Inadequate Helmet Fit Increases Concussion Severity in American High
School Football Players

Greenhill DA, Navo P, Zhao H,
Torg J, Comstock RD, Boden BP. Sports
. March 2016. doi:10.1177/1941738116639027.

Take Home Message: An athlete with a poorly fit helmet that sustains a
concussion may have an increased risk of more severe symptoms and prolonged

There has been much discussion
and research into the potential for protective equipment to alter the risk of
sports-related concussion.  However, there
is insufficient evidence to suggest that any type of helmet or protective
equipment used in football can reduce the risk of sustaining a sports-related
concussion.  Investigation into the
effects of proper fit and concussion risk is currently limited. Thus,
Greenhill, et al. sought to understand if an athlete with an improperly fit
helmet at the time of an injury is more likely to have longer recovery and more
severe symptoms after sustaining a concussion. For a nine-year period, data was
collected from a sample of 100 high schools participating in a national
surveillance system. A Certified Athletic Trainer determined if an athlete had
an improperly fit helmet at the time of injury. Of the 4580 concussions that
were sustained during this time period, 3172 had information regarding helmet
fit. Among those concussions, athletic trainers determined that 102 helmets had
an improperly fitted helmet. When compared to athletes with a properly fit
helmet, concussed athletes with an improperly fitted helmet had averaged more
symptoms during recovery and were more likely to have symptoms that persisted
longer than 7 days (37% versus 31%). The 2012 NFHS helmet rule change failed to influence the number of helmets that were
properly fit.
Independent of fit, an athlete who wore a helmet with a
gel or foam liner was more likely to lose consciousness after a concussion
compared with an athlete with an air-filled liner helmet.  However, there was no association between
helmet liner type and symptom severity.

Very few medical professionals
will argue the merits and necessity of the helmet in football. The results of
this study are noteworthy because they bring to light a completely different
issue with helmets, which seems obvious but unfortunately is still an issue:
sports equipment should fit properly. Maintaining proper fit should be
emphasized to athletes as a fundamental of the game, just as important as
proper tackling and following the rules of play.  Athletes on the professional and colligate
level sometime set poor examples on proper equipment fit. Clinicians need to
make emphasizing injury risk associated with poorly-fit equipment to the youth
athlete a priority. While these results are interesting, they should be viewed
carefully. Data was not cited for symptoms in a category beyond seven
days.  It is widely accepted that the
majority of young adults will recover in 7–10 days, with youth athletes taking
longer, so it is possible that the results of this study could normalize
between the fit and poorly-fit helmet groups if the endpoints were more
specific of time of recovery. Additionally, as the authors mention, this study
lacked uniformity for method of helmet fit assessment. Further research is
necessary to determine reproducibility and clarify assessment protocol. Perhaps
a simple real-time method to assess helmet fit on the side line could become an
important risk reduction tool for an easily modifiable risk factor. In the
meantime, clinicians need to educate their athletes about the risk associated
with poorly-fit helmets and that it could lead to them missing more time after
a concussion.

Questions for Discussion: Do you think there is an easy way to quickly
and effectively assess helmet fit on the sideline? Do you think protective
equipment will ever evolve enough to reduce concussion rates or severity in
sports that require a helmet?

Written By: Stephen Stache, MD
Reviewed By: Jeffrey Driban

Related Posted:

Greenhill, D., Navo, P., Zhao, H., Torg, J., Comstock, R., & Boden, B. (2016). Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players Sports Health: A Multidisciplinary Approach DOI: 10.1177/1941738116639027