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Poor Football Helmet Fit Linked With More Severe Concussions, Longer Recovery In High School Players

Coaches, trainers and physicians need to supervise helmet checks throughout the sports season, experts say

High school football players with ill-fitting helmets are at greater risk for concussions of greater severity and duration, according to a study presented at the 2016 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS).

In particular, air-bladder lined helmets are  associated with concussions of longer duration, which may be in part due to poor maintenance and air leakage. 

"This study suggests that incorrect helmet fit may be one variable that predisposes a football player to sustain a more severe concussion," said senior study author Joseph Torg, MD, an orthopaedic surgeon specializing in sports medicine at Temple University Health System.

The study is the first to single out the impact of helmet fit based on a long period of study covering nine sports seasons from 2005 to 2014. Orthopaedic sports medicine experts analyzed information from 4,580 athletes ranging in age from 13 to 19. Data was obtained from the National High School Sports-Related Injury Surveillance System (High School RIOTM for players with first-time concussions.

Athletes who suffered concussions due to improper fitting helmets had higher rates of drowsiness, hyperexcitability and sensitivity to noise. Many of these athletes experienced more than one of the 13 concussive symptoms reviewed retrospectively in the study. In addition, athletes wearing helmets lined with air bladders suffered concussions in which symptoms persisted longer.

"Correct helmet fit varies with helmet design, and players are encouraged to fit their equipment according to manufacturers' instructions," said study co-author Dustin Greenhill, MD, an orthopaedic surgery resident at Temple.


Dr. Greenhill explained that when helmets don't fit correctly, an athlete's cervical muscles in their neck and head may not be able to reduce the force of impact on the brain, especially when parts of the body rotate during high-speed hits. Helmet fit can change and evolve during the season and games, due to sweat, hair style, rain, cold weather clothing, and other factors.

"The risk factor of poor helmet fit should be minimized through mandated adult supervision and midseason spot checks," Dr. Greenhill said.

The study also suggested that the 2012 rule adopted by the National Federation of State aimed at ensuring proper helmet fit in high school athletes by requiring removal of athletes whose helmets come off during play to miss at least one play has failed to effectively improve the percentage of helmets that fit or the severity of concussions sustained in high school football. Team physicians, athletic trainers, coaches, and high-school officials should require proper oversight of helmet fit in high school athletes in order to decrease concussion severity and duration.  

Properly fitted helmets maximize protection against concussion 

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.

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; 
  • 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;


"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," said Joseph Torg, MD, lead author of the paper and a professor at Temple University in Philadelphia, who developed the guidelines with the assistance of Paul Kelly, Athletic Equipment Supervisor at Temple University and a certified member of the Athletic Equipment Manager's Association.

 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.")

Buying different style helmets
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.

Helmet fitting is step-by-step process

Step1. Prepare Helmets
Before beginning any helmet fitting session, all the helmets should be properly prepared.
Inspect each helmet, inside and out making sure it is clean and there are no defects.
Be sure any used helmet has been properly reconditioned.
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. Player holding football helmet

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.

For more information, please visit www.AEMA1.com.

*Important note: Dr. Torg's research paper, while presented to a respected sports medicine organization, was never published in a peer-reviewed journal. While there are numerous reasons why a research paper is never published, it is possible that the paper could not pass the rigorous scientific scrutiny such journals demand before publication, and thus his findings should be viewed with caution, especially since MomsTEAM is not aware of anything in the medical literature replicating his findings. 

Navo PD, Comstock RD, Torg JS, Zhao H, Boden BP. Inadequate Fit Inreases Concussion Severity in American High School Football Players. Paper 845. Presented at American Academy of Orthopaedic Surgeons, Orlando Florida, March 4, 2016  

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.