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Transcript: End-of-Season Health & Safety Briefing, February 3, 2023

The NFL hosted on February 3, 2023, a virtual media briefing to discuss player health and safety topics, including 2022 regular season injury data.


  • Jeff Miller, NFL Executive Vice President Overseeing Player Health & Safety
  • Dr. Allen Sills, NFL Chief Medical Officer
  • Dr. Christina Mack, Chief Scientific Officer, IQVIA; Advisor to the NFL

Miller: Good morning, everybody. And I look forward to seeing many of you in person next week when we are in Arizona. And thanks to Allen and to Christina for their work this season. We give everybody – or tried to provide everybody – an update on injury rates, specific injury and health and safety initiatives every year, and we have some of that data to share with you this morning. We'll talk a lot about overall injuries. We'll certainly talk about lower extremity injuries, preseason injuries, concussions, some of our initiatives, broadly about ways to mitigate more and more of the injuries and make the game safer for the players who play it and what our goals are for this coming season.

But before we get to all of that, I just think it's important to always stop and talk a little bit about the incident on field from a few weeks ago – Damar Hamlin and the heroic nature of the work that was done by our on-field first responders to resuscitate him, to ensure that he got the best possible medical care, to effectuate our Emergency Action Plan, and to pay tribute to all of those people who do this work every single day and everyone at every one of our teams and at our practice facilities as well, to ensure that our players are getting the best possible medical care. Many of you have heard this by now but I think it bears repeating: We're talking in the neighborhood of 30, at least, medical personnel at each and every one of our games. Whether that's a preseason game or whether we're playing internationally, those people are there. They rehearse those Emergency Action Plans, they practice them in the offseason. They're prepared with the best equipment and personnel to ensure that should they be needed, or the Emergency Action Plan needs to be pursued, that they're ready to go. And that demonstrated itself about a month ago and to their credit, we ended up with what could have been a tragedy, ending up being as good a possible result as it could be. So, I just want to take a minute and pay tribute to them.

As a league, you may have seen this morning, that we're working more closely – as a result of that incident – with the American Heart Association, a longtime partner, and the American Red Cross to encourage CPR education. We noted a couple of rather disturbing statistics recently, including the fact that only 16 percent of high schools across the country have access to AED Machines. That there are more than 100 youth athletes who suffer cardiac episodes every year. And with an AED Machine nearby, and I'm sure Allen can talk to this too, many of the worst outcomes can be prevented. So, we announced that we're going to be raising a lot of money for the American Heart Association [and] that they're going to continue their education. They're going to be on site at Super Bowl and NFL experience with their mobile pop-up CPR training. So hopefully some of you will get a chance to check that out. Hopefully you'll get a chance to spend some time with us over the course of the next few weeks or months as we look to advocate, again, for more advances in the health and safety of sport – not just at the NFL level but throughout football and hopefully beyond that. We've done this work, as many of you know, in concussions in the past, and tried to raise the profile of Emergency Action Plans. And now we're going to do something increasingly dedicated to heart health and cardiac issues. And at some point, probably wrap this all up and try to work with organizations like the AHA or the Korey Stringer Institute to improve sports safety at all levels of sport throughout our country. We've got a big platform and an opportunity to do this, and the Damar Hamlin episode certainly provides a little bit more attention to it. And so hopefully we'll take advantage of that opportunity and raise the level of sports safety provided to everybody who plays sports across the country. So just want to make that note here at the outset. We're really proud of the work we'll be doing with the American Heart Association American and the Red Cross. Want to stop on that. Allen, you've been very involved in this as well if you wanted to add anything off the top.

Sills: Yeah, not a lot to add Jeff, thank you. I'd like to express my own personal appreciation and certainly the appreciation on behalf of the entire NFL family to the medical staffs of Buffalo, Cincinnati, to the University of Cincinnati Medical Center, and all the first responders that Jeff mentioned. Their performance in that moment was remarkable in the sense that it brought the attention of a nation together. But in another sense, it reflects, as Jeff said, the preparation planning that we do for every single game, and that planning obviously starts many months in advance with the Emergency Action Plans, with the rehearsals that Jeff mentioned and the preparation. And simply put, we don't ever want to use any of those plans, but we have them in place and we're prepared. And so, if there is a tragic moment like what we witnessed, we're ready to move into action. So, I want to express my admiration for the crew that night. And just to remind everyone that we're prepared for those types of events at every one of our NFL games.

But I think more broadly, as Jeff alluded to, the message to the entire medical community is this isn't something that just could happen in NFL games. As he mentioned, this is an event that could occur at any athletic activity, at any level. So we should all be prepared. I challenge every one of you: if you haven't taken a CPR course, take a CPR course [and] get certified. And we will be really actively working with our partners at all levels of play and other sports. I've been working with other Chief Medical Officers of professional sports leagues. How can we continue to increase the awareness and education of these important issues? We need to get coaches trained in CPR we need to get AEDs at youth athletic events. And as Jeff mentioned, we'll be partnering with a number of groups to work on those areas. So, Jeff, I'll toss it back to you.

Miller: Okay, thanks, Allen. Let's jump into some of the injury numbers. Again, compiled by IQVIA, who provides this information to both us and the Players Association every year, as you know. So we'll walk through some of it between Christina, Allen and myself. Starting with just overall injuries, just a top line number. Overall injuries in games this year, whether it be preseason games or regular season games, were down somewhere between five and six percent. To put a little bit finer point on it for the regular season, we were down 5.6 percent game injuries for the preseason, I'm sorry 5.6 percent overall, 6.2 percent for the preseason, and 5.4 percent down for the regular season. So overall injuries, as a whole, were down.

One large intervention made this year, as many of you know, was around understanding acclimation periods at the beginning of the preseason. We see – and have seen for years now – a substantial intensity or density of injuries right at the beginning of the preseason, the first couple of weeks [of] training camp before we start preseason games, where we have a disproportionate number of injuries to our players, specifically around lower extremity injuries. And so, as a result, we worked with our engineering consultants, our epidemiologist consultants, and unveiled a bit of a new acclamation period for the preseason, which I think we can share here. This slide, which was shared with all the clubs when we met one on one with them throughout the offseason. What we did with the training camp calendar for the first few days was put limitations on days two through five, which is before the pads go on, the maximum number of minutes that clubs could spend on field. Then after the day six mandatory day off, to re-ramp players as they put the helmets and pads on and got ready for contact. As you can see, there were limitations made there. Over time, we find that that these limitations don't really have any substantial or any effect on the amount of time that players are on field. Teams that use acclimation periods catch up in terms of total number of minutes spent. And as a result of some of these changes, we believe after one year of data, we saw substantial decreases to the sort of lower extremity injuries that we were focused on. During this training camp period, again, before the first preseason game, we saw a decrease of about 25 percent of lower extremity injuries. And that carried through throughout the rest of the preseason, where overall we were down 14 percent of these sorts of injuries year over year. We think that those are major benefits as we had shared with the clubs when we provided this information. Many clubs, if not all clubs, we're seeing two to three players who would suffer a lower extremity injury – a groin strain, a hamstring strain, something like that – in those first 10 days, first eight days of the preseason, and it would recur throughout the course of the entirety of the season. So, by decreasing those by working on an acclamation period of training camp ramp up, as we call it, we saw substantial decreases.

Now let me say one more point and then I'll turn it over to Allen for a little bit, sorry, to Christina for a little bit more color. We've also worked with the clubs to ensure that there are sensors on every player and every activity. So, there's a lot more data than there used to be for us to look at – not just recording injuries, but also seeing the amount of movement, the intensity of the practices, the number of accelerations that players go through. It's a very highly defined and analytical process now to better understand how clubs are working with their players to prepare them, not just for the preseason, but for the regular season. And so, one of the key offseason efforts we'll make is again to focus on this period of time, which has such a density of injuries. Take all the data that we have now collected and share back with the clubs how they compare to the other 31. How are they running their practices? What are the loads put on their players? Where are they seeing injuries? And how do they stack up against their counterparts in the hopes that we can raise the level of preparation for all clubs and decrease the number of injuries? So, Christina, anything on that before we move on?

Mack: Hi everyone, I'll make three quick points on that. When we all talked at this time last year, we talked about strains and why we're so focused on reducing strains. And one of the reasons and the most important reason is that muscle strains are the highest burden injury to our players, year over year. Over 30% of muscle strains happen in preseason. So, if you remember when we talked about this last year, we were really focused on finding evidence and then making an evidence-based change or intervention to try to bring these strains down, which is what we just described. The second is kind of the power of the evidence that the league has pulled together that we've been able to analyze to come to this. We've pulled together, as you know, we have a foundational Electronic Health Record system that every single injury – whether or not it misses time – is entered into, but because we've been able to add this wearable data that the players have, during practices and games, we've been able to see how long are they practicing, how long are they playing, how are they safely being brought back to season, and then how can we put an intervention around that to reduce injuries? So, when we saw this 25 percent decrease, or 14 percent decrease in training camp, we were really encouraged by the approach, encouraged by the seriousness with which the clubs were modifying their training camp and trying to bring players back more safely. And so, we'll continue to build upon that as we go into next season.

Miller: Allen, you want to pick up on some of the other injury trends that we saw?

Sills: Yeah, I think I'll just start by saying if we think about different periods of the season, we've really come to view the entire experience in four different blocks. So, we think about the training camp, meaning that part of preseason prior to the first preseason game, then the rest of the preseason encompassing all the preseason games up to the start of the regular season. And then there's a block that really encompasses the first five weeks of the regular season. I'll come back and speak about that in a moment. And then we have the rest of the season. So, if you think about those four different blocks, we really look at what's happening with injury and illness during each of those, what might be driving that and what are the effective present prevention strategies.

Jeff and Dr. Mack mentioned the substantial reductions in the preseason and the training camps specifically where we were down 25 percent with lower extremity strains, for example, and this concept of how do we bring players back safely to get them prepared is something we spent a lot of time and energy focusing on. I think now we want to extend those benefits into those next two blocks – into the rest of preseason and into the first of the regular season. And we need to do more work in that regular season block those first five weeks. Injuries in that first five weeks were up this year. And so that's something we're really going to be doubling down to try to understand what's driving that and again, how do we transition from the preseason to the regular season? One of the things we look at is participation in preseason. We know that that preseason game participation among players who make 53-man roster continues to go down. There's also a rise in joint practices and we've got some data that suggests that participating in football at game speed, whether it's in a preseason game or in a joint practice, may have some protective effects when it comes to injuries in that early regular season block. So, again, more work to be done there.

But I think what Jeff and Christina conveyed is we had a lot of success in that training camp block. We want to now extend that into the preseason block and into this first five weeks of the regular season, particularly with regard to lower extremity injuries because lower extremity strains are still our number one burden injury, meaning that NFL players miss more time because of those injuries than any other injury. So that will remain a big focus of ours going forward. Jeff?

Miller: Let me just hit on one other note really quick. Been a lot of discussion on field surfaces, certainly, during the during the regular season. That data comparing field services is not yet ready. The information we have on lower extremity injuries is just hot off the presses. We need to analyze contact versus non-contact injuries on different surfaces. And obviously there's a lot more that goes into that analysis: previous injury history of players, the weather condition, the intensity of practices or games, and certainly the different sorts of surfaces they played on. So that's something we're going to be working on between now and the Combine, and happy to share that information as we get it but a lot more analysis to be done there. Allen, do you want to talk about concussions?

Sills: Would be happy to, Jeff, thanks. Obviously I think the starting place for talking about concussions is that there was a number of high-profile cases and attention and a lot of commentary about our concussion protocol this particular season. My summary of it is that we continue to become more cautious and conservative in our evaluation and diagnosis of concussion. And that's not just an opinion, that's backed up by the data. Our data shows that we did more evaluations for concussion in game this season than previous seasons. Our rate is about 1.6 concussion evaluations per game and that's continued to increase over the past three years. We had more medical timeouts this season than we've ever had by a very wide margin, almost double our previous high. Medical timeouts are when the athletic trainer spotters call down to stop the game. We've had 33 of those thus far throughout the regular season and postseason. And again, that's almost double our previous season's high, showing again this this idea that we want to get anyone who might be injured off the field. And we continue to do three to four concussion evaluations for every one concussion that we diagnose. And so, I think those statistics, along with as you know we made a protocol change during the season to even broaden and strengthen the definition of concussion, are things that I think show that that we're continuing to be even more conservative and cautious in the diagnosis [and] the recognition of this injury. There's some very good news out of the preseason with regard to concussions. Concussions were down in the preseason in games and practices. In fact, we had an eight year low for preseason practice concussions. And obviously one of the big interventions there was the Guardian Cap – the protective shells that, as you know, were mandated to be worn during training camp. Among the player positions – as you know certain positions were mandated to wear – among those position groups who were mandated to wear the Guardian Cap, [there was a] 52 percent reduction in preseason practice concussions during the mandate period, versus what the three-year average had been for those positions during that period. So again, comparing apples to apples, the same players who were wearing the cap this year versus the three-year average for those position groups showed a 52 percent reduction in concussions. And of those concussions that occurred, half of them – 50 percent – were due to impacts to the facemask, which is obviously an area that's not covered by the Guardian Cap. So, I think our initial experience with the Guardian Cap was overwhelmingly positive. We did not see an uptick in associated other injuries as a result of the wearing of the cap. And so, we'll be having a very active discussion about extending the use of the Guardian Cap, potentially to more position groups and potentially longer in the requirement period.

When we move to the regular season, our concussions were up this season (despite that decrease in the preseason). We're up about 23 concussions overall in the regular season – that's an 18% increase. I think that there are a lot of factors that we're looking into as to what could be driving that. Obviously, I mentioned earlier that we're doing more evaluations than ever. We did change the protocol to become even more conservative. We had the more medical timeouts that I mentioned and certainly we know that we continue to emphasize the importance of player self-reporting. And we've seen fairly similar numbers with that. So those facts [and] statistics are there, and it's something again that we'll work on and try to take a very close look at. I will say there was no increase in the number of players who had multiple concussions, meaning more than one per season, and no difference in the numbers of return to play, how long it took players to return. The median for return to play after a first concussion remains about nine days in the NFL. And for a second concussion, it's about 13 days. So those numbers have held relatively stable. Let me turn it over to Dr. Mack to give us a little bit of context about these numbers and what they mean versus the trends over the last few seasons.

Dr. Mack: Sure, absolutely. I'm going to pull up a slide here. So let me let me start by orienting you to this slide. So, the top line graph that you see, which is the solid line graph, represents eight years of regular season game concussion numbers. And if you look over to the right over the 2022, you can see that increase from 126 to 149 regular season game concussions that we just talked about. If you look back a little bit to the middle of the slide, you also see that March decrease after 2017 prior to the 2018 season from 179 to 127, which is a decrease that as you can see by that gray bar, which I'll talk about in a minute, has been sustained now for five seasons. So, from 2018 to this 2022 season, the concussion numbers have ranged from 126 to 149 in regular season games, compared with that range of 166 to 183 prior to 2018. And what we're trying to do here is kind of give context to that number.

So, if you look, the other important piece here is if you look at that dashed line before 2021, that line denotes where a 17th regular season game was added to what was previously a 16-game regular season. So, we're normalizing that with the rates below. So, if you look below this chart, you see the green line. What we're looking at now are rates. And so, this reflects the numbers above accounting for the number of games that there are, and so it's normalized to that change to a 17-game season from a 16-game season two years ago. And again, looking at that green light all the way over on the right, you can see that increase in concussion rates per game that Dr. Sills just talked about for this season. So, I want to talk for a moment about these gray bands. And again, just to give context to these numbers as we think about it. So, I want to talk about statistical confidence intervals and those are the gray bands that you see here. These represent the expected range due to natural variation – and we've talked about this in the past, we show this every year – it's a 95 percent confidence interval and it contains what we would expect to see in terms of normal statistical fluctuations or statistical variance. So, the bouncing around of numbers that happened by chance over time. So in 2018, after we had a number of concussion reduction efforts, which I'll talk about in a minute, we saw that decrease from 179 to 127 in concussions – and consider that a new benchmark, essentially a kind of a new goal from which we want to reduce concussions to create that new normal, and that's that lower rate band. So, this season, we did see that uptick. It is still kind of within that new range, again, that we're trying to come down from. We're focused on those reduction efforts but we're also kind of focused on the fact that we're seeing some changes that are below where we were before. If you can go to the next slide, I want to talk about the efforts have been put in place to detect concussions as well as efforts put in place to reduce them, and that will kind of explain the change in that gray bar. So let's see, if we can go to the next slide.

The bottom part of this slide, if you look at the orange header, describes the reduction intervention. So, this is the changes to rules and improvements to equipment that started and launched in 2018. And that we evolve and push forward and improve every year since, so you see you see continued changes to rules, continued improvements to equipment and helmets year over year, and again, continued focus. In green, what you can see started in 2015, are the many efforts put forth to diagnose and evaluate concussions as well as make sure that all of the concussions are reported into the system so that we're counting them, so that we're looking at them, so that we're better understanding the mechanism, and so that we can really focus our concussion reduction efforts. And so that includes the ATC spotter program, the unaffiliated neurotrauma consultant program, the medical tents, and all the different pieces that we can pull from and then evolve every year to try to improve our ability to diagnose, detect, report and safely reduce concussions. So, in summary, as Allen said, we did see an increase in concussions – that increase was driven by regular season games this year. You see that here on the slide over 2022, continued reduction efforts to bring that number down as we move forward.

Sills: Thanks, Dr. Mack. And I'll just close this section quickly to say we'll have a clear and consistent, continued effort to reduce concussions. But the real key to that concussion reduction is going to be prevention. That means a major focus on getting the head out of the game: how can we reduce overall head impacts? And as we think about head impacts, I like to classify them into three different buckets. There are intentional ones, where someone's intentionally hitting someone in the head, which is obviously against the rules and is really rare. There's one I call unavoidable, where players accidentally hit the ground or accidentally collide with each other, that are common to all sports. And then there's a big bucket of avoidable head contact, where the head is contacted but it didn't have to be, there are other ways that the play could have developed. That's a big focus. We have some great new tools at our disposal in working in this area. The first is the ability to actually count head impacts during games with an artificial intelligence program that can go through and assign a number for every single player. We'll be sharing that data broadly with our clubs, our coaches, our players, because we think once they have this data, they can act upon it. Obviously, there's a big component of education of how the game is played and taught, and also how practices and drills are conducted, to try to reduce those numbers of head impacts. Of course, equipment, we talked about the Guardian Cap and a continued evolution for those unavoidable head impacts. And then lastly, rule changes. We'll continue to work with the Competition Committee on that. So again, we'll have a continued, very major focus on getting the head out of the game, because reducing the number of head impacts is going to be the main driver for reducing concussions. Jeff, back to you.

Miller: Okay, thanks for that, Allen. Let me touch on a couple more areas and then we'll open it up for questions. Quarterbacks: We did see between quarterbacks and special teams plays, 60 percent of the increase in concussions that Allen and Christina just spoke about came in those two areas, both quarterbacks and special teams. It's something that obviously we'll take away and talk to the Competition Committee about, both quarterback injuries as well as special teams. On special teams, I think we've talked about this in the past, that about one out of every five concussions we see in games occurs on either kickoff or punt, that the injury rate on kickoff or punt varies from between 1.5-2x a play from scrimmage. A lot of work to be done there. I don't think there are any easy solutions, but it's something that we want to spend a fair amount of time focused on. And it's not just head injuries. Similarly, as concussions, about 20 percent of all ACL injuries that we see during the regular season occur on special teams, as well. These are high speed plays, very exciting plays as we all know, but also providing some level of risk that we want to address for our player population and work with the coaches in the competition committee to address. On the issue of quarterbacks, specifically, it was a higher number of concussions than we typically see, as I mentioned. We will pursue each and every one of those injuries, concussions included, take a look at the video, try to deconstruct those, understand them better over the next few weeks, share our findings and learnings with the Competition Committee, and take a look at how we may prevent those on a going forward basis. One potential intervention, which is exciting, is that I think we are getting very close now to a quarterback-specific helmet. We've talked now for a number of years about our goal of position specificity and helmets, and for the first time saw an offensive line-designed helmet from VICIS. Similarly, I think this fall, hopefully this fall, we will see an entrant in that space that looks at the sorts of hits that quarterbacks take and adjusts the helmet to prevent against those. More to come on that, but we're hoping at least, hopefully this year if not next year, we'll have something in that space as well. Speaking of other injury categories real quickly, we've taken a look the last couple of years since we changed the format of the regular season from 16 and four [preseason games] to 17 regular season games and three preseason games. Add that last week, Week 18, for the second year in a row we have seen no injury increase in the last week of the regular season. Similarly, we always look at Thursday night games and compare those to games played on other nights of the week or days of the week. No increase there. And international games, as we play more of those of course we're going to examine any injury or health issues that come with playing games internationally. And again, in that space [we] haven't seen any increased injury rate from international games. Small number of games, but it is something that we research. So, nothing to report in any of those three areas.

Finally, let's talk for a minute about next steps and things that we will share with the competition committee. I mentioned quarterback injuries, I mentioned special teams – those will be primary priorities for us. Allen mentioned the Guardian Cap. I think we have spent time with Guardian Cap and with the players and the Players Association, getting feedback from them, and there was some feedback that we wanted to pursue. Issues like fit of the cap, issues like heat with the cap, which we are investigating now. We think the fit will be better with work that we have done with Guardian Cap. We are researching issues around heat, and we'll make sure that anything that we find there can be addressed. But assuming that we come to a good place in those spaces, and I imagine that we will, we'll look to expand the use of the Guardian Cap, probably beyond the second preseason game and probably to other position groups, because we saw such benefits from it this preseason. So, something to watch there.

Allen mentioned head impact reductions. Also, we're going to share that information of course with the clubs. There'll be a series of individual club meetings where we look at their injury rates, their head impacts, their concussion rates and other things that come up in the health and safety space. We found that very beneficial last year, comparing each one of the clubs, giving them their data and comparing them to all 31. I think that touches on it. I mentioned, of course, surface and cleats, something that we're going to pursue over the next month when we have more information there, but that will continue to be a priority for us and I'm sure for the Players Association. We work jointly with them, it bears repeating, on a joint surfaces committee, and we'll continue to meet with them and share the learnings with them and hopefully benefit from the advice of experts in those spaces as well. I think that wraps it up in terms of priorities.

REPORTER: This is for anyone, it's a two-part question. First of all, you touched on this a little bit, but when the concussion numbers are up like they were, how do you go about trying to determine whether the actual number of concussions were up or whether you just were diagnosing more of the concussions that were there? And the second part is there was a lot of talk last year about trying to make punt plays safer. I don't think anything was actually done last off-season. Is that still a point of emphasis and do you have any thoughts on how it might come about if you think there's anything that still can be done there?

Sills: So, I think, Mark, first of all, we look at every single concussion that's diagnosed in many ways. We look at the biomechanics of it, we look at the mechanism of the diagnosis and the injury evaluation and what was done and how it's done. And our goal is simple. We want to make sure that we diagnose every single player who's injured by recognizing them and using all the tools we have at our disposal. At the same time, you've heard us say before, you've heard me say as a clinician, concussions remain difficult to diagnose sometimes. It's not an injury that we have an X-ray test or a blood test for, and so we have to put together a comprehensive network and look at that network and think about how we're doing on that. I will tell you Mark, one of the things we evaluate is how many players did we analyze or evaluate on game day that didn't subsequently get diagnosed with a concussion. That number this season is one percent, meaning one percent of all concussions that were evaluated on game day were cleared to return and then came back and were diagnosed. And that number has been fairly consistent. I think as a clinician in that area, I would tell you that that's something that we see, that sometimes concussions do present on a delayed basis with delayed symptoms that may show up a few hours to a few days later. It's a number that I wish were zero, but medically speaking, it's unlikely to be zero. I think again, I go back to saying we want to drive these numbers down. We want to diagnose them with a high degree of fidelity, but we want to prevent them. And I think that's what goes to this head impact reduction work. It's going to be very key that we look at that very critically, as I said, and holistically from how we train, how we practice, how we play the game, and what the rules are as far as allowable head contact. We want the numbers of concussions to go down, but more importantly, we want the number of head impacts to go down. And now that we can measure that, we'll be tracking that and working very actively against it. Jeff, I'll let you talk about the punt.

Miller: Yeah, thanks Allen. And Mark, the very simple answer to your question is yes, it remains a priority. As you've seen, changes throughout the years on the kickoff, we need to pursue those on the punt as well. There aren't a lot of injuries because the play isn't as frequent as a play from a scrimmage. Nevertheless, the injuries on special teams plays are disproportionate to how frequently the plays exist. And therefore, as we look to decrease injuries in all spaces – whether they be lower extremity injuries or major ligament injuries or concussions – we look at every place where they occur and where they occur disproportionately. And they do on special teams plays. I don't have an answer for you as to how to go about doing it, but we'll certainly meet with the competition committee, with special teams coaches, with others who have ideas in this space to try to think of ways that we can drive down some of those injuries going forward.

REPORTER: Hi there. Good morning. Thanks for doing this. My question is related to high ankle sprains and in the lower extremity injuries. Clearly, you know, hamstring strains have been identified as a priority and rightfully so. But it feels like – and I'm wondering if you have any data that you can share, either now or at a future point – that high ankle sprains are on the rise. Obviously, there are several mechanisms for them. But related to that, I'm wondering if there's been any discussion about some of these tackling mechanisms, like we see this hip-drop tackle and the subsequent high-ankle sprains that's costing some high-profile positions, especially quarterbacks in the league. So just curious your thoughts on that, any numbers on that or how you're approaching it. Thank you.

Miller: Allen, do you want to get started or me to go?

Sills: Yeah, I can I start. Stephania, high ankle sprains are squarely in the crosshairs for us. They are one of our top burden injuries. We've been looking at that and working against that and we'll continue to do so. Obviously, a multifactorial injury with a lot of things that go into it. But you mentioned, particularly, that there are certain types of contact, and that is something that we and our bioengineers, our epidemiologists have identified. I think it'll be a very active offseason conversation to look at the mechanism. Obviously, the hip-drop tackle is not the only cause of ankle sprains. There are certainly other things and other factors. And once again, trying to work upstream to the prevention side. We've been, for example, doing a study looking at taping and bracing and spatting, and how that affects the incidence of some of these injuries. Also looking at some of the neuromuscular screening that gets done on players and how that might predict players who have some vulnerability to injury. So again, pretty comprehensive approach to it. But we have noted that type of tackle that you mentioned, and I think it needs to be a very active discussion point again with the Competition Committee and others this season.

REPORTER: Hi guys. Good morning. Thank you for doing this. Understanding that the field surface data collection and dissemination is still ongoing, so totally take that in context, but in terms of the overall conversation about improving safety standards and reducing injuries on all playing surfaces, I'm wondering if you guys could characterize the ongoing conversation about possibly introducing more pregame standards for field safety outside of firmness. And also, in light of the sort of vocal conversation with players about things like heaters being introduced when temperatures drop suddenly, whether or not those things are mandated by the league, wondering if you guys have some characterization of those conversations moving forward.

Miller: Yeah, it's a good question and an ongoing and important conversation that we have with the Players Association. You may know that, structurally, we have agreed in our Collective Bargaining Agreement to have a committee that works on surfaces jointly appointed by us and the Players Association with experts involved and many of the rest of us participating and listening in. So, it's a point of active conversation. One of the topics of that committee, and will continue to be, is the sort of metrics that you identified about how do you identify different characteristics of surfaces, whether that be a natural grass surface or a synthetic surface or different sorts of synthetic surfaces. Hardness is one metric. Are there better or different or more detailed ways to work on that? And there's a substantial amount of time, effort and money being spent to try to move into that direction. I think we'll hear more of that this coming year. We have got some efforts underway currently, which I guess I would characterize as demos for this year. But I think more to come as we better understand the characteristics of surfaces both synthetic and natural. And then of course, importantly, whether any of those characteristics contribute to – in some way – injurious effects.

QUESTION: Hello guys, and Christina. This is about helmet weight. I'm wondering about the validity of the speculation out there and what we saw this past season with some high-profile players getting concussed when the back of their head smashes onto the field. Is it perhaps likelier that a player falling backward like that now is more likely to be concussed – compared to say 10 or 20 or 30 years ago – because the helmet is heavier, if it indeed is so much heavier, even just in recent years with the upgrade of red, yellow green helmets? Is there validity to that concern? Is the number of concussions in past years – I know you don't have the data for this year – has it been logged, and is it on the rise? And what can be done to make players as safe or safer with, if they are, heavier helmets.

Sills: So, John, again, we look at the mechanism of every concussion, and head to ground is obviously one of the mechanisms that we see. There are a lot of factors that have to do with that if you look at the nature of that concussion, beyond just where the head is hit, but is there any protective action of the individual falling? What are the surface characteristics? So, you're trying to look at all elements of that. I think helmet to ground concussions, as far as a percentage, we don't have the data for this season, but we will be looking very carefully, is that number going up? Obviously, it is more common in quarterbacks because they're often falling in that unprotected fashion and so they strike the back of the head. Again, it's something that we look at in a very holistic way. With regard to weight of the helmets, and Jeff can weigh in on this as well, you certainly are looking at a variety of factors for the safety of the helmet, which is how it reduces or mitigates force, and then you know what is the fit, the contour and the overall perception and the input of the player as well. Weight is one of those considerations. So, heavier is not always better, but at the same time, lighter is not always better, either. Our engineers take all that into account. Obviously, they're working together with the Players Association engineers in the testing. It is an active area of discussion and something that we look at. But as Jeff mentioned, what we're really driving to here is position-specific helmets. Particularly for quarterbacks, given their propensity to have this particular type of fall, Jeff mentioned that there was an offensive line position-specific helmet already introduced. What about a quarterback-specific helmet, is that something that's achievable? I think we'll have more to say about that in the offseason. And Jeff, you may want to amplify that as well.

Miller: Yeah, John, all I would add to it is that since we started our engineering work, engineering roadmap work, and testing of helmets and better understanding the sorts of hits on field, frequency and the magnitude and direction, location of those hits and replicating that in the lab, we have seen improvement in helmets and their mitigation properties at 9x the rate we were seeing before. So helmets are tremendously better than they were five years ago from absorbing and mitigating the forces that can be translated to cause concussion. Full stop. Is there more work to be done? Absolutely. There's no question about that, and the engineering will continue to improve. But credit to the helmet manufacturers for taking the information that we've shared with them and creating better models, and they will continue to. But the helmets that players are wearing today are vastly better than the helmets they were wearing just a few short years ago. We will continue to learn more. There hasn't been enough innovation in certain spaces. Allen mentioned the possibility of increased position specificity, and I talked a little bit about the likelihood or possibility of a quarterback-specific helmet coming on market soon. We're hoping that in fact does happen and we'll continue to encourage those sorts of disruptive ideas with the helmet manufacturers as we move forward.

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