A Rugged Truth: Preventing Death Amongst NCAA Football Players

In 1906, the organization which would become the NCAA was founded after President Theodore Roosevelt called leaders to reform “. . . the rugged nature of early-day football. . . [which]resulted in numerous injuries and deaths. . .”

In its century-long existence, the NCAA has taken measures to further its purpose of “. . . govern[ing] competition in a fair, safe, equitable and sportsmanlike manner. . .”  In 2007, the NCAA passed legislation requiring student-athletes “beginning their initial season of eligibility” to complete a physical examination prior to engaging in “practice, competition or out-of-season conditioning activities.”  Additionally, as of August 1, 2010, NCAA Division I student-athletes are required to be tested for sickle cell trait as part of their physical examination, unless they sign a waiver to opt out of the screening.

Sickle cell trait is a genetic disorder.  A sickle cell trait carrier’s hemoglobin “. . . tend[s] to cluster together, and cannot easily move through blood vessels.”  The clustering of sickle cells “. . . causes a blockage [which] stops the movement of oxygen-carrying blood.”  Sickle cell trait is more prevalent amongst the African-American community than other races.  A 1987 report, “Sickle-Cell Trait As A Risk Factor For Sudden Death In Physical Training” noted that eight percent of African-American U.S. Military recruits tested positive for sickle cell trait, whereas only .08 percent of “non-black” recruits tested positive.

As of 2006, every state and the District of Columbia screens newborns for sickle cell trait.  However, specific mandates are not in place in terms of notifying an infant’s parents of their child’s carrier status.  Additionally, many carriers of the trait do not experience symptoms, as the disorder is largely considered “benign.”  As such, many carriers are unaware of their sickle cell trait status.  Nonetheless, sickle cell trait carriers face complications, including death, when encountering “. . . intense, stressful conditions, exhaustion, [and] hypoxia (low oxygen).”

Since 2000, 21 NCAA football players have died while participating in the sport.  Sickle cell trait has been “. . . linked to at least nine of the 21 deaths of collegiate football players. . .”

Of the 21 deaths, none have come during the course of games.  Rather, all have come during pre-season workouts or practice activities.

Scott Anderson has been an athletic trainer at the collegiate level for 24 years.  He currently is the head athletic trainer at the University of Oklahoma, where he has worked for the past 15 years.  He previously served as Co-Chair of the National Athletic Trainers’ Association (NATA) Inter-Association Task Force on Sickle Cell Trait and the Athlete.  When asked about the role that conditioning activities played in the deaths of 21 NCAA football players since 2000, Anderson said,

“As we look at NCAA football, there have been 21 non-traumatic deaths since 2000.  One could start a clock at the conclusion of the BCS National Championship game and then stop the clock 100 hours into August pre-season practices.  Other than two deaths that occurred during September conditioning drills, that area is the window of every single non-traumatic death since 2000.  Eighteen of the deaths have occurred in non-practice activities.  The three occurring  in football practice, appear to be related to some conditioning element during practice.”

In April 2011, the NCAA considered a proposal which would have eliminated a student-athlete’s “. . . option to decline the sickle cell solubility test,” meaning that every Division I NCAA student-athlete would be tested for sickle cell trait prior to participating in intercollegiate athletics.

This proposal was rejected by the NCAA.

While it is not immediately clear to individuals outside of the NCAA legislative process why the proposal was struck down, there are likely several reasons why mandatory testing of student-athletes for sickle cell trait was not approved.

1.  Given the high prevalence for the trait in African-Americans, there arguably is a risk that these student-athletes could be discriminated against in terms of practice participation and playing time by coaches scared of instigating sickle cell trait complications in the student-athlete.

According to Anderson, since 1974, when the NCAA instituted its recommendation that student-athletes be screened for sickle cell trait, “there’s been no evidence that there has been any athletes discriminated against because of their sickle cell trait carrier status.”

Furthermore, Anderson was quick to point out that sickle cell trait carrier status is not indicative of an individual being ill-fitted to play sports.  The NFL tests all of its players for sickle cell trait and there has never been a report of a player in the league being discriminated against in terms of playing time as a result of his carrier status.  

“There’s evidence of athletes who have excelled with sickle cell trait.  It is not a counterintuitive to participation in sport.  All that is necessitated is some awareness that can come through screening and targeted education that can take place because of that knowledge and some precautions that expand the margin of safety for the athlete which doesn’t compromise their participation,” said Anderson.

2.  Because of the low prevalence rate for the trait in certain races, it is arguably not the best practice of medicine to test those who are at low risk for having the trait.

“The risk of sickling in a blond golfer is virtually nill, so the argument is, why subject the blond golfer to screening?  Some doctors say it’s not good medicine to do that,” according to Anderson.

However, Anderson discusses the success the University of Oklahoma has had in screening all of its student-athletes for sickle cell trait.

“When we implemented screening, we implemented it on a voluntary basis.  We left it at the discretion of the athlete whether they were screened or not.  We quickly discerned we were leaving too much to chance with that.  Within a couple of years of screening, we made it mandatory across the board.  As we made it mandatory, we went back and screened a number of our players who were currently here.  We identified one out of that group that had sickle cell trait.  It was as much revelation to that individual as it was to us.  [Since the University of Oklahoma has screened student-athletes] we’ve identified 22 football players with sickle cell trait.  Of those, 19 did not know that they had sickle cell trait.  In every case but two, one of the parents knew that they had sickle cell trait.  In one case, the parents didn’t know either that the child had sickle cell trait,” said Anderson.

3.  Sickle cell trait testing is a genetic test performed through blood testing.  Genetic blood testing is intrusive and by not allowing a student-athlete to decline the test, the student-athlete’s right to privacy is arguably violated.

It should be noted, that while urine samples are not seen as being as intrusive as blood samples, the NCAA mandates the drug testing of student-athletes.

It is not immediately clear how many Division I student-athletes decline sickle cell testing prior to participating in intercollegiate athletics.

However, given the chance to decline the test, it is possible that some student-athletes enter the field of competition unknowing of whether they are carriers of a trait which could kill them if proper precautions aren’t taken.

Imagine you are an eighteen-year-old African-American college freshman.

You were the star football player at your high school and heavily recruited.  Your athletic abilities, as well as your academic history, granted you the opportunity to receive a full-scholarship at one of the nation’s top universities to play football under a coaching staff which can best develop your game.

Prior to beginning summer conditioning, you’re told you must complete a physical examination.  Prior to the physical examination, you learn that the NCAA requires a blood sample be taken from you to test you for something called sickle cell trait.  You remember that a cousin has suffered with Sickle Cell Anemia for some time.  You on the other hand, have never shown any of the symptoms he’s experienced.

You then learn that you can opt out of having your blood drawn to test you for this trait.

Wanting to make an informed decision as to whether you should let a doctor draw your blood to test you for something you’re sure you don’t have, you hop on the internet to learn more about sickle cell trait.  You quickly realize your race is more heavily affected by the trait.  You also learn that if you work out too hard, your health could be affected.

Working out and your health is what got you to the point of having to endure a physical examination to participate in NCAA athletics.  You fear that if your test results are positive, your coach will not give you the playing time you deserve or allow you to be tested to perform to the best of your ability at practices.  You don’t want to risk losing all you’ve worked for to get here and play Division I football by a silly test for something you’re certain you don’t have turning up positive.

So you sign the waiver.  And you decline the test.

You don’t know if you are a carrier for sickle cell trait.  And your coach and athletic trainers don’t either.

Did the NCAA make a mistake by allowing such a simple, yet important decision to be placed in the hands of eighteen-year-old incoming student-athletes?

In 2004, Aaron Richardson was an 18-year-old freshman at Bowling Green State University.  Richardson was a talented high school athlete whose heart was set on becoming a walk-on defensive back for the university’s football team.

On September 5, 2004, in 85 degree heat, Richardson hit the practice field with the team.  With the team, Richardson ran “gassers”–a conditioning exercise involving interval sprints from sideline to sideline, and also engaged in a stretching regimen.  Slowly into the stretching regimen, Richardson began complaining of cramping in his lower legs.

Initially, a student coach attempted to alleviate Richardson’s cramping by stretching his calves and hamstrings.  Richardson left the field on his own power and returned to the locker room where he laid on the floor in the prone position and continued to complain about cramping in his legs.  Richardson was sweating and breathing heavily.  A student assistant tried to give Richardson Gatorade to hydrate him, but Richardson could only take two sips.

Then, Richardson experienced cramping in his abdomen.  He would later complain of full-body cramping, as an athletic trainer checked his  legs and couldn’t find any physical signs of cramping.

The head athletic trainer leaned over Richardson and said, “Rough first day?”

The young man replied, “Yea, rough first day.”

Shortly thereafter, 911 was called.  Before paramedics arrived, Richardson stopped breathing and was without a pulse.  The head athletic trainer performed CPR and an Automatic Electronic Debirillator was used.

At 5:35 p.m. on September 15, 2004, Aaron Richardson was pronounced dead.

Richardson’s life ended on the same day his collegiate football career began.

Aaron Richardson’s death occurred before the NCAA required physical examinations.  Richardson died before athletes had the ability to opt out of sickle cell trait testing.  Richardson himself was tested for the trait at age seven and was found to be a carrier.  However, prior to September 15, 2004, Richardson never experienced sickling.

Some eleven years later, an eighteen-year-old Richardson filled out a medical history form to participate in football at Bowling Green State University.  Without the prompting of the adult who accompanied his seven-year-old self to a doctor’s appointment to receive a diagnosis that he was a sickle cell trait carrier, Richardson failed to note his sickle cell trait status on the medical history form.  Given the age at which he was tested, along with the fact that he never experienced sickling, one could surmise that Richardson was unaware that he was a carrier for sickle cell trait.

The facts surrounding Richardson’s death are clear, because they are found in a 2010 court decision.

In 2010, an Ohio court heard Richardson’s family’s case for wrongful death and survivorship against Bowling Green State University (Estate of Richardson v. Bowling Green State Univ., 2010 Ohio 3475 (2010)).  Richardson’s family asserted that when he “. . . first complained of cramping while stretching on the practice field, the standard of care required an immediate evaluation of his condition by a qualified athletic trainer.”  Richardson’s family argued that if he was competently examined closer to when he began complaining of cramping, the training staff would have been alerted “. . . to the possibility that Aaron’s condition was more serious than simple exertional cramping” and that “. . . a call for emergency medical attention made at or near that time would have assured that Aaron would receive life-saving treatment.”

The court found that “. . . the standard of care did not require defendant’s training staff to perform an examination of Aaron before he left the field. The court is persuaded by. . . testimony that cramping in the lower legs is a common condition among practicing athletes and that an athlete who complains of calf pain after having run pre-practice gassers, need not be evaluated by training staff. Moreover, as noted above, defendant’s training staff could not have had knowledge that Aaron had sickle cell trait or even that he suffered from any other medical condition that would have put him at risk of a more serious problem. . .”

Later, the court noted, “The question whether the standard of care would have required greater vigilance on the part of BGSU’s training staff had they been aware of Aaron’s particular medical condition prior to the start of practice is a more difficult question for the court but not the relevant inquiry in this case.”

The court in Estate of Richardson established an “ignorance is bliss” precedent.  This precedent means that if an athletic training staff does not know of a student-athlete’s sickle cell trait carrier status, it cannot be found negligent for failing to treat a student-athlete as required when he or she experiences sickle exertion.

Given this precedent, the NCAA and its member institutions are arguably not setting themselves up for legal battles by allowing student-athletes to opt out of sickle cell trait testing.

A century ago, deaths in football occurred because of the rugged nature of the sport.

In the past decade, over half of the sport’s deaths arose because of the ignorance of a student-athlete’s carrying of a medical trait and the proper way to treat it.

While legal precedent provides a windfall, the NCAA should remember the basis for which it was founded and mandate sickle cell trait testing of all student-athletes.

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