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  • Writer's pictureRandon Hall, MD

High School Football Injuries will Surge after Pandemic Downtime

Evidence suggests that a culmination of multiple factors will likely lead to a surge of injuries in high school athletes. The COVID-19 pandemic has created the perfect storm for young athletes to be woefully unprepared for the upcoming season, particularly here in the state of Arizona.

The Paradox

One critical reason supporting this prediction is the novel concept of The Training-Injury Prevention Paradox (1). The theory that athletes who are otherwise accustomed to persistent (chronic) high training loads have fewer injuries than athletes training at lower loads when exposed to a significant (acute) increase in activity. The idea further explores the term acute:chronic workload ratio which contrasts baseline training levels for an athlete to abrupt changes in training intensity to predict injury (1). In other words, it is not always the total amount of training you perform but the intensity of acute training compared to baseline training that puts you at risk.

The Situation

In late March, the Arizona Interscholastic Association (AIA) canceled all high school Spring sports, in addition, most districts followed suit with the closure of scholastic athletic facilities and training rooms. As a result, Spring football activities such as "big man" competitions and passing leagues did not occur. Additionally, normal preseason football camps did not happen. Moreover, all facilities classified as a gym or workout facility have been closed for the past month, making it difficult to work out on one’s own. Not to mention, many parts of Arizona average temperatures over 100 degrees during the summer with highs up to 116 in Phoenix this year. As the postponed season approaches, this scenario leads to a high-risk workload ratio of relatively low chronic loads combined with an abrupt peak in activity leading to non-contact injuries.

The Evidence

There is ample evidence to support this prediction for high school athletes. Let’s look at the NFL lockout of 2011; where players reported to training camp just 17 days prior to the preseason games. Parkeh and colleagues showed, on average, there were 5 Achilles tendon ruptures per entire season in the NFL from 1997 to 2002 (2). In 2011 there were 12 in just the preseason alone. In effect, a 400% increase compared to the 1 to 3 that would have been expected during normal preseason (3). In addition, after the NBA lockout of 2011 there were eleven ACL tears in the season and half that followed compared to the previous year having only three (4). Lastly, Sampson et al showed an exceptionally high risk of injury in preseason NCAA football athletes with low 21-day chronic loads and high acute:chronic workload ratios (5).

The solution

At the writing of this article, the Arizona Interscholastic Association has set a date for the first football practice to take place on September 7th. If all goes well, games are scheduled to start a minimum of 23 days later. This situation begs the question: what can we do to prevent injury?

There is no one size fits all solution, but this concept argues that hard appropriate can be protective over time. Yet, it is the excessive and rapid increases in training loads that are largely responsible for non-contact soft tissue injuries. First, know where your athletes are in terms of baseline workload, (ie survey or fitness test). Keep in mind that the offseason resources for training can differ dramatically between athletes. Lastly, consider a gradual increase in training intensity (~10-15 % weekly) to keep acute:chronic workload ratio low.

Its understandable coaches will want to hit the ground running to prepare for the season, but it is critical to realize that many athletes will be starting at dramatically lower baselines than would be expected in early September. Likewise, the most well-trained athlete cannot contribute on field, if sidelined due to injury.


  1. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder?. Br J Sports Med. 2016;50(5):273-280. doi:10.1136/bjsports-2015-095788

  2. Parekh SG, Wray WH 3rd, Brimmo O, Sennett BJ, Wapner KL. Epidemiology and outcomes of Achilles tendon ruptures in the National Football League. Foot Ankle Spec. 2009;2(6):283-286. doi:10.1177/1938640009351138

  3. Myer GD, Faigenbaum AD, Cherny CE, Heidt RS Jr, Hewett TE. Did the NFL Lockout expose the Achilles heel of competitive sports?. J Orthop Sports Phys Ther. 2011;41(10):702-705. doi:10.2519/jospt.2011.0107

  4. Forbes. (2020, Deveney) A Medical Expert Predicted 2011 Post-Lockout Injury Spike. Now He Has A Warning For The NBA's Return. Retrieved from

  5. Sampson JA, Murray A, Williams S, et al. Injury risk-workload associations in NCAA American college football. J Sci Med Sport. 2018;21(12):1215-1220. doi:10.1016/j.jsams.2018.05.019


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