Sport Safety Policies Frequently Asked Questions

What was the purpose of this study?

The purpose of this study is to provide a graded assessment of the implementation of health and safety policies pertaining to the leading causes of sudden death and catastrophic injury in sport at the state level for secondary school athletics within the United States and District of Columbia.

What are the leading causes of death for secondary school athletes?

The leading causes of death among secondary school athletes are: sudden cardiac arrest, traumatic head injuries, exertional heat stroke, and exertional sickling.

What is exertional sickling?

Exertional sickling is a potentially fatal medical condition occurring in athletes carrying the sickle cell trait. It occurs when some of the red blood cells change into a “sickle” shape and cause a buildup of red blood cells in small blood vessels. This leads to decreased blood flow, a potential breakdown of muscle tissue, and eventually cell death, known as fulminant rhabdomyolysis.

How was each state assessed and scored?

A rubric was created in which each state was assessed based on five equally weighted sections pertaining to sudden cardiac arrest, traumatic head injuries, exertional heat stroke, appropriate medical coverage, and emergency preparedness. Current evidence-based best practices from the Interassociation Task Force for Preventing Sudden Death in Secondary School Athletics published in the Journal of Athletic Training in 2013 were used to form the content of the grading rubric.

Researchers gathered health and safety policies surrounding the leading causes of sudden death and catastrophic injury in sport from each state’s public high school athletic association, enacted legislation, and Department of Education that were in place for the 2017-2017 academic year. States received points on the rubric if associated policies were required or mandated to be followed by the state high school athletics association member schools in that respective state. States did not receive points on the rubric if polices were only recommended or encouraged. Each state received an aggregate score based on how many safety policies they had in place and how comprehensive they were. The best score was 100. Final scores were converted into percentages for each state, which were then ranked from 1 to 51 based on their percentage score.

What was the original outcome of the study in August, 2017?

North Carolina has the most comprehensive health and safety polices in place for secondary school athletics, with a score of 78.75%. Colorado has the fewest, with a score of 23%. The median state score was 47.1%. States scoring in the top 10% were North Carolina, Kentucky, Massachusetts, New Jersey, and South Dakota. States scoring in the bottom 10% were Minnesota, Montana, Iowa, California, and Colorado. A complete list of the rankings can be found above.

Have the individual states been made aware of the study results?

States were made aware of their individual score following the grading of their respective state. Individual state results were sent to each state’s high school athletics association executive director as well as the attendees of the 2017 Collaborative Solutions for Safety in Sports Meeting held in Kansas City, MO. This also allowed the state representatives the opportunity to review the rubric and provide the researchers any feedback if discrepancies were identified.

How many secondary school athletes are injured each year?

More than 7.8 million secondary school athletes participate in a wide variety of sanctioned sports annually. From 1982 to 2015, there have been 735 fatalities (185 from direct causes, 550 from indirect causes). During that time, there have also been 626 catastrophic injuries (613 from direct causes, 13 from indirect causes). Direct causes are attributed to trauma (e.g. athlete-to-athlete or athlete-to-object contact). Indirect causes are exertion based (e.g. exertional heat stroke, sudden cardiac arrest, asthma).

Can you tell me more about the evidence-based practices used in this study?

The safety measures used as the basis for this study come from evidence-based best practices that have been endorsed by some of the leading medical organizations in the United States, including: the American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine The practices have also been endorsed by the: Canadian Athletic Therapists Association, Gatorade Sports Science Institute, Korey Stringer Institute, Matthew A. Gfeller Sport-Related Traumatic Brain Injury Research Center, National Athletic Trainers’ Association, and the National Center for Catastrophic Sport Injury Research. Other endorsements include: the National Council on Strength & Fitness, National Federation of State High School Associations, National Interscholastic Athletic Administrators Association, and the National Strength and Conditioning Association. More information about these recommendations can be found in a 2013 report titled: “The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations.”

I checked this page a few months ago, and the rankings are different, what happened?

Provided the goal of this study was to bring awareness to the current policies mandated at the state level, we are hopeful that states will continue to make positive changes as time goes on. Therefore, our rankings are fluid in order to best reflect the current policies mandated in each state.

You can find a summary of the information that was most recently changed, and an archive of previous rankings here.


How often do you update the rankings?

We re-review all state policies once a year and make changes based off the new findings. Further, if states inform us that they made a change (either the state high school athletics association or the state legislation) we will update the ranking in the next quarter.

My school is a private school, how does the information affect us?

The information gathered in the study was from state high school athletics association that govern public schools and state legislation. If a policy is mandated by state legislation, the policy would affect all schools – regardless of public, private or other status. In this study, if a policy is mandated by the state high school athletics association, it would likely not affect private schools. Private schools often have their own leagues that are governed independently of the public-school organizations. Please contact us for additional information.