What to know about the risks of youth sports

A player looks to make a catch during a 7-on-7 flag football game at Milton High School in 2020.Jonathan Wiggs/Globe Staff

If your kid plays football — or any sport, really — watching Buffalo Bills safety Damar Hamlin collapse during Monday Night Football was pretty terrifying. Hamlin suffered cardiac arrest after a tackle, getting medical treatment on the field for almost 20 minutes before being rushed to the hospital. The incident has fueled discussion of commotio cordis, caused by chest wall impact, which can cause heart arrhythmia. It reminded parents that sometimes sports are unpredictable. And, sometimes, they’re really scary.

My sixth-grader is about to start intramural flag football next week, so I was especially happy to talk to two experts about the risks: Dr. Robert Cantu, director of the Cantu Concussion Center at Emerson Health in Concord, and Dr. Mininder Kocher, chief of the Division of Sports Medicine at Boston Children’s Hospital.

“What happened with Hamlin on Monday night is an extremely rare and unusual event — and so it brings up awareness of safety of the sport. The way I think about it, as a sports medicine surgeon, is not necessarily is a sport or activity safe, yes or no. It’s a gradient,” Kocher says.

Here’s what to know.

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Football gets riskier with age. Organized youth football for kids ages 5 to 15 has 12 percent fewer injuries per player than organized soccer in the same age range, 50 percent fewer injuries than bicycle riding, and 74 percent fewer injuries than skateboarding, says Kocher, quoting data from the American Academy of Orthopaedic Surgeons.

“Typically, [kids are playing] flag football. If it is tackle, the kids are relatively small, padded, and the force they generate is much less than when they’re in high school. We see the transition in high school, when they’re bigger, hitting harder, and the injury rates start to increase,” Kocher says.

Once kids are in high school, shoulder dislocation, knee ligament and ACL injuries, and concussions become more prevalent.

“I’m a supporter of playing flag football until high school. I’m not a supporter of tackle or kids taking unnecessary hits at a young age, because those hits add up,” Cantu says.

It’s important to assess your family’s cardiac risk. Cantu urges families to understand their cardiac risk profile. On exertion, some athletes can collapse because of unrecognized cardiomyopathy (problems with the heart muscle that make it tougher to pump blood) or congenital anomalies.

“There’s been a debate in the medical community over a cost-effective way to screen people for congenital anomalies, and it continues to go on, because incidence is low. Procedures involve imaging of the heart, and they’re not cheap,” Cantu acknowledges. “But there is agreement that, if someone is in a family with a history of sudden cardiac death, the medical community says that person ought to be [screened]” through imaging of the heart.

There are simple ways to reduce risk. Kocher suggests that youth leagues consider grouping players not by age but by weight, since kids hit puberty at different times.

Well-fitting equipment, such as pads, helmets, mouth guards, and chest protectors are also important.

“If your child is going to play a collision sport — including baseball, softball, lacrosse, and ice hockey — parents might want to think about investing in a chest protector,” Cantu says.

Reducing contact during practice also helps, which could be the way of the future.

“Many college and pro teams are now having contact practices 1 or 2 days per week,” Kocher says.

Player education is also essential: Novice football players especially need to be trained on how to tackle without targeting the head. To that end, Kocher is a proponent of eliminating or at least moving kickoffs, when players run at each other like “rams in the mountains,” he says, which can cause concussions. (The NFL estimates that over the course of all games during the 2015-2017 seasons, the kickoff represented just 6 percent of plays but 12 percent of concussions.)

Fields also matter. Kocher also sees more ACL injury rates on turf fields over grass ones.

“This happens particularly if kids are using a cleat with an aggressive cleat pattern. When there are bigger cleats around the periphery of the shoe, the foot gets more fixed to the ground, and you get more rotation through the knee, which tears the ACL. That’s why we see few ACL tears in hockey. The foot isn’t fixed to the ground,” Kocher says.

Know the warning signs of concussions. “In the younger groups, we don’t see as many because [players] aren’t generating as much force, but we do see concussions in high school athletes,” Kocher says.

Cantu urges parents to be on the lookout for warning signs: physical symptoms such as headache and lightheadedness, cognitive issues with thought and memory, difficulty with dizziness or balance, excessive drowsiness or sleeplessness, and anxiety or depression.

“Normally, the cognitive symptoms and physical symptoms occur quite soon after the hit, if not immediately — but emotional [symptoms] might be delayed by two or three days,” Cantu says, so remain vigilant.

Fortunately, most people recover completely from mild to moderate concussions, Cantu says.

Meanwhile, concussion management has made advances. These days, concussed players are typically required to sit out the game and return up to a week later, Kocher notes.

“The main concern is if you have a concussion and someone goes back to play before they’re recovered,” Kocher says. This can cause second impact syndrome (SIS), a dangerous condition where the brain rapidly swells shortly after a second concussion, before initial symptoms have abated.

What about commotio cordis? Commotio cordis is unusual in football and happens more often in baseball, softball, and hockey.

“This is more likely to happen in the 10-to-16 age group than it is to someone in their 20s or 30s. We’re not sure why. Maybe the chest of that age group is more compliant, meaning it moves more when it’s impacted by a ball. We know it’s more common in boys and rare in girls. We do know that it’s a significant cause of athletic death in the school-age group,” Cantu says.

He emphasizes that parent and player education is key to risk reduction.

“Be aware that taking a blow to your chest is not innocuous. If you’re a hockey player — and we see this all the time — don’t purposefully take a blow to your chest and think it won’t be a big deal. As a baseball player, learn how to get away from a ball by turning so you don’t take it in the chest. These things ought to be taught and understood, and it applies not just to athletes but to people playing in the park,” Cantu says.

Grooming your child to become a junior superstar? Sports specialization carries risk. You might think you’re helping your child build talent — or boost their chances for a scholarship — by focusing on one sport. Not necessarily.

“We see a lot of injuries in pediatric athletes related to early sports specialization. Early sports specialization increases risk of injuries and burnout because they’re putting all their eggs in one basket. We [also] see psychological burnout. The data are clear: Olympic and pro athletes are more likely to play multiple sports,” Kocher says.

Yes, sports carry risks. But there’s an upside. “Each sport has a risk and an injury profile but also has some benefits,” Kocher says.

Research from the Aspen Institute’s Project Play, with which Kocher has been involved, has shown that this is especially true for football: The sport’s advantages include teaching teamwork and building friendships.

“For a play to work, you need 11 people all doing their part,” he says.