Authors: Rachele E. Vogelpohl, PhD, ATC

Corresponding Author:
Rachele E. Vogelpohl
109 HC Nunn Drive
Highland Heights, KY 41099

Rachele Vogelpohl is an assistant professor and Athletic Training Program director at Northern Kentucky University, and is a certified athletic trainer. She graduated from Northern Kentucky University with a bachelor’s degree and from the University of Hawaii, Manoa with both a master’s and doctoral degree.

The Value of Athletic Training Employment in Secondary School Athletics

Millions of secondary school students participate in interscholastic athletics each year, and unfortunately, injuries occur. Athletic trainers are health care providers specifically trained in injury prevention, diagnosis, and rehabilitation. Employment of an athletic trainer in the secondary school setting ensures that the student athletes are participating in a safe environment, that they are being cared for free of charge, and that emergency situations are handled in the proper way.

Keywords: Athletic Trainer, Interscholastic Athletics, Sport Safety, Sports Injuries

Nearly 8 million students participate in high school interscholastic athletic programs each year in the United States (4, 19). The number of student athletes has drastically risen over the last five decades, where participation has doubled since the 1970’s (19). Part of this increase is due to Title IX legislation which required schools to increase opportunities for female student athletes (2). Female student athlete participation increased from just under 300,000 in 1971-1972, the year Title IX was passed, to 3.3 million in 2015-2016, while male participation has increased from 3.7 million to 4.5 million during the same time (19).

Although there is debate over the value of interscholastic athletic programs, especially in times of budget cuts, there is research to support the positive impact of interscholastic athletic program participation. It has been suggested that student athletes have higher grade point averages, better attendance rates, lower discipline referrals, lower dropout rates, and higher graduate rates than those who do not participate in high school athletic programs (6, 20). Additionally, skills like discipline, team work, self-confidence, fair play, acceptance of others, goal setting, and leadership are developed as part of athletic participation that the student athlete will carry with them to the future (18). Most importantly, interscholastic athletic programs provide opportunities for all, including minorities and students from disadvantaged backgrounds (7).

Due to the large student athlete population and the potential immediate and future benefits of interscholastic athletics, it is important to ensure that the student athletes are properly cared for and have a safe environment in which to participate. Athletic trainers (ATs) are recognized by the American Medical Association as health care professionals who focus on injury prevention, injury diagnosis, and injury rehabilitation (12). Athletic trainers work under the direction of a physician, and act as the facilitator of the entire sports medicine team. Working closely with a physician, the AT can more efficiently refer patients directly to the physician which will save money by minimizing emergency room visits and additional physician referrals. Athletic trainers are specifically trained to handle emergency situations during athletic activities and are extensively trained in concussion diagnosis.

Athletic Trainer Employment in the Secondary School
The extent of AT employment in the secondary school setting varies. Some schools have full-time AT employment where the AT attends practices and competitions for the different male and female sports as well as offer open clinic hours for students to walk in when they have an injury. Other secondary schools have part-time employment of ATs, where the ATs are only responsible for working football and/basketball competitions, but do not work with any other sports, attend practices, or have clinic hours. Finally, many schools have no access to an AT. A recent study indicated that approximately 70% of public secondary schools reported having some type of AT employment for athletic activities (22). Of those schools, 37% reported full-time AT employment, 31% part-time employment, and 2% reported employing multiple ATs (22). Private secondary schools had lower overall AT employment with 58% of all responding high schools reporting some type of AT employment, with 28% reporting full-time employment and 30% reporting part-time employment or some type of access to an AT (21). In both the public and private high schools, larger schools in more populated areas offered more AT employment, while smaller and/or rural school had limited to no AT employment (21, 22).

Injuries in Interscholastic Athletics
Although some AT employment for interscholastic athletics is positive, having an AT only at football or basketball games will not address the areas where many injuries occur. It is estimated that 1 in 5 or approximately 1.4 million high school student athletes sustain injuries each year due to participation in interscholastic participation (23). Approximately 60% of all injuries sustained during interscholastic participation occur during practice rather than during competition (17).

Unfortunately, due to the nature and demand of the sports that are played in the high school setting, serious and life threatening injuries occur. During the 2014-2015 academic year, the National Center for Catastrophic Sport Injury Research (NCCSIR) reported that 62 catastrophic injuries occurred in interscholastic athletics (14). Of those 62 catastrophic injuries, 22 resulted in fatalities while the rest were considered non-fatal or serious. Some of these student athletes did make a full recovery, while others will have continued disabilities. Since the NCCSIR began tracking catastrophic injuries in 1982, high school football alone resulted in 1130 catastrophic injuries which resulted in 354 fatalities from either direct or indirect mechanism, with 47% occurring during competition, 33% during practice, and the remainder during other team related actives such as conditioning, strength training, or scrimmages. The NCCSIR defines a direct mechanism as an injury that resulted directly from participation in the skills of the sport such as collision with another player, while they define an indirect mechanism as an injury that was caused by exertion while participating in a sport activity or by a complication that was secondary to a non-fatal injury and resulted in systematic failure, such as a cardiac event or heat illness (14).

Due to the collision nature of football, it is often thought that the direct contact mechanism is the leading cause of catastrophic injury, however, of the fatalities reported in football since 1982, 126 were a result of direct mechanism and 228 were the result of indirect mechanism. In addition to football, cheerleading, baseball, wrestling, and track and field account for the sports with the next highest rates of direct injuries, while male basketball, male track and field, wrestling, male soccer, male cross country, and baseball account for the next highest rates of indirect injuries. In all sports, the most common direct catastrophic injuries were a result of a fracture to the neck (36.7%) and traumatic brain injury (33.3%), while 75% of all indirect injuries were heart related and 14.6% are related to the total body such as heat stroke, sickle cell, stroke, asthma, or diabetic emergency (14).

Athletic trainers are specifically trained in preventing and caring for emergency situations, especially among the athletic population. Having an AT on site in the event of a direct mechanism catastrophic injury will better ensure that the athlete is immediately cared for in the correct manor to limit the extent of the injury. They are able to implement lifesaving skills while taking into consideration the proper way to navigate the equipment that the sport might entail in which other health care professionals may not be familiar. It is estimated that approximately 25% of spinal injuries have been made worse by improperly handling an individual wearing equipment during evaluation and transportation (24). Athletic trainers are familiar with the different types and models of equipment, and have training and experience in the proper equipment removal techniques. Emergency medical services (EMS) personnel often have little to no experience safely removing the facemask, helmet or shoulder pads in football athletes with a suspected cervical spine injury. The specialized training in the athletic population by the AT can help limit the extent of the injury to the athlete by providing appropriate care.

Additionally, indirect injuries such as cardiac arrest, heat stroke, asthma, and diabetic emergencies can be handled quickly and efficiently with an AT on site. A larger percentage of catastrophic injuries occur from an indirect cause, and can happen during any exertional activity including competition, practice, or training (14). An AT on site is available and trained to perform CPR and use the AED on an athlete having a cardiac arrest which could save their life. In an athlete with cardiac arrest, the longer it takes for CPR to begin and AED to be used, the lower the chance of survival. The onsite AT is able to provide emergency treatment until the EMS arrive to take over. Exertional heat illness is another cause of indirect catastrophic injury. A full-time AT is available to not only educate athletes and coaches on the importance of hydration in preventing heat illness and recognizing the signs and symptoms of heat illness, but they are also there for immediate action. Heat stroke is a life threatening condition that must be dealt with immediately or the illness could be fatal (1). The onsite AT can immediately intervene to lower the athlete’s core body temperature to a safe range so that the patient can be transported to the hospital, as the patient should not be transported until the core body temperature is lowered to 102°F (1). Athletic trainers are also trained to care for other sudden life threatening conditions such as asthma attacks, diabetic emergencies, and allergic reactions that can be cared for directly to reduce the risk of death.

Recently, traumatic brain injuries have become an important topic of conversation due to the emerging research on both the immediate and long-term negative effects of concussions. Participation in athletics while having symptoms of a concussion can lead to increased and prolonged symptoms, while sustaining another head impact when participating with a concussion can lead to long term brain impairment known as post-concussion syndrome, or to death due to increased pressure in the brain known as second impact syndrome (3). The potential long-term effects of multiple concussions are very serious. Diseases such as chronic traumatic encephalopathy (CTE) and pseudobulbar affect (PBA) have been found in individuals who had documented histories of concussions and/or repetitive asymptomatic subconcussive head impacts (26). Chronic traumatic encephalopathy is a degenerative disease of the brain that causes memory loss, depression, and dementia, and currently can only be diagnosed post-mortem (25). Pseudobulbar affect (PBA) is a neurological disorder that has recently been linked to traumatic brain injury that causes outbursts of laughter or crying in inappropriate contexts (11). Concussion awareness, immediate diagnosis, and action is the number one way to prevent fatalities due to concussion (3).

More than 400,000 concussions occur in high school athletics each year and many more go unreported because many athletes, coaches, and parents do not fully understand what a concussion is or that it has even occurred (2, 10, 28). Children and young teenagers are at a higher risk for sustaining a concussion and take longer to recover from a concussion than adults due to their developing brains (27). Football has the highest overall number of concussion diagnosis making up 27.1% of all football injuries diagnosed during competition, and 22.9% of all injuries diagnosed from practice. Football is not the only sport with high rates of concussions. Girls soccer and basketball have the highest proportions of concussions, when looking at all injuries sustained in the sport (4). Concussions in girls soccer and basketball makes up 34.5% and 25.6% of all injuries in these sports while concussions make up 18.9% and 8.8% of all boys soccer and basketball injuries (4). Concussions do not only occur during competition, but are very common in practice as well. In girls soccer and basketball, concussion made up 36% and 31% of the injuries that occurred during competition and 31% and 17% of the injuries that occurred during practice, respectively (4).

Over the past decade, the number of diagnosed concussions has significantly increased. In the 2005-2006 academic year in high school athletics, 9.1% of all injuries were concussions, while in 2014-2015 academic year, that number increased to 24.6% (4). This increase in concussion diagnosis is likely due to increased awareness, on site ATs, and concussion legislation implemented by the states. Athletic trainers are extensively trained on recognizing signs and symptoms of concussions, concussion diagnosis, and return to play protocols following concussions (3). They work closely with physicians to determine when the athlete is safely able to return to play.

Currently, all 50 states have legislation on how to handle concussions in interscholastic athletics (5, 8, 13). There are three primary themes that are included in each state’s legislation and include: 1) concussion education for athletes, parents, and coaches; 2) removal of the athlete from sport participation if a concussion is suspected; and 3) requiring a health care professional to clear the athlete prior to returning to sport participation (9). Athletic trainers are able to carry out each of these three themes. Prior to sport participation, ATs can hold meetings that educate student athletes, parents, and coaches about concussions, the dangers of concussions, the signs and symptoms to recognize concussions, and what to do when a concussion has occurred. They are able to recognize athletes who have sustained a concussion during practice or competition and make sure that they are removed from participation and that they receive proper treatment. They are then able to facilitate appointments with a physician in order for the athlete to be cleared to play. When an AT is not available in high school athletics, these responsibilities fall to the coaches, parents and/or administrators. These individuals are not specifically trained to identify or to treat concussions, and as a result, the wellbeing of the student athlete may be at risk.

Liability Issues Associated with Injury
Additionally, not having an AT available could leave the school vulnerable to legal action in the event a concussion is not handled properly. Athletic trainers can create and implement a concussion policy that specifically describes the actions that should be taken in the event of a concussion. The concussion policy could not only include the mandatory items required by concussion legislation, but could also include items such as baseline concussion testing, concussion diagnosis screening, minimum time the athlete is removed from athletic participation, notification of teachers regarding concussion signs and symptoms, and specifying the type of health care provider who can clear the athlete for participation. It has been noted that in some cases, school administrators would accept notes from parents stating that they believe their child is cleared to participate in their sport (10). Specifically defining the policy and procedures in case of a concussion, and having the AT be responsible for overseeing the process will limit the liability to the school.

Many schools have parents sign a waiver to allow their child to participate in interscholastic athletics indicating that they are aware of the risks involved. However, in recent legal cases involving concussions, the courts have found that the signed waiver is not enforceable leaving the school at risk (26). In the past few years there have been several settlements in favor of the student athlete regarding concussions. Most of these lawsuits involve individuals with multiple concussions, returning to participation too soon, negligent supervision, lack of emergency medical response plan, and inadequate immediate medical response (26).

Athletic trainers can also help to reduce liability by creating and carrying out emergency action plans in case of an emergency. Emergency action plans are developed for each athletic facility/venue and document the plan of action in case of an emergency. There are also specific plans developed in case of weather emergencies. Having an athletic trainer on site for both practices and games ensures that these plans are being followed. Whether it is an emergency situation where EMS need to be called, or lightning is in the area and play needs to be suspended and shelter be taken, the AT is there to quickly and efficiently facilitate the plan, which will in turn decrease mistakes that could lead to liability issues.

Additional Benefits of Hiring a Full Time AT
Hiring a full-time athletic trainer in the secondary school setting not only ensures that the athlete will be properly cared for in the event of an emergency, it will also help to reduce the overall risk of injury as well as the cost to the athlete’s family if an injury does occur. One study analyzing the types of services provided by the AT in the high school setting found that 48.8% of services performed by the AT were preventative in nature, 37.2% were care for a current injury, and 13.9% were care for a new injury (15). These services provided by the AT at the secondary school setting help to prevent injury from occurring, or reoccurring after the initial injury. If an AT is not available, the student athlete would not receive any preventative care treatments which could put them at greater risk of sustaining an injury. If an injury does occur, they have to go to an outpatient clinic for their rehabilitation, and many families do not have the funds available for those services. If proper rehabilitation is not conducted, the chances of re-injury are very high. Previous research found that two ATs in the high school setting provided 13,766 treatments (prevention, diagnosis, treatment, and rehabilitation). If these treatments were done in the outpatient clinic, they would be valued at $2,753,200, while in the high school setting, these services were free to the student athletes (16).

In more rural settings, athletic trainers may be one of the few health care providers to which student athletes have immediate access. There tends to be limited availability of physicians, EMS, and hospitals, making the full-time athletic trainer even more valuable. However, AT employment in the rural setting is limited, with one study finding that only 11% of rural schools in Idaho had access to an AT and only 9% had access to a physician for high school athletics (10). If ATs are not available, all medical decisions will fall to the coaches who may be only trained in CPR.

Interscholastic athletics are very popular extracurricular activities for high school students and the overall, lifelong benefits from participation are vast. At the same time, the risk of injury during participation is also very common. It is important for schools to keep their students safe, which can more easily be done by hiring an AT. Full-time AT employment, for all sports practices and competitions ensures a safer environment for participation, minimizes initial injury and re-injury, limits liability to the school by quickly responding to life threatening emergencies and implementing emergency action plans, and reduces the healthcare cost associated with injury to the families of injured student athletes. Administrators often site budgetary constraints as the primary reason for not hiring an AT. There are ways to gain AT employment outside of hiring a full-time employee at the school. Many hospitals, rehabilitation clinics, and physicians partner with schools to provide employment. Additionally, local universities often hire graduate assistants through the university to provide AT employment at the high school setting. These options may be more cost effective to the school, while still gaining the full-time AT employment needed to provide the safest environment for interscholastic participation.


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