Football remains one of the most popular sports in America, but participation at the high school level in South Dakota is falling steadily as the risk of brain injuries becomes clearer.
Participation in 11-player boys football in South Dakota fell by 5.2% over the past three years and 16.6% over the past decade, according to data from the National Federation of State High School Associations, which has done annual surveys for more than 25 years.
Participation in nine-player football fell by 3.7% nationwide over the past 10 years, according to the survey.
The decreases came as student enrollment in grades nine through 12 in South Dakota was essentially flat during that 10-year time frame.
Nationally, participation fell across all sports for the first time in nearly 30 years; in boys 11-player high school football — the sport with the highest participation — fell nationally by 5.2% last year to about 1.1 million players.
Studies have shown that from 5% to 10% of youth football players will suffer a concussion at some point during a full season.
Supporters see the sport as one that builds character, focuses on teamwork, and is fun to play. Furthermore, population trends in the state show reduced enrollment in many rural schools and decreased opportunities for play.
“I think it’s more than just looking at the number and saying, ‘Well, over this period of time we’re down all these kids participating and that it’s because we’re concerned about safety,’” said John Krogstrand, assistant director of the South Dakota High School Athletics Association, who oversees boys sports for the group. “I think it’s much more than that.”
South Dakota had 3,756 participants in 11-player football in 68 schools in 2009 and 3,133 in 66 schools last year, according to the national survey. For comparison, the state had 3,576 participants in boys basketball last year, and 697 in boys soccer.
Krogstrand noted that his association and school districts have implemented safety guidelines, improved equipment and instituted concussion protocols to prevent head injuries and treat them better.
In South Dakota, the reduction in participation has led some districts to enter into co-op agreements in which schools form a single team. Other schools have moved from 11- to nine-player football.
Most parents are aware of the risks, yet many say they believe the game has gotten safer as the awareness of head injuries has risen.
Dale Uttecht of Sioux Falls recently watched his son, Joe, play football for Sioux Falls Washington against Rapid City Stevens. Uttecht said he sometimes holds his breath while watching another son, Logan, play wide receiver for Augustana University.
“All the players are bigger, faster and stronger, so any injuries are going to be worse,” he said.
Uttecht said the increased recognition of the risks of head injuries has led to changes that he believes make the game safer, including at Washington High, where a certified trainer is present for all practices and games.
“You always have concerns, but I hear about concussions in soccer and basketball, too,” Uttecht said.
Numerous research studies have shown a strong correlation between concussions and contact sports. A concussion is a mild traumatic brain injury in which the head and brain shake violently, often causing confusion, headaches, dizziness, nausea or vomiting, and in severe cases, loss of consciousness. Evidence shows that the longer a person plays football and the more hits to the head they take, the chance for long-range impairment or illnesses increases.
In its literature on concussions and sports, doctors at the Sanford Health Orthopedics & Sports Medicine Department in Sioux Falls write that, “One of the worst things any athlete can do for their health is to keep playing after a concussion.”
Yet those same physicians report that as many as 40% of youth who suffer a concussion return to play sooner than safety guidelines suggest. They also point to research showing that athletes who suffer one concussion are more likely to have subsequent concussions and can face “potentially catastrophic consequences” if a second concussion occurs.
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A growing concern for athletes in contact sports is the finding that chronic traumatic encephalopathy, or CTE, has been diagnosed in people who have had repeated jolts or hits to the head.
CTE has no treatment or cure and can lead to mood disorders, memory loss, behavior problems and dramatic personality changes. In CTE, a destructive protein spreads through the brain, killing brain cells along the way.
CTE research and individual cases have raised concerns over the potential for brain damage in football players. CTE can only be diagnosed in the brain by autopsy following death.
The results of a 2017 study by researchers at Boston University and reported in the Journal of the American Medical Association showed that CTE was found in the brains of 177 of 202 former football players, including 99% of those who played professionally and had been in the game the longest.
Study conclusions were limited, however, because of “selection bias” since the donated brains tended to come from patients who exhibited symptoms of cognition or behavioral problems before death.
New research at BU in 2018 further heightened concerns about repeated brain injuries and the connection to a condition called Lewy body disease, which can increase the risk of dementia, Parkinson’s disease and Alzheimer’s disease. The study showed that participants in contact sports including football, hockey and boxing were more likely to develop Lewy body disease, even independently of symptoms of CTE.
CTE risks drew national attention after Aaron Hernandez, a college and professional football star, committed suicide in 2017 while incarcerated at the age of 27. Doctors later said his brain showed the worst case of CTE they had ever seen in someone so young.
The NFL has made concussion identification and prevention a top priority over the past few years, expanding examinations and increasing the list of symptoms that can prevent a player from returning to a game.
The South Dakota High School Activities Association has links to information about both concussions and CTE on its website under a “Health & Safety Issues” heading, including a sample Return to Competition form that outlines protocol for returning athletes back to competition after suffering concussion symptoms. The form concludes with the advice, “When in doubt, sit them out.”
Krogstrand noted that his association and school districts across the state have been aggressive and hands-on in improving safety for football players and improving protocols to address injuries when they do occur.
Coaches, athletic directors and referees are required to complete an annual online course about concussion prevention, identification and treatment (players with concussions must have physician approval before returning to plays, for example). Other new rules limit the time and amount of contact players can have in practices, he said.
“We’re doing everything we can with the information when we get it to minimize risk for student athletes and make it as safe as we can with the knowledge that there’s risk that is natural and inherent to the game,” Krogstrand said.
One youth football league in South Dakota is anticipating strong participation in the future, in part because of a greater focus on safety and improved communication with parents.
Lee Kruse, a director of the Black Hills Youth Football League, said participation in the West River league has risen from 850 players in 2015 to 902 this year. The league features players in pads in tackle-football games in several leagues ranging from first through seventh grades, though it has no connection to the school system.
Kruse said the increased information on concussion risks led league organizers to drop team sizes to six players and ban all special-teams plays, including punts and kickoffs, which are more likely to include running collisions. The league also increased training for coaches and referees, who must be certified, and purchased new equipment for players.
Organizers also reduced the focus on scoring and instead promote game play that focuses on knowing the rules and exhibiting sportsmanship.
“We go over the top on safety, and play for the right reasons, because it’s about development and not touchdowns at this age,” Kruse said. “I just feel like we’re doing a lot of things right to create a positive experience.”