdoor activity should be allowed at all.
What is best drink choice for hydration breaks? For several reasons, a chilled sports drink is better than water alone. Athletes are likely to drink more than if offered water alone. The electrolytes in a sports drink will help replace the electrolytes lost via sweat while helping the body retain a desirable fluid level.
The goal is to avoid a loss more than 2% of body weight
The goal is to avoid a loss more than 2% of body weight because at that point, performance begins to suffer. Most athletes are unaware of this threshold. ATs who share this knowledge with their athletes are likely to have better cooperation from those athletes when implementing a rehydration plan.
According to the NATA’s position statement on fluid replacement, “More than 2% hypohydration causes a decrease in sweat rate and sweating onset. Severe hypohydration (greater than 5%) threatens the ability to maintain normal body temperature, exercise intensity, and vital organ function. A potential consequence of hypohydration is a generally linear increase in core temperature during physical activity, with core temperature rising approximately 0.158C to 0.208C for every 1% of body weight lost (due to sweating) during activity. When a hypohydrated individual exercises, the added thermal strain is due to both impaired skin blood flow and altered sweating responses.”
Because older individuals, namely coaches and referees, are even more sensitive to the effects of heat and do not sweat as efficiently, they should be part of any AT’s rehydration plan.
Given that multiple studies have demonstrated that 50% or more of athletes, at all levels, begin a practice or game already at some level of dehydration, an AT’s rehydration plan should include having coolers full of sports drinks or water available right from the start of any event.
Athletes should be encouraged to drink until no longer thirsty.
Not only does the AT face having 50% of participants hypohydrated, the AT covering a flag football or 7-on-7 tournament is unlikely to know who skipped breakfast, who has respiratory or gastrointestinal illness, who pre-hydrated with an energy drink, or who has sickle cell trait.
Consequently, exertional heat illness — specifically heat stroke — may still occur despite the best hydration plan and strict adherence to weather alert levels. The NATA fluid replacement statement warns, “Thermoregulation is compromised by hypohydration greater than 1%, and the risk of exertional heat illness increases at moderate to severe levels (greater than 3%).” Therefore, ATs must always be prepared to diagnose and treat heat stroke during late spring, summer, and early fall events.
The only reliable method of determining if an athlete’s temperature has reached 105 degrees Fahrenheit is via a rectal thermometer. Once an athlete has reached that critical threshold, the situation has become a true medical emergency and, according to the Korey Stringer Institute, an AT has only 30 minutes to reverse the process with onsite cooling in a cold-water tub. Otherwise, severe internal organ damage and death become likely.
Prior to any event where heat illness is a concern, organizers and ATs should have already established with local EMS that treatment for suspected heat illness will be to cool first and transport second.
While ATs may have more than enough to do keeping a watchful eye on those playing flag football or 7-on-7, the event may also include a linemen skills competition.
The current issue (May-June 2025) of Sports Health includes a study entitled “Preventing Exertional Heat Stroke in Football: Time for a Paradigm Shift.” In it, the authors warn, “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.”
Consequently, according to the article, since 2001, 97% of the victims of fatal exertional heat stroke in football were linemen and over one third of the incidents resulted from “punishment” runs. Of note, no such deaths occurred in games.
To protect linemen, then, the authors of the study advocate training linemen for the way they play the game and – during contests, unlike other positions – they hardly ever sprint. The lead author of the investigation was Scott Anderson, the retired head athletic trainer at the University of Oklahoma. He and his colleagues urge improving safety by prohibiting for linemen “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 advocates a four-week duration for linemen.
Regardless of what part of the season it is, Anderson and company call for the elimination of punishment drills for all players.
Whether linemen are present or not, Anderson’s data and advice are worth sharing with coaches at flag football and 7-on-7 tournaments this summer. They will need it once tackle football conditioning and practices begin.
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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