I guess in baseball terms, I'm the guy batting ninth in the lineup. Is that right? You know, kind of the weakest hitter. So I've had all the heavy hitters. But it's a real pleasure to be here. I want to say thanks to Dr. Voos and the program committee, certainly to the folks at AOSSM, leadership of NFLPS and PFAS for putting this course together. Really appreciate the chance to have this group come together. You've got a great faculty. Also want to say thank you to the men and women who are the team physicians, the athletic trainers, the sports staff of the NFL. Their work's what's going to be reflected today. A lot of you are in the audience. And you'll recognize your work. So can't thank you enough. And you're really the bedrock of everything we're doing. And it's my joy to get to be associated with those folks on a day-to-day basis. Disclosures, I'm a full-time employee of the National Football League, which has some relevance to my talk. But what I'd like to do is kind of zoom out a little bit and think about this issue of safety in the game. You know, you've heard a lot about descriptive epidemiology, how injuries occur, what injuries occur. We've obviously done a pretty good job, I think, of counting injuries and understanding. But we're really trying to shift our focus around this idea of prevention. And can the game really be made safer? And while that might sound like sort of a basic or elementary question, I think some people kind of doubt that. And often we'll say, you know, it's football. It's collision sport. There are going to be injuries. And these things are going to occur. But we've tried to look at it with our group and as a league, really, and say, we do believe the game can be made safer if we understand the drivers of injury, if we understand some of these mechanisms and how they may intersect. And so as we think about how to reduce injury, there are a lot of strategies, there are a lot of levers we can pull. We can think about equipment, and that's a pretty obvious one. But what about rules and how style of play has impact on injury? What about how we train, teach, and coach the game? I just came from our owners meeting in Arizona this week. And we spent an hour with the head coaches of the league going over some of the data. Because we've come to realize they are really at the tip of the spear when it comes to a lot of the injuries. You heard in the talk on college football, how many injuries occur in practice? So much of that we think is avoidable by simply changing how we practice, the structure, the type of drills, the nature of the interaction, and then obviously supervision and medical support. So this slide probably reflects the most fun and enjoyable part of my job. And that's all the different data sources that we have available to us in the NFL. All of our teams report their injuries to the same electronic health record, which actually just changed this week. We're in the midst of a brand new EMR. So you can imagine how nice my email is running this week. But at any rate, we have all that health data from our teams. But we also have game reports. We have game personnel medical reports. We have incredible amounts of sensor data. All of our players wear sensors during their training and game competition. We have equipment tracking. Helmets are tagged so that we have RFID chips that know exactly what helmet each player is wearing. Cleats are tagged. Shoulder pads are tagged. And so we can take all that plus a lot of environmental stadium data and, of course, video and put all that together. And with our partners at IQVIA that you heard about from Tim and BioCorps and Engineering Group, really begin to sort of comprehensively understand injuries in a way that others can't. And here's one example. As we started looking at concussions and how we could affect the incidence of that, our engineers went in and took all the video from each injury. So we've got the injury report from the club medical. We've got a game day medical report. We know the circumstances and the environment of the injury. Now they go in and take the video and they mapped it against 150 different variables. Who hit who? What was the speed? What was the direction? What was the play type? Where was it on the field? What was the environment? And from that, they created a finite element model here. Sorry, it doesn't look like my video is going to play. I don't know if you can hit play for me on the video there. But they're able to reconstruct a collision that occurs on the field here. And as you see these two players collide, on the left-hand side of the slide are the force vectors represented by the helmets, this digitized reconstruction. And you can see the Bears player who's actually injured has a secondary peak of this angular acceleration after this head-to-head collision. And so taking this type of engineering analysis, they created a finite element model and said, OK, if we're going to design a better helmet, it's got to withstand this type of force. This is the type of environment where these injury-causing collisions are occurring. And so that's the power of the data that we have, taking the medical data, the monitoring data, the video, and putting it together. So you heard from Tim that injury burden is so important to us. To me, this is our North Star, is we try to start to organize ourselves. And if we say, we want to make the game safer, we have to start here. What are the injuries that keep our players off the field? And these are the high-burden injuries. You heard from Tim already, the hamstring actually leads the list. I think that probably comes as a surprise to people. But hamstring injuries cause players to miss more time than any other injury. And so that's got to be the main focus of our attention. You see that ACL is number two, not as many injuries, more time lost. And as you go down the list, you'll see the others that appear here. But you'll notice that the majority of these are in the lower extremity. They happen below the waist. And so while we get a lot of press about concussion, it's near and dear to my heart, and we'll talk about it, we really, as we started thinking about how do we focus our efforts, our prevention efforts, our research efforts, this has to guide us. And so we have set up task forces against each of these high-burden injury areas. Many of these leaders that are here today, Julie Freymire's in the room and Roland Ramirez with the shoulder, Lee Weiss that you're going to hear from the soft tissue task force, Ben Stolberg, who's here in New Orleans with the ACL and knee task force, Nate Weir in Green Bay in the foot and ankle task force. And so you'll hear a lot of this work presented over the next couple of days. But we've given each of these groups the goal of saying, how can we not just describe, but actively reduce and prevent injuries affiliated with your area? And I won't spend a lot of time laboring over this since Tim touched on some of it. You'll also hear from some of these other individuals. But this is how we organize ourselves. And as we think again about something like LEX, injuries, we've got a lot of levers, again, we can pull. Again, how does the surface contribute? What's about training and so forth? What's the role of the cleats? Bracing and taping you heard about already. So there are a lot of factors, again, that we can sort of look at comprehensively to really understand the role for these injuries. And I'll give you one illustration of that. You'll probably hear from Lee about lower extremity strains. When we started really digging into this and we start talking to coaches about it, we really want to grab their attention about it. And so we looked at how many players that are getting the strains are missing the roster. Sorry, let me go back. And how many of these then were recurrent. And there was a large burden of recurrent. And so we start talking to coaches about the preseason. And we said, you know what? Getting your players acclimated, doing this ramp up really matters because you're going to lose two or three players to injury who are going to suffer with that injury the entire season. It's going to start in the preseason. It's going to linger throughout the entire season. We've got to really focus on prevention in that preseason. We got some traction from that, but this is what really convinced them. And I'm going to walk you through this slide because it's busy but very compelling to coaches. This looks at all of our teams in the league. Each bar is a team. It looks at four seasons, 17, 18, 19, and 21. We took out 2020 because there was a global pandemic that totally changed our preseason that year. And we've been to the teams to say during that preseason, for the preseason lower extremity strains, were they in the lowest one-third, the highest one-third, or the middle one-third of all NFL teams? Where did they fall out? And as you can see, a couple of factors here. Teams tend to be similar year over year. You know, if you're a team that tends to have high strains, you tend to have it year over year. If you're a team that's low strains, you tend to be in the lower group. But we presented this data to coaches. And again, few people engaged, but one longtime NFL coach who was in the room stood up and said, hey, Doc, I want to keep my players safe, but I got to win games. That's how I keep my job. Can you tell me how this affects winning and losing? Pretty fair question, something we hadn't looked at. So we actually went back and looked at the relationship to outcome to these lower extremity strains. And you can see the Lombardi trophies dropped in here that showed that the four Super Bowl winners in those years happened to be down here on the favorable end of the graph. I wouldn't be showing you this slide if they'd been down here on this side. But I will just say that this now catches the coach's attention. Now we've got the head coach's attention to say, wow, okay, maybe what you're telling me really is relevant. Doesn't come as a shock to us, right? Healthy teams win. But this has direct link to say, how can something that seems as narrowly focused as a hamstring injury in the preseason, how can that actually ultimately affect outcome? And so we've kind of challenged ourselves to start doing these types of analyses. It's new to us, right? We rarely talk about winning and losing. But in a business like ours, a pro sports, these are the issues, again, that help us with persuading coaches around changing behavior. And so we met with coaches one-on-one last year. We met with every club. We talked about strategies for how you could bring players back. Tim mentioned this about how do you optimize that first period. Again, Lee Weiss gives tons of credit to he and his group of really doing the hard work to talk about how this duration and intensity ramp should be done. I'll let him talk some more of the details. But the bottom line is it worked. This is the data from 2022. 25% decrease in hamstring strains through the first three weeks of our training camp. You can see the gains were a little more modest through the rest of training camp, but overall 16% reduction for the entire preseason last year. And then strains went down in the season overall as well, kind of reflecting the fact that we did not have that recurrent burden injury. So I show you this, again, as kind of a proof of concept. We started with the data. We looked at the driving mechanisms. Lee and his group really went in and said, how can we pull some levers here to affect this? We went back to coaches. We needed to communicate to them how they played a vital role in this with managing the time and the activity in those first two weeks. And then we measured the outcome and fortunately saw a really positive effect. Our challenge this year and what challenged Lee and others is, how do we extend this kind of drop into these other periods? Because we've recognized now that we need some additional strategies as Tim talked about, pads come on, we get into preseason games, joint practices and things like that. So we'll have more to do with that. Tim mentioned biomechanical movement analysis. And I think this is another thing that we're excited about using these digitized screening tools. Again, if the videos will play here, you'll see that as this athlete performs a movement, we're able to not only do a digital capture. I'm sorry, it doesn't look like it's gonna play for me, but we're not only able to digitally capture this athlete in a complex motion, measuring ground reaction forces, measuring the posture, the pose, the angles that are generating. And now going back and looking at that in relationship to this athlete's risk of injury. I think this is not only gonna be a great tool for screening and talking about how we individualize that preparation, things like Tim mentioned ACL prevention, hamstring prevention. But I think this is also gonna help us in rehab. As we're bringing players back from injury, have they fully recovered? Right now we rely on their perceptions, some brief maybe physical exertions and whether or not pain occurs. But can we do more sophisticated physiologic and performance measures that actually determine whether recovery is complete or not? I think this is gonna be really important for us. Tim mentioned turf or cleats, and he mentioned that beast. Well, we now have a mobile beast. It looks something like this, which is a little device that drives around on the field. And it's gonna make those types of turf measurements that we talked about. We have a lot of work to do to understand surface. I could spend an hour telling you how complex it is. It's not just natural versus artificial, it's variability within those categories and variability of the individual surface. Obviously the grass in Green Bay plays very different in August than it does in January. So we've got to really get away from just good surface, bad surface, and get a lot more quantitative about the surface characteristics, the stiffness, the infill, the restitution, the force. All of those characteristics I think are gonna correlate with injury, whether it's natural or artificial. And so this device this year, which we'll be deploying, drives around the field, surveys it. And we'll do that on a longitudinal basis, not just one time. Because clearly we can't measure the field once in August or once in October and use that as a characterization of the field for the entire season. We also have to think about performance, though. As we measure surfaces, we can make a super safe surface, but if athletes can't perform on it, they're not gonna be happy. And so we're doing some work, as you can see here, having elite athletes actually perform football movements on different surfaces and determine how does they perceive that surface in terms of performance. Because we've got to find that balance between safety and performance and trying to, again, optimize both of those. And ultimately we hope, like I said, for the helmets that we can develop this finite element parametric turf model so that whether, again, it's natural or grass, you're designing it to specific characteristics. Not does it look great, not do we paint a great logo on there, but what are the characteristics and how consistent can those be? Now we get to something I can actually speak about with some depth, and that's head impacts. And to me, this is one of our biggest challenges, not just in the NFL, but in sports as a whole. How can we reduce the incidence and severity of all head impacts in sport? I think this is a challenge we all have to embrace and adopt, and it's a real phenomenon, and it is something that I think we can make progress on. Because when I think about head impacts in sports, I kind of think about three big buckets. There are those that are intentional, where somebody goes after the head. Pretty much everyone would say that shouldn't be a part of any game, right? That needs to be against the rules, and that's a culture. There's a challenge, as was mentioned in the talk about college sports. How do you judge intent? I don't think you can make very good rules about intent, because very, very hard to judge. Obviously, no player ever says they had the intent to injure someone else. But I think intentional head contact, we set aside. There's what I'd call inadvertent head contact, where players accidentally collide with each other, or they hit on the ground. Those are common to all sports, and those are very difficult to eliminate. But that leaves us with the big, big, big bucket in the middle of what I would call avoidable head contact, which means there was a head contact, but there didn't have to be. Think of it that the head was involved, but there was a different way, there was a different technique. And this is, again, where we come back to the role of coaching, and why I think as sports medicine providers, we're gonna spend more and more and more, we should spend more and more time with our coaches, educating them, helping them look at how they're teaching, coaching, and practicing the game. And we have to be able to demonstrate you can be just as effective at a movement. For example, in football, at blocking, without using your head as you can with using the head. There will be some element of rules change here, but rules change won't really get at this. It's primarily a culture and a teaching issue. And so as again, we think about how can we affect this in football, I like to talk about helmet impact or head impact reduction as volume, intensity, and density. So volume, we gotta drop the total number of times the head is hit. That's for both games and practices. People tend to focus on games. Let's don't forget how much contact can and does occur in practice. And we have to think about that cumulative effect. You know, think about a pitch count in baseball and how effective that's been with injuries. We monitor pitchers across the season. We should be thinking about head contact in the same way. And again, this isn't just about tackling. This is also about blocking. Intensity is we'd like to drop the force of any blow that does occur. And we'll spend a moment talking about that. I think here equipment does play a role. And then density, how many impacts per a given unit of time. We're really in our infancy at understanding this, what are risks and what are thresholds. But again, this is gonna affect our game and practice schedule. I think real time monitoring is something that's really gonna help us here. We're gonna need the ability to measure this. Again, work that our engineers have done. If you watch the right guard here, hopefully this video will play for us. And you'll see that this guard is gonna go and have an impact, boom, right there. Small, short impact. You'll see it again, just a very brief moment of this angular acceleration. But we've got players now in the NFL and some in the NCAA wearing these instrumented mouth guards. They can measure the force and help us to understand that even in a collision like this where there wasn't an obvious concussion, there can be a fairly high degree of force that can occur that can be injurious over time. And so we have to understand that. But mouth guard sensors are hard. There's a lot of technology that goes into that. There are a lot of engineering challenges. So our engineers have developed what I think is one of, again, the revolutionary things that have helped us understand this. And that's an artificial intelligence system that can count helmet impacts by watching video. So basically, you'll see on this play, if we run it again, each time there's a helmet impact, there's a sticker that'll occur with a player. And we can actually let the computer watch the entire game. You see that interaction there. It's going to measure who's hitting who, how frequent that's occurring, and give us very detailed information. We used to have people do this by hand. I always say that is a job you do not want to have to watch games and count helmet impacts. It would take a person two, three days to watch a game. Takes the computer 10 to 12 minutes. So now our engineers have gone back and looked at every NFL game since 2015 and counted all the helmet impacts. And when we do that, we can compare concussion data with impact data. Concussions, who's sustaining them? No surprise, again, as you heard. It's our linemen, O-line and D-line. But they also have the most helmet impacts. You can see here that as you start to look at video, helmet impacts are much more common among linemen than any other position. D-line, actually, the most. But if you look at the cumulative effect, it's the O-line. And why is that? Well, D-linemen tend to sub in and out. O-line tends to not. So in terms of total number, it's the offensive linemen. So now we can generate a graph like this. What this shows you is a season summary of helmet impacts for every one of our clubs, one to 32, from the most to the least number of helmet impacts. And we started last year a pilot program of giving this data to our clubs. We're actually gonna give it to all of them this year on a weekly basis. So every week, our club will get a report showing for their O-line and D-line, where did they rank one to 32 in terms of number of helmet impacts for their linemen for that week, compared against the league, and for the season as a whole. And what we saw last year as we did this with a couple of clubs is this is the kind of data that coaches need to begin to start changing behavior. Because we not only give them the team-based data, we will give them individual players. So they'll get their report where they are on the graph. Okay, here was our team, here's our D-line, here's our O-line, but we can break it down further and say, here's the helmet impact rate for your tackle, your guard, your center, all the way up and down. And so I think all of us would understand what we can measure, we can now change. Now we've got the ability to measure this, and I think it's gonna be really instructive. Let me also say, I didn't put the slide in because I forgot in the crunch of time, but I'm happy to report that, and we showed the coaches this week, guess who the team was that was the absolute lowest in the number of helmet impacts last year for the whole season? Any guesses? Maybe from this side of the room on the, one, two, third row. Yeah, it happened to be the Super Bowl champions, whose training staff is here. Again, pretty nice argument when we go in and talk to coaches about how this is a relevant topic, the fact that the Super Bowl champion had the lowest helmet impact rate. But this is very player-specific, and so I wanna show you how dramatic this can be. Walk you through this. This is a graph of head contact of offensive guards, 2020-21 season. Every dot is one player for one season, okay? So two seasons of data, every dot's one player. And I wanna call your attention to the ends of the curve, player A, player B, we've called them. These are very evenly matched, same size, same number of years experience, very highly effective, both all pro guards, but a two X difference in the amount of head contact between those two individuals. Two times difference. And why is that? Well, when you put on the tape and you watch this player play, that player tends to lead with his head on almost every block. This player down here, much more of a hands and shoulders technique. And so as we look at these team numbers, it's very, very heavily driven, obviously, by individual player behavior. But the point of this slide is, you can play the position very effectively without using your head. We just have to be able to demonstrate that and show the different examples. And so, again, go back to our interaction with coaches. How are we teaching players? What are we doing that will either promote or protect against head contact? And again, I'll give a shout out. We've had some coaching thought leaders that we've been working very closely with who are really looking at drills and things. If you look at some of the tools that we use, this is probably not the right way to teach some of this, right? That's teaching bending over, using your head as the leading point of contact. And so we're really working with groups to understand how are they teaching, what's the language, and how can we do a better job of that as we try to affect player behavior? As I said, sort of getting into this hands first, as opposed to getting the head into a block. Now, I mentioned equipment. I think equipment plays a role here. It's clearly not the big driver, the driver's behavior in coaching, but equipment can assist. And last year, most of you know, we introduced the Guardian Cap in the NFL. Many of you have used it in college or high school levels. But our engineers tested this version of the Guardian Cap, it's the NXT version, and found that it had about a 10 to 15% force reduction for each blow. If both players were wearing it, that was an additive effect. And so last year, our players wore this in the first couple of weeks of preseason. Just this week, a day before yesterday, our owners passed an expansion of this. So this year, the position groups that you see listed here, the linemen, O-line, D-line, tight end, running backs and linebackers will wear this for all helmeted practices in the preseason, anytime a helmet is on, and then all contact practices for the regular season. Why do these position groups start? Well, because those are the ones that have those highest rates of helmet contact. And because, you know, we wanna start with those in the practice areas where we see the highest density. Obviously last year, there was a lot of hubbub about this. You know, there was some less than enthusiastic adopters. And I actually put this up because I really am an admirer and Coach Tomlin is a friend, and he actually put this on not to mock it, but he had every single player on his team wear it, whether they were mandated or not. And he was a big advocate, and he just said, we're gonna do this. It's keeping you safer, and this is what we need to do. And that coach buy-in, again, had so much of a positive impact, no pun intended, on really getting this adopted and getting it to be worn. So we saw dramatic, really almost unexpected results last year. There was a 52% reduction in preseason practice concussions among the position groups that wore the guardian cap relative to their three-year average. Those who were not wearing the guardian cap, no difference. Same concussion rates as always. Those who wore the guardian cap, 52% drop. I'm gonna say to you right now, I don't expect that every single year. And if that number had been zero, I would not have considered that a failure. And you say, why do you say that, Doc? Well, we didn't introduce this to primarily be a concussion protection device, right? Again, the goal of the guardian cap was that blow after blow, play after play, reduction in force whenever a collision occurs. So the fact that it reduced concussions to us is almost a bonus. But I think, again, we don't want the notion to be this is a concussion protection device. It's primarily there to reduce that intensity metric that I talked about with each one. Something else that was really fascinating was of the concussions that did occur in those players with a guardian cap, half of them were due to an impact with a face mask, which is obviously not covered. We're not gonna get that covered with a guardian cap. So again, really, really impressive efficacy from this introduction. We did not see any increase in neck injuries. We also did not see any increase in concussions in the games when the players who wore them in practice took them off. Okay, so players wearing it all week in practice gets in a preseason game, didn't see any increase in the rate. We obviously had some feedback from our trainers and others that heat management was a challenge or a concern. We've studied that with the Corey Stringer Institute, with North Carolina State. They actually did some really elegant work and showed there was no reduction in heat transfer with the guardian cap. In fact, it might even help in some environments. The only negative is if you're wearing a black guardian cap in a really hot weather environment, there probably is some heat absorption, but light colored caps, no difference in heat management. And there were some challenges with slippage. And so the cap's been redesigned a little bit this year to sort of reduce that. So overall, again, I think the message has to be, this isn't the total solve. We're not gonna solve head injuries in football by this, but it's another step we can take as we try to change behavior and add some protection. And I like to sort of make the analogy that this is like an airbag or side impact protection or seat belts. The best way to be safe is to avoid the collision, but if there is a collision, hopefully this is something that gives us a little bit of extra margin of protection. So this just shows you that reduction and shows you as well that I said, half of the concussions that occurred happened in areas that were not covered by the guardian cap. So there's been a little bit of a design update, as I mentioned this year, that's gonna go down a little bit lower to keep it from slipping. You actually want the cap to slip a little bit because that's part of the protection and it'll be fixated just a little bit better than it was before. One other thing that we're talking a lot about as equipment that you'll see emphasize are position specific helmets. Again, from that engineering work, we've learned that different players are injured in different mechanisms. So quarterbacks, for example, tend to be injured by falling against the ground, blow to the occipital area, they're sort of getting rid of the ball, they're unprotected. And so our engineers have modeled that in the lab and have used that to actually help companies design a better helmet. And so this year, there is a quarterback specific helmet, it's made by Vysis. You can see that it's got increased padding and stiffness back here in that occipital area. It performs better, about an 18% performance improvement over the better performing helmets on our helmet poster. And so we're really emphasizing this as something that we think can make, again, an additional margin of safety for quarterbacks. There's also an offensive line specific helmet, the Trench, it's called. And again, it's got additional protection in the front of the helmet, which is where the linemen tend to take the majority of these blows that are causing a concussion. So I think you'll see both of these on our fields this year. There's been some interest in both. And again, I think we're a year or two away from seeing even more choices, defensive back or defensive secondary related helmets, wide receiver specific helmets, things of that nature. I think in the future, different players, different positions will be wearing different helmets. So again, every year, as you know, we put out this poster, which ranks helmets based on laboratory testing. It's been really extensively validated. It correlates really well with what happens on field. And I will just say that every year new helmet models come in and get up here at the top of the poster and best performing, others get pushed down. And that innovation will continue. Helmets will continue to get better. But again, we'll start to break this apart. And rather than just having one chart, we'll actually have instructions for different positions. So this year you'll see, for example, as I said, specific instructions or data for alignment and for quarterbacks. So let me just close and say lots more work to do. I think this is to me, one of the most exciting times in sports medicine, as we think not just about counting these injuries and treating them, but preventing them. Everyone in the room has a role to play there. Most of what I've showed you today, I've tried to say I think can be translatable to other levels of play and also other sports, but obviously much more work to do, but particularly on surface and on some of the lower extremity injuries. We didn't even talk about shoulder, didn't have time to get into that. So there's a lot more to be done, but I'm excited about where we are. And I'll just put in one last plug to say that I think, as you hopefully will get the flavor from our task forces, this work isn't just about physicians and athletic trainers. We have to involve strength and conditioning, performance managers, sports scientists, equipment managers, all of these individuals who are part of this modern day athletic medicine, need to have a seat at the table as we discuss these issues. And importantly, as I keep coming back to coaches, we have to be intersecting with coaches and really bringing them into these discussions because they control so much of the environment that's really gonna be a driver for injury. I put this up just to say that I send a newsletter out a couple of times a month. If you'd like to get on the list, you can sign up. You don't have to look at my picture each month, thankfully, but love to be able to share things like what I've shared with you today. We do that on a pretty regular basis. It's free. So if you'd like to sign up, just go to the website and we'll be glad to put you on the list. Thanks again so much for having me and have a great meeting here. Thank you.

safety in football

injury prevention

coaches' role

data sources

lower extremity injuries

equipment in injury prevention