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Making Sure Football Helmet Fits: A Simple, But Effective Way To Minimize Concussion Risk?

Air bladder helmets increase risk of catastrophic injury; no evidence that new football helmet technology reduces risk of mTBI

Making sure that football helmets fit properly, and that those with air bladder linings are properly inflated, may be two of the simplest but most effective ways to minimize the risk of concussion and catastrophic brain injury, say researchers in a paper1 presented to the February 11, 2012 meeting of the American Orthopaedic Society for Sports Medicine.

Specific findings

The paper by researchers at Temple University, the Orthopedic Center in Rockville, Maryland, and the Nationwide Children's Hospital in Columbus, Ohio, found that:

  • athletes wearing properly fitted football helmets, as reported by team certified athletic trainers, were 82% less likely to experience concussion with loss of consciousness (LOC);
  • Helmet age, condition (new vs. reconditioned) or helmet lining type (foam, air, gel) were not significant predictors of amnesia or LOC; Young football player with mouthguard
  • Air bladder helmet liners pose an increased risk of catastrophic intracranial brain injury (subdural hematoma/cerebral edema), with 84% of the injuries of this type occurring between 1989 and 2001 involving air bladder helmets.  The increased risk may be related, the authors said, to decreased maintenance, as air-bladder systems are prone to leaking, and helmet fit may be compromised with an insufficiently filled air bladder; and
  • The risk of concussion with associated amnesia increased 35% for each increased school grade level, which the authors said may be a function of increased exposure or due to endemic factors.

New helmets don't reduce risk

The paper found that the percentage of high school and college football players sustaining concussion has remained relatively constant over a 30-year period and is relatively small (4 to 6%); that the number of those experiencing post-concussion syndrome or a protracted recovery is very small; and that the number sustaining an intracranial injury is extremely small (4 to 8 per season, or 0.6 per 100,000),

That such percentages have persisted despite improvements in helmet technology led the paper's authors to question whether they were having any protective effect.  Consistent with previous meta-analyses, the paper found no definitive data to support the view that advanced football helmet technology and design is more protective against concussion or intracranial hemorrhage.

Predisposition to injury?

"It is well recognized that air bladders deflate on a regular basis and helmet fitting, particularly in high schools, is haphazard.  Yet many thousands of youngsters with poorly fitting helmets and/or deflated bladders receive multiple heat impacts without injury," noted lead author, Joseph Torg, MD, of Temple University.  This  "strongly suggests" that those who suffer concussion (mTBI) or experience a protracted recovery are predisposed to injury.

The paper thus suggest that the "first and currently unappreciated step" in resolving both acute brain injury problems should be to identify the factors that make an athlete more susceptible to mTBI/concussion and intracranial injury and take steps to disrupt the predisposing injury combinations, including:

Possible Factors Predisposing Players To Concussion Or Catastrophic Brain Injury

  • Helmet type or fit
  • Environmental
  • Dehydration
  • Viral illness
  • Medications
  • Anatomic factors 
  • Gender
  • Body mass index (BMI)
  • Genetic
  • Psychiatric
  • Age
  • Prior concussion
  • Depression
  • Fatigue
  • Hormonal disturbance
  • Others to be identified
  •  Metabolic
  • ADHD
  • Position
  • Migraine headaches
  • History of previous head injury

New guidelines for proper helmet fitting 

"As we look at preventing concussions and minimizing risk, it is important to realize that it is the responsibility of the athletic director and head football coach to have policies that: Insure that each player has a properly-fitted helmet and that a responsible adult supervises and oversees proper helmet air bladder inflation on a weekly basis," Torg said. (Think this isn't a problem? Think again.  A February 9, 2012 story in the Boston Globe reports that players letting the air out for comfort, making their helmets too loose is such a common problem at one local high school that the coach "often walks around with an air pump to reinflate the helmets.")

The protocol, believed by the authors to be the first published protocol for appropriate headgear fitting, was developed with the assistance of Paul Kelly, Athletic Equipment Supervisor at Temple University and a certified member of the Athletic Equipment Manager's Association. 

The guidelines recognize, as a preliminary matter, that:

  •  While there is no "concussion proof" helmet, concussions or the severity of concussion can be minimized with a properly fitted helmet combined with proper playing technique;
  • As heads come in various shapes and sizes, when it comes time for a football program to purchase helmets, it should buy more than one style, as carrying at least two styles will allow the program to fit a broad range of heads; and
  • The pamphlet that accompanies all newly purchased helmets needs to be kept on file, updated and old versions replaced.

Step1. Prepare Helmets

Before beginning any helmet fitting session, all the helmets should be properly prepared.

  1. Inspect each helmet, inside and out making sure it is clean and there are no defects.
  2. Be sure any used helmet has been properly reconditioned.
  3. Be certain that the NOCSAE stamp and helmet warning label is clearly legible on the outside of the helmet.

Step 2. Obtain Athlete Information

Ask if athlete has ever had any prior concussions or a broken nose. Find out what kind of helmet was worn before and if there were any issues. Ask how did it fit and how it felt?

Check for any physical abnormalities on athlete's head.

Step 3. Measure Head

Using a cloth tape measure, begin at the side of the head and wrap around about 1 inch above the eyebrow and around the occipital lobe to obtain head circumference to determine

Helmet size.

  • Medium will range around 20-22.5 inches
  • Large will range around 21.5-23.25 inches
  • XL will range around 23-25.5 inches

Step 4. Select Helmet and Fit

This is based on product knowledge and information from the last 2 steps. There will be variance.

  • Athlete may try on 2 or 3 helmets and should select the one most comfortable.
  • To fit helmet selected, follow manufacturers fitting instructions.
  • Inflation should raise the frontal rim of helmet about one inch above eyebrow and snug around circumference of the head.
  • Jaw pads should be touching the jaw and not the ears.
  • The rear padding should be infirm but with comfortable contact with the head.

Step 5. Chinstrap

The chinstrap simply keeps the helmet on the head while playing. The chinstrap is not a means to adjust the fit of the helmet. With the cup centered on the chin, the front or high should first be adjusted and buckled followed by the rear or low hook straps.
There should be equal tension on all the straps.

Step 6. Check Fit

  • Crown pressure: Pull helmet straight down on athlete's head. You are looking for the pressure to be evenly distributed on the top of the head and the helmet should not come down on the nose.
  • Lateral grip: Place your hands on each side of the helmet and ask the athlete to hold the head still. Gently force the helmet from side to side. What you are looking for here is the helmet padding to grip the head and not slide across the face. Facial skin should bunch up.
  • Vertical grip: Again, place your hands on each side of the helmet and ask the athlete to hold the head still. Gently roll the helmet backward and forward. The skin on the forehead should move with the helmet and with enough force it will eventually slip a little ,but it should catch on the eyebrow without coming down on the nose.

Step 7. Maintenance.

  • Helmets, especially air bladder helmets, will change throughout the season.
  • Helmets should be examined weekly to insure they remain properly fitted in good condition.
  • Recheck the air-bladder suspension and helmet fit following the above guidelines.
  • Fill the bladder only while the helmet is in place on the athlete's head. Facemasks may be bent with contact. Replace as needed.
  • Check helmet shell for cracks and helmet hardware for rust. Replace screws as needed to insure the facemask can be removed easily in an emergency.

Final steps

When you have completed the fitting, ask whether the athlete is comfortable with the helmet, and let the athlete know that you are pleased with the fit. Record all pertinent information about the athlete's helmet and be sure it is specifically distinguished for the respective athlete.

Be sure to explain to the athlete what you are doing through each step and why. This serves 2 purposes. The athlete's trust in you is reinforced and will be confident not worrying about getting hurt when playing. More importantly it educates the athlete to quicker troubleshoot any problems that may occur with the helmet.


1. Torg J, Boden B, Hirsch H, Fowler J, Gaughan J, Comstock RD, Tierney R, Kelly P.  Athletic Induced mTBI and Catastrophic Intracranial Injuries: Determining Helmet Efficacy and Predisposing Injury Profiles.  Presentation Paper AOSSM 2012.

Posted February 12, 2012; updated July 13, 2013

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