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High Concussion Rate in Boys' Lacrosse Blamed On Intentional Head-to-Head Contact With Defenseless Players

Few penalties called; stricter rules enforcement recommended


Lacrosse may be the fastest-growing high school boy's sport in the United States, but only football and ice hockey have higher concussion rates.[1,2] A new study [3]  pinpoints a possible culprit: widespread and intentional use of helmets during player-to-player contact, often to defenseless players, and usually without a penalty being called.

Lacrosse players colliding going for loose ball

Researchers at the Medstar Sports Medicine Research Center in Baltimore videotaped 518 boys' lacrosse games at 25 public high schools in Fairfax County, Virginia during the 2008 and 2009 seasons. A total of 86 concussions were identified and treated by athletic trainers.

Analyzing the 34 concussions in which video captured the injury mechanism, they found that:

  • every one resulted from player-to-player contact, not stick or ball contact;
  • In over three-quarters of the incidents resulting in concussion, the striking player used his head to initiate impact;
  • The injured player's head was the initial point of contact in six out of ten of such collisions;  
  • The most frequent location of initial impact, involved in six out of ten incidents, was the side of the helmet;
  • In 19 out of 34 (56%) collisions, the struck player did not appear to anticipate contact and was deemed "defenseless" (defined by US Lacrosse, the National Football League, and National Hockey League rules as a struck player who was "blind-sided" or unable to see and therefore anticipate and prepare his or her body for an impending collision). [Note: in order to standardize the evaluation of player preparedness for bodily collisions in lacrosse, researchers developed a 10-item Lacrosse Collision Readiness Index (LCRI));
  • Penalties were called in only 9 out of the 34 cases (26.5%];
  • In 23 (68%) cases, a subsequent impact occurred immediately after the initial player-to-player contact and may have contributed to those concussive events;
  • The most frequently injured player positions were midfield (53%) and defense (27%);
  • 24 occurred in the attacking zone, and 10 (30%) occurred in the midfield zone;
  • In the 5 seconds of game play preceding each of the 34 concussions, players were most frequently on the offensive before the injury (44%) and that most did not have possession of the ball at the moment of injury (59%); and
  • At the moment of collision, players were most frequently attempting to pick up a loose ball (47%) or handling a ball (41%)(e.g. running with ball possession) at the time of injury.
The study's findings were consistent with previous studies showing that the majority of injuries in boys' high school lacrosse , and specifically concussions, [6] were the result of player-to-player contact, which were considered "legal" collisions in that no penalty was called in 70% of the head injury cases analyzed, [7] and that midfielders sustained more concussions than other players (47.6% in the most recent study). [8]

Preventing defenseless hits

The findings suggest that "the principal causes of concussions in boys' lacrosse are associated with intentional use of helmets during player-to-player contact," wrote lead author, Andrew E. Lincoln, ScD, MS, Director of the Sports Medicine Research Center, MedStar Health Research Institute at Union Memorial Hospital in Baltimore.  

"Our findings also demonstrate that the struck player was unaware and unprepared for the impending impact in about half of the collisions resulting in concussions and captured on video.  These 'defenseless hits' represent scenarios where the player's full attention is focused on obtaining possession of the ball, and therefore, the player may be vulnerable to unanticipated contact from an opponent."

study in youth hockey reporting the importance of "heads up" play "may suggest ways to help decrease the incidence of concussions in boys' high school lacrosse," wrote Lincoln.  The "importance of situational awareness and readiness for contact [needs to be] further emphasized to players, coaches, and officials.

Teaching players to take a "heads up" approach (as is being done in boys' hockey and football), and emphasizing the importance of increasing the strength of neck muscles are areas that are gaining increasing attention as ways of mitigating the rotational forces that are seen by experts as the principal injury mechanism of concussion. This would appear to be especially relevant to lacrosse, as Dr. Lincoln's study reports that impacts to the side of the helmet and the parietal lobe of the brain were involved in about a third of all concussion impacts to the head, impacts that presumably resulted in precisely the kind of spinning of the brain that can lead to concussion.

Better rules enforcement needed 

The absence of penalty calls on most of these plays suggests an area for exploration, such as the extent to which rules governing player to player contact are enforced and how effective these rules are for the prevention of head injury at various levels of the sport," the study concluded.

As in boys' hockey and football, rules against intentional contact to the head are only as good as the officials charged with enforcing them.

Commenting on the study in an email to MomsTEAM, Steve Stenersen, CEO of US Lacrosse, expressed support for the study's recommendation about ways to reduce concussions in the sport, expressing the view that "violent collision should be removed from boys'/men's lacrosse."  

To demonstrate US Lacrosse's ongoing committment to improving the safety of the game of lacrosse, he noted that the organization had recently created a new full-time position of Director of Health & Safety.

August 18, 2013 update: In July 2013, the National Federation of State High School Associations (NFHS) modified Rule 5-3-5 of the boys' lacrosse rule to make clear that a body-check that targets a player in a defenseless position is illegal.  The rule now includes examples of such illegal body-checks, including but not limited to: a) body-checking a player from his "blind side"; b) body-checking a player who has his head down in an attempt to play a loose ball; and c) body-checking a player whose head is turned away to receive a pass, even if that player turns toward the contact immediately before the body-check. A minimum of a two- or three-minute no- releasable penalty is assessed for this violation.

In making the change, Kent Summers, NFHS director of performing arts and sports and liaison to the Boys Lacrosse Rules Committee, stated that, "Intentional player-to-player collisions with players in a defenseless position are a concern, and this revision will reinforce the need to eliminate these collisions from the game."

In addition, the NFHS strengthened the penalty in Rule 5-4 for checks involving the head/neck by dropping the possibility of a one-minute penalty. Thus, a minimum two- or three-minute non releasable penalty will now be enforced for this violation. Summers said this increased penalty will reinforce the need to eliminate hits to the head/neck from the game.

Commenting on the NFHS rule changes, Stenersen of US Lacrosse said, "We're fortunate that we have a very positive relationship with the NFHS and were very much involved in the development of these rule changes. As the sport's national governing body, our biggest ongoing challenge is to effectively balance game integrity with player safety in all that we do to advance both versions of the sport. The NFHS rule changes reflect continued refinement of rules and associated penalties that are focused on reducing the risk of serious injury in boys' lacrosse, and they reflect the value and importance of strong collaboration between our organizations."

1. Marar M, McIlvain NM, Fields SK, Comstock RD.  Epidemiology of Concussions Among United States High School Athletes in 20 Sports. Am J Sports Med. 2012;40(4):747-755 (third highest, behind football and boys' ice hockey)

2. Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Norris JB, Hinton RY.  Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39:958-963 (second highest, behind only football).

3. Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Hinton RY. Video Incident Analysis of Concussions in Boys' High School Lacrosse.  Am J. Sport Med. 2013;20(10). doi:10.1177/0363546513476265 (published online ahead of print February 14, 2013)(accessed February 14, 2013). 

4. Mihalik, Jason, Blackburn, J. Troy, Greenwald, Richard M., Cantu, Robert C, Marshall, Stephen W., Guskiewicz, Kevin, M. Collision Type and Player Anticipation Affect Head Impact Severity Among Youth Ice Hockey Players. Pediatrics 2010;125(6): e1394-e1401. 

5. Carter EA, Westerman BJ, Lincoln AE, Hunting KL. Common game injury scenarios in men's and women's lacrosse.  Int J Inj Contr Saf Promot 2010;17:111-118.

6. Hinton RY, Lincoln AE, Almquist JL, Douguih WA, Sharma KM. Epidemiology of lacrosse injuries in high school-aged girls and boys: a 3-year prospective study.  Am J Sports Med. 2005;33:1305-1314. 

7. Caswell SV, Lincoln AE, Almquist JL, Dunn RE, Hinton RY. Video incident analysis of head injuries in high school girls' lacrosse.  Am J Sports Med. 2012;40;756-762.

8. Marar M, McIlvain NM, Fields SK, Comstock RD.  Epidemiology of Concussions Among United States High School Athletes in 20 Sports. Am J Sports Med 2012;40(10):747-755. 

Posted February 22, 2013; updated August 20, 2013