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Ralph Nader and League of Fans Call for Federal Government-led Advancement in Prevention of Sports Injuries June 8, 2005
Today, Ralph Nader and the sports reform project League of Fans sent a letter to federal health and safety officials arguing that their agencies "have been collectively deficient in research, preservation of data, recommendations and overall recognition of the public health magnitude of sports injuries."
The letter was sent to Michael Leavitt, Secretary of Health and Human Services; Julie Louise Gerberding, Director of the Centers for Disease Control and Prevention; Ileana Arias, Acting Director of the National Center for Injury Prevention and Control; and Hal Stratton, Chairman of the U.S. Consumer Product Safety Commission.
Enclosed with the letter are recommendations urging the establishment of a task force to formulate sports injury policy and implement "a pro-active national program regarding health and safety in sports, at all levels and age groups, with the goal of minimizing the risk of injury to participants in informal and organized sports, recreation and exercise." The letter follows.
June 8, 2005
The Honorable Michael O. Leavitt
Julie Louise Gerberding, M.D., M.P.H
Ileana Arias, Ph.D.
Hal Stratton
Dear Guardians of Public Health and Safety:
Sports injuries, which cost American consumers tens of billions of dollars each year, could be significantly diminished by injury prevention programs.
According to the 2002 CDC Injury Research Agenda, “More than 10,000 people receive treatment in the nation’s emergency departments each day for injuries sustained in [sports, recreation, and exercise] activities. At least one of every five [emergency department] visits for an injury results from participation in sports or recreation.”
Many preventable sports injuries cause long-term damage. As Sara Pierce reported in the May 2, 2005 edition of the Montgomery Blair High School (Silver Spring, MD) newspaper Silver Chips, Erica Nowak, now a senior, sprained her ankle during a lacrosse game in 2002 but returned to play two days later against her doctor’s warnings and now suffers the painful consequences of poor injury management. Three years later and still playing, with the pain unbearable at times, Nowak’s ankle requires weekly physical therapy sessions. “It’s gotten to the point where I need major physical therapy and maybe even surgery,” said Nowak. “But as much as I appreciate what the doctor tells me, sitting out the season is really not an option.” Even if Nowak’s original injury was not preventable, the long-term, possibly life-long damage from injury mismanagement certainly was preventable.
Some preventable sports injuries can cause death. Such is the case with the October 1, 2003 death of six-year old first-grader Zachary Tran from Vernon Hills, Illinois. According to Brooke de Lench, Editor-in-Chief of MomsTeam.com, the official cause of death was cardiac arrest due to massive head injuries. But had the soccer goalpost that fell on him during practice been secured, as it should have been, Tran would still be alive. According to the Consumer Product Safety Commission, Tran was at least the twenty-seventh person to die from a falling goalpost since 1979. A preventable death.
14-year old Eisenhower High School (Alsip, IL) freshman football player James Van Slette had a known history of concussions, four (three from football) in the previous five years, and one so serious that it knocked him unconscious. Three days after playing in the final game of the season, Van Slette died in the middle of the night after earlier waking up feverish and vomiting. According to Brooke de Lench, Van Slette “had confided to friends -- but not to his family or coaches -- that he was having severe headaches and might have suffered a fifth concussion” during the final game. While preliminary autopsy results were inconclusive, it is possible that Van Slette died of “second impact syndrome,” suffered when a second head injury (such as a concussion or cerebral contusion) occurs before symptoms associated with a previous head injury have cleared. In all likelihood, Van Slette’s death was also preventable.
The Consumer Product Safety Commission estimates that injuries to children younger than 15 years old involved with 29 popular sports cost the U.S. public more than $49 billion per year.
Many of these injuries are overuse injuries that are preventable. Relatively few people, however, are aware of the serious and growing problem of overuse injuries. As Bill Pennington reported in the February 22, 2005 edition of The New York Times, “Around the country, doctors in pediatric sports medicine say it is as if they have happened upon a new childhood disease, and the cause is the overaggressive culture of organized youth sports.” Pennington wrote that “. . . one factor was repeatedly cited as the prime cause for the outbreak in overuse injuries among young athletes: specialization in one sport at an early age and the year-round, almost manic, training for it that often follows.”
As David H. Janda, M.D. wrote in his book The Awakening of a Surgeon: One Doctor's Journey to Fight the System and Empower Your Community:
"With increasing worldwide participation in sports, injuries have become an epidemic of global proportions. Those of us on the front lines of health care delivery feel frustrated and perplexed by the apparent inability of government, business and medical research facilities to focus on the issue of injury and injury prevention."
We believe that the Department of Health and Human Services (HHS), the Centers for Disease Control and Prevention (CDC), the National Center for Injury Prevention and Control (NCIPC), and the Consumer Product Safety Commission (CPSC) have been collectively deficient in research, preservation of data, recommendations and overall recognition of the public health magnitude of sports injuries.
Therefore, we urge your respective agencies to make it a high-visibility priority to: 1) establish a task force to formulate sports injury policy due to the differing jurisdictions of the various government agencies dealing with sports injuries; and 2) implement a pro-active national program regarding health and safety in sports, at all levels and age groups, with the goal of minimizing the risk of injury to participants in informal and organized sports, recreation and exercise.
Injury is the major reason people quit a sport. And common misconceptions about sports injuries act as a barrier to increased participation in physical activity. Nonetheless, increasing numbers of Americans are participating in various sports activities and taking advantage of the many benefits that sports and physical activity can provide. Unfortunately, the lack of a coordinated and pro-active approach toward preventing sports injuries in this country contributes to an increase in the number and severity of injuries for youth, adult and senior level sports participants. These injuries undercut not only the ability of people to participate in sports, but the efforts of the many public and private organizations working to get more Americans physically active.
According to Bruce Svare, Ph.D., founder and director of the National Institute for Sports Reform (NISR), in his book Reforming Sports Before the Clock Runs Out:
"Clearly, more time, effort, and resources need to be devoted to the important area of prevention if this [sports injury] trend is to be reversed. Our athletes are becoming more skilled and are training harder than ever before, but we do not devote adequate resources and attention to health and safety issues. Many studies now show that equipment and training changes could effectively prevent many sports injuries. However, sports governing bodies do little to incorporate these changes because of cost, tradition, pressure from equipment and insurance companies, and the benign neglect of our federal government."
Current federal efforts do highlight the need to get people participating in sports and other physical activities and address the treatment of injuries when they occur. But programs to prevent sports injuries are overlooked, suffer from inadequate focus, insufficient funds allocated to a meaningful effort, and from the lack of administrative consolidation that could launch a concrete program with a concrete purpose that would have broad support across the country.
The “Preventing Injuries in Sports, Recreation and Exercise” chapter of the 2002 CDC Injury Research Agenda is a start. These nine pages recognize the sports injury problem in this country and indicate that the CDC has an interest in doing something about it. Most importantly, perhaps, is that the CDC admitted in its report that the federal government lacks good data on sports injuries, stating:
"Few data exist about injury incidence and prevalence, costs, relative risks of injury from different activities, risk and protective factors, and effective programs to prevent [sports, recreation, and exercise (SRE)] injuries. While some [emergency department (ED)] surveillance data are available, they lack exposure information and exclude the large proportion of sports, recreation, and exercise injuries that are treated in primary care settings, sports medicine clinics, orthopedic clinics, and chiropractic clinics."
Despite the federal government’s lack of data on sports injuries, the CDC report touched on the known magnitude of sports injuries:
- SRE injuries . . . place a large burden on the health care system for both initial care and rehabilitation. They also result in costs related to lost productivity and other factors. Despite the large number of ED visits for these injuries, most medically treated SRE-related injuries are treated by health care providers outside of the emergency setting, indicating that the magnitude of the problem is much greater than ED statistics suggest.
- In 1999, Americans made an estimated 1.5 million ED visits for injuries sustained while playing basketball, baseball, softball, football, or soccer. Approximately 715,000 sports and recreation injuries occur each year in school settings alone. Injuries are also a leading reason people stop participating in potentially beneficial physical activity.
- Recent reports estimate that approximately 3.7 million ED visits occur each year for injuries related to participation in sports and recreation.
- The cost of [anterior cruciate ligament (ACL)] reconstruction alone, not including initial evaluation or rehabilitation, is just under $1 billion per year in the U.S. Data from other countries also suggest that the cost of other SRE-related injuries is quite high.
- In 1996, people ages 65 and older made 53,000 sports-related ED visits. This represented an increase of 54% since 1990, while the population grew by only 8% in the same time period. As Americans live longer, they will likely remain active longer, increasing the need for effective injury prevention strategies for active older adults. Additionally, research suggests that exercise is important for older Americans to maintain physical and mental health and independence.
The CDC report also recognized the federal government’s responsibilities for injury prevention:
- CDC’s mission includes both promoting physical activity and preventing injuries. While another center at CDC has an active research program in physical activity, the Injury Center includes a focus on sports, recreation, and exercise injury prevention. Although the scope and depth of this research has been limited, the Injury Center is uniquely positioned to provide epidemiologic and prevention research about SRE-related injuries.
- Working with other agencies, nonprofit organizations, and professional organizations, the Injury Center can provide complementary research to facilitate safe sporting environments and identify risk and protective behaviors.
The CDC report acknowledged that prevention measures work to minimize sports injuries:
- Effective interventions exist to prevent SRE injuries, but they frequently are not used. . . . CDC’s strength in program implementation, evaluation, and health communication makes research in this area a natural opportunity, and advances will be broadly applicable to other health promotion areas.
- Many promising interventions exist but have not been evaluated. These include modifications of physical play environments, use of current and newly designed safety gear, and gender- and age-specific equipment requirements.
One example of a potentially successful injury prevention measure is the use of breakaway bases, as opposed to stationary bases, on baseball and softball fields. Baseball and softball have long been plagued, and continue to be plagued today, by injuries due to sliding into stationary bases. In fact, about 70 percent of all softball and baseball injuries are caused by sliding into a base. Some of the more serious injuries include ankle fractures, knee sprains, wrist and shoulder dislocations, and head injuries.
The previously mentioned Dr. David Janda is one of the experts leading the fight in the area of sports injury prevention in this country. An orthopedic surgeon based in Ann Arbor, Michigan, Dr. Janda founded and directs the independent, nonprofit Institute for Preventative Sports Medicine (IPSM). Over a two year period (1986-87) and during his residency at the University of Michigan, Janda studied the effectiveness of the breakaway bases for injury prevention and documented his findings in The Awakening of a Surgeon.
The stationary bases still found all across the country are just that -- fixed, immovable objects. The base is “bolted to a metal post, then sunk into the ground, and fixed in concrete. . . . So a player who slides into this iceberg the wrong way can do a tremendous amount of damage to him or herself,” writes Dr. Janda. In the conclusion of his study, Dr. Janda states:
"Base-sliding injuries are the result of many factors, including judgment errors by the runner, poor technique and inadequate physical conditioning. But the breakaway base can effectively modify the outcome of these factors as a form of passive intervention -- in much the same fashion as an automobile air bag mitigates the outcome of an accident caused by another driver."
The breakaway bases Dr. Janda studied consisted of a rubber mat attached to a post which is inserted into the ground and a base that snapped onto the rubber mat. The bases came in youth, teen, adult and pro models, and differed only in the amount of force it took for the bases to breakaway. Under normal play, breakaway bases separate during just 3% of slides, posing little threat to game quality. When the bases did release, umpires did not have difficulty with judgement calls since the rubber mat that is flush with the infield surface was considered the base when determining if the runner was safe or out.
Over the two years of the study, there were no complaints by players or administrators regarding the use of breakaway bases as opposed to traditional stationary bases. According to Dr. Janda, on the fields used for the study:
"Teams played 637 games on breakaway-base fields and 635 on stationary-base fields. The same players in the same leagues played in all the games. By the end of the study, 45 people sustained injuries on the stationary-base fields, and two on the breakaway-base fields. In other words, we realized a 96% reduction in injuries by switching from stationary bases to breakaway bases. Furthermore, the 45 people injured on the stationary bases had medical bills of over $50,000 during a one-year period. The two people injured on the breakaway bases had medical bills of $700. So we experienced a 99% reduction in health care expenditures by switching from stationary to breakaway bases."
The breakaway base study was later published in The Journal of the American Medical Association, and analyzed by the Centers for Disease Control and Prevention. Dr. Janda wrote that “Based on their analysis of our study, the CDC concluded that if all the [bases on baseball and softball] fields in the United States were switched from stationary to breakaway bases, it would prevent approximately 1.7 million injuries a year and save two billion dollars in associated health care costs a year nationally.”
Despite these findings, and many more injuries and medical bills, breakaway bases still haven’t been widely adopted. How can it be that a federal government agency makes such a clear conclusion about the benefits of a simple injury prevention measure that would not interfere with the integrity of the sport but would prevent millions of injuries and save billions of dollars in health care costs yet nothing is done?
One reason may be that several stationary base companies attempted to sabotage the financing, block production, undermine distribution , and misrepresent breakaway bases to leagues and officials. As Dr. Janda explained:
"[The Hollywood Base Company] did everything they could to prevent the use of breakaway bases solely because they didn’t have a financial interest in the product. During trade shows and on business calls, they would tell people that breakaway bases were inferior, that our studies were wrong, and that the product shouldn’t be used. I firmly believe that one of the reasons Major League Baseball refused to adopt breakaway bases had to do with its ties either through licensing agreements and/or fees to the Hollywood Base Company and other stationary base manufacturers."
No matter the financial interests of powerful companies, the Consumer Product Safety Commission has the regulatory authority to effect change. Unfortunately, this appears to be typical of government inaction, even in the face of overwhelming independent evidence, regarding sports injury prevention. The federal government's continued delay in supporting basic initiatives in sports health, safety and injury prevention is not without its price, as the safety of millions of American sports participants is heavily influenced by sporting goods manufacturers and governing bodies of the various sports whose interests, financial or otherwise, may coincide with maintaining the status quo.
Such is the case with the continued use of high-performance aluminum bats in college, high school and youth baseball. These bats carry a greater injury risk to players from batted balls than wood bats due to the higher speeds at which baseballs are propelled from them, and due to the larger “sweet spots” the high-performance bats possess. The National Collegiate Athletic Association (NCAA) and National Federation of State High School Associations (NFHS), have each stated in the past that they want the performance of bats to be wood-like, yet neither governing body is willing to either: 1) require bats to be made out of wood; or 2) require aluminum bats to not exceed the performance of wood in any way.
Instead of bringing bat performance in line with the “wood standard,” a level of injury risk associated with wood bats that has been generally accepted by all associated with the game of baseball as a “reasonable” level of risk for over a century, the NCAA and NFHS have failed to take the necessary steps to lesson the likelihood for tragedy.
As the major high-performance bat manufacturers (who also make wood bats) fight to maintain their profit margins, they argue that aluminum bats are as safe as wood and that there is no way to prove that the players who have been injured from balls launched off aluminum bats would not have been hit if the balls came off wood bats. But as Bill Thurston, baseball coach at Amherst College and former rules editor of the NCAA baseball rules committee, told The New York Times, “That's true. If I have a car accident going 70 mph, I can't prove it wouldn't have happened if I were going 55 mph. But I would like those chances.”
J.W. MacKay, a designer of high-performance bats for Hillerich & Bradsby from 1986 to 1997 resigned out of concern that the bats being designed and produced were much too dangerous to players. Now a whistleblower, MacKay works to undo his past work through lobbying for tougher regulations, providing expert testimony and releasing internal memos from the bat companies showing their disregard for safety. “Little did I know when I designed those bats, we would end up with something that was just lethal,” MacKay told the Associated Press. “Bats now act like tennis rackets.”
MacKay has also requested that the federal government establish rules requiring all non-wood baseball bats to perform like wood bats, and has asserted that bat manufacturers violated federal law by failing to report information about serious injuries sustained by people injured by their products. As MacKay told the News and Observer, “Every time someone gets hit by an impact from an aluminum bat, they get a fractured skull, it seems like. It doesn't take a rocket scientist to see what we did was wrong.”
On April 24, 2005, the Christian Science Monitor reported that Montana Governor Brian Schweitzer signed “an unprecedented resolution calling upon American Legion baseball, with its thousands of teams nationally, to adopt wood bats out of concern that aluminum counterparts propel balls at dangerous speeds.” In response, the American Legion issued a press release on May 5, 2005, stating “ . . . the American Legion’s National Baseball Subcommittee has concluded that there is no substantial evidence in scientific research to support the claim that baseball bats made from wood are ‘safer’ than bats manufactured from metal or composite materials.” Larry Price, Chairman of the subcommittee, added “ . . . The American Legion will maintain the current rule, which leaves the option for wood bats to the teams that play American Legion ball.”
Gov. Schweitzer’s non-binding measure was a reaction to the 2003 death of 18-year-old pitcher Brandon Patch, who was struck and killed by a high velocity line drive off of an aluminum bat. “We have a responsibility to protect our young people in their sports endeavors,” said Gov. Schweitzer. “Sometimes, common sense solutions have to come from an unlikely place like Montana.”
The establishment of adequate standards of responsibility in sports injury prevention should not be left to the manufacturers, as it mainly is now. The low quality of their performance in many cases accentuates the urgent need for publicly defined and enforced standards of safety in sports. Basic industry philosophy is a barrier to a rational quest for sports injury prevention. Companies within the sporting goods industry, not unlike many other companies and industries, are often concerned more with market share and profitability than with public welfare where their products are involved.
Only the federal government can undertake the critical task of stimulating and guiding public and private initiatives for safety and injury prevention in sports. A democratic government is far better equipped to resolve competing interests and determine whatever is required from the vast spectrum of available science and technology to achieve a safer sports environment than are corporations whose all-absorbing objective is higher and higher profits. As “the lead federal agency for protecting the health and safety of people,” the CDC, through its National Center for Injury Prevention and Control and with the implementation of enforceable standards by the Consumer Product Safety Commission, is the ideal agency to establish a task force to implement adequate standards in sports injury prevention.
Dr. Janda explained instances in The Awakening of a Surgeon where he tested sporting goods products on behalf of the Institute for Preventative Sports Medicine with the intention of releasing the scientific evidence for the benefit of the public. Ethical problems arose as manufacturers of the products being tested put profits over people in attempting to suppress the data and protect their flawed products.
These problems, and suppressed solutions, cannot be left to the vagaries of the market. As documented in The Awakening of a Surgeon, one example illustrates the point: Worth Inc. spent millions of dollars to market its RIF (Reduced Injury Factor) baseballs with an advertising campaign using the names of children who had died after being struck in the chest with baseballs. The firm was promoting the superior protective safety of its baseballs, implying that if they were in use, those children would still be alive. But the Institute for Preventative Sports Medicine’s independent scientific research found that the RIF baseballs afforded no significant protection and may have actually increased the risk of the injury it was marketed to prevent.
This illustration included: the admission by a representative of Worth Inc., in deposition and under oath, that the company never actually tested the product for what it was supposed to prevent; threats directed toward scientific researchers who were testing the product; Worth Inc. claiming its product had met the requirements of the National Operating Committee for the Safety of Athletic Equipment (an organization funded by the sporting goods manufacturers, with an especially close relationship to the president of Worth). The Consumer Product Safety Commission (CPSC) eventually recommended the product as effective, ignoring all of the scientific research that had proven otherwise and leading to the question of whether company pressure had been applied to the CPSC. Varying types and degrees of RIF baseballs and softballs are on the market today.
The government’s approach to the sports injury problem is fragmented and scattered among numerous federal agencies whose studies, for the most part, exclude sports equipment from their areas of responsibility, produce few policy recommendations and are not evaluated with the idea of translating knowledge into action. If your respective agencies are to be made capable of securing continually safer sports for everyone that will allow them to reach their goals of a more active and healthier citizenry, they will require a sharply focused supportive constituency that is dedicated and skilled in pursuing the interests of sports injury prevention.
Until this constituency assumes the leadership role that their superior knowledge makes available to them, legislators, governing bodies and other sports administrators will continue to display indifference toward action. This indifference is supported by a major misconception that is so entrenched in the lore of the sports world it is itself a cliché applied to virtually every instance in which a player is injured during a television or radio broadcast sporting event. Commentators, coaches and even athletes in interviews typically assert that “injuries are part of the game” and that there is very little anyone can do to prevent them or to reduce their severity. False!
Consider the severity of injuries trainers and doctors would be dealing with if not for the advancements in safety used in today’s sports -- advancements that in no way disrupt traditional game play. In baseball, equipment improvements such as batting helmets, catching equipment, padding on outfield walls and closer monitoring of pitchers intentionally throwing at batters have prevented countless injuries. In addition to improved helmets and other protective equipment in football, rules changes that have come into effect, such as those preventing spearing, chop-blocking (though for some reason not completely illegal in the NFL), clipping, clothes-lining and late hits on defenseless players, have prevented potentially devastating injuries.
It doesn’t take a persistent orthopedic surgeon dedicated to the prevention of sports injuries to know that many injuries can be prevented. For example, fans of the National Football League have all seen severe injuries which could have been prevented such as the season ending knee, ankle and foot injuries to celebrated players caused by artificial turf, sometimes without contact with other players. Some former players have said that artificial turf is responsible for shortening their careers, due either to severe injuries caused by the turf or due to the quicker wearing down of the body over a period of time when playing on turf. And some of the game's greatest stars, such as Gayle Sayers, Billy Sims and Jack Lambert, attribute career-ending injuries to artificial turf.
In February, 2005, Results of the “2004 NFL Players Association's (NFLPA) Playing Surfaces Opinion Survey” were released and included the opinions of 1514 active players from all 32 teams. The questions asked players to compare grass to artificial turf:
“Which surface do you think is more likely to contribute to injury?” 91.2 percent answered “Artificial Turf”;
“Which surface do you think causes more soreness and fatigue to play on?” 96.4 percent answered “Artificial Turf”;
“Which surface do you think is more likely to shorten your career?” 85.6 percent answered “Artificial Turf” (13.5 percent “Neither,” 0.6 percent “Grass”);
“Do you believe that you have had one or more injuries on artificial turf that would not have occurred on grass?” 41.5 percent answered “Yes” (22.8 percent “No”);
“Which surface do you think is more likely to affect your quality of life after football?” 87.4 percent answered “Artificial Turf” (9.8 percent “Neither”);
“When you become a free agent, how important a consideration will it be for you to sign with a team which has a grass home field?” 23.5 percent answered “Very Important,” 43.5 percent “Somewhat Important,” 33 percent “Not Important”;
“What type of surface do you prefer to play on?” 84.6 percent answered “Grass” (8.5 percent “No Preference,” 6.9 percent “Artificial Turf”).
The results of the NFLPA survey clearly show that NFL players almost unanimously agree that, even with the new generation of artificial turf fields installed in some football stadiums, they are safer playing on natural grass fields. And the risks are certainly not limited to football. Fans of Major League Baseball have witnessed how some of the best players are forced to take days off because their home field has artificial turf which can cause severe back, leg and joint pain that could lead to more serious injury and the need for extended time on the disabled list. These situations are outrageous and amount to knowing refusal to prevent trauma.
Many injuries are preventable and players need no scientific evidence to know that they have been put in harms way just by having to play on artificial turf. Today, new artificial turf surfaces are being installed for recreational fields all across the country despite the only claims of safety coming from the manufacturers. The only valid justification for using artificial turf is that it reduces costs of field preparation. Will preventable injuries be dismissed as “injuries are part of the game” in the youth and adult organized and recreational sports played on these fields as well? It is up to our guardians of public health and safety to investigate whether they are being put in harms way, and if so, to work to minimize the risk of injury.
A federal government task force dedicated to the advancement of sports injury prevention efforts and dispersal of news, information and recommendations on sports health, safety and injury prevention would give state and local governmental organizations, athletic governing bodies, educators, coaches, players, parents, health care providers, equipment manufacturers, insurance companies, activists and communities the best available tools to adopt, encourage or demand preventative measures.
If we are to fully combat the problems associated with sedentary lifestyles and physical inactivity, we must develop safer sports practices so more people can participate in them for longer periods of time. Better resources for injury prevention would also promote the nonphysical benefits of sports participation such as self-confidence, teamwork, character-building, skill development, self-efficacy, perseverance, sportsmanship and so on.
Is it not the responsibility of government to protect public health when it is known safety conditions can be improved? We believe that each of you and your respective agencies have the responsibility to take a pro-active role, making it a priority to prevent and reduce the severity of sports injuries at all levels, thereby increasing participation in sports and other physical activities, changing attitudes toward a healthier lifestyle and improving public health.
Enclosed are summarized recommendations for some of what a national pro-active sports injury prevention program should incorporate.
Sincerely,
Ralph Nader
Shawn McCarthy
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