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Am Fam Physician. 2022;106(5):543-548

Related letter to the editor: Helmet and Pad Removal for Football Head and Neck Injuries

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Although rare, sport-related injuries to the head and neck can be life threatening; therefore, timely and appropriate treatment is critical. Preparation is key for the sideline physician and begins well before arriving on the sideline. Knowing the athletic trainer and support staff, establishing a chain of command and emergency action plan, and having all the appropriate equipment readily available are important for game or practice preparedness. At the athletic event, physicians should have a clear line of sight to the field of play and easy access to reach the field when necessary. When performing an on-field assessment of any athlete who is not moving, whether conscious, unconscious, or with decreased consciousness, head and neck injury must be assumed, and the injured athlete should be placed on a spine board with cervical spine stabilization and transported to the emergency department for further evaluation. Generally, helmets and pads are left on while the injured athlete is being transported. Concussion is among the most common head and neck injuries in athletes, and if concussion is suspected, the athlete cannot return to the game on the same day. Nasal fractures do not always require immediate closed reduction; however, orbital, maxillary, or mandibular fractures require transport to the emergency department. For tooth avulsion, time is important; reimplantation should be attempted within 30 minutes of injury.

Head, neck, and cervical spine injuries are common in athletes of all ages, and the incidence seems to increase with age.1,2 Soft tissue injuries such as neck sprains and strains or facial lacerations are much more common than vertebral fractures and spinal cord injury.13 Many of these injuries are self-limited and can be managed on the sideline or in the training room.3 Although catastrophic cervical spine injuries are uncommon, they are associated with significant morbidity and mortality and can have significant lifetime costs.4 When an athlete appears to be injured, the sideline physician must be prepared to provide a focused assessment and treatment plan.


Before being on the sideline at a game or practice, it is important to be as prepared as possible in the event of any injury. When covering games at the high school level or higher, athletic trainers are typically present at most games and practices. Many times, they will be the first point of contact if an athlete is injured, and sideline physicians should at least make a quick introduction before the game or practice to establish a plan in the event of any athlete injury.5 Knowledge of the closest trauma center, available resources such as the venue’s emergency action plan, and location of an automated external defibrillator (AED) and spine board are critical. During the game or practice, the sideline physician should have a clear, unobstructed view of the field of play and quick, easy access to the field, if needed.6 Access to a treatment room, where more detailed evaluation and treatment can be administered, should be made available when appropriate and feasible.6 Awareness of supplies available in the athletic trainer bag and training room to assess injured athletes is critical. Examples of supplies include an eye kit, flashlight, and nasal packing material. A more complete list of supplies is provided by a consensus statement on sideline preparedness from several organizations including the American Academy of Family Physicians.7

Neck Injuries

The initial evaluation of an injured athlete with suspected head or neck trauma should include assessment of airway, breathing, circulation, disability, and exposure according to the principles of Advanced Trauma Life Support.3,6,8 This should be followed by a spine evaluation and neurologic assessment using the Glasgow Coma Scale.5

Any athlete not moving, whether conscious, unconscious, or with decreased consciousness, should be considered to have a cervical spine injury3,8 (Table 15,911). The cervical spine should be stabilized, and the athlete transferred to a spine board using the log roll or lift and slide maneuver ( These maneuvers involve rolling the athlete to the side and transferring them onto the spine board; alternatively, the athlete should be lifted and slid onto the spine board with assistance from trained personnel such as athletic trainers.5,8,12,13 The sideline physician is usually at the head of the athlete providing cervical spine stabilization and providing instruction to other clinicians assisting in stabilizing the athlete.5,8,12,13 The athlete should then be transported to the emergency department by emergency medical services (Table 23,5,8,1014). In sports such as football and hockey where the athletes are wearing helmets and pads, it is recommended to leave the equipment in place during transfer.5,8,13 If there is altered mental status or an airway needs to be established, the face mask can be removed.5,8 If either the helmet or pads need to be removed, both should be removed together to avoid causing any cervical hyperflexion or hyperextension, and this should be performed by a team of trained personnel comprising at least two or three additional people.5,8 For a demonstration of helmet and pad removal, see:

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