Why the study?
Linemen account for over 90% of exertional heat stroke deaths in collegiate and secondary school American football, motivating the development of consensus-based specific risk reduction recommendations for this population.
Provides 20 Delphi-consensus recommendations to reduce exertional heat stroke risk and deaths in secondary school and collegiate American football linemen through tailored training, acclimatization, and on-site cooling strategies.
May guide targeted EHS prevention in linemen; leaves open prospective validation before practice adoption.
BACKGROUND: Linemen make up over 90% of all exertional heat stroke (EHS) deaths in collegiate and secondary school American football deaths. PURPOSE: This document aims to accomplish 3 purposes: (1) briefly summarize the need for specific risk reduction recommendations for EHS in secondary school and collegiate American football linemen, (2) provide new recommendations for the reduction of EHS in football linemen developed with Delphi procedures to build consensus, and (3) summarize the evidence for the existing and new best-practice recommendations that currently exist for EHS risk reduction. DESIGN: Delphi-based Task Force Recommendations. LEVEL OF EVIDENCE: Level 3. METHODS: A multidisciplinary group of experts was convened to build consensus on EHS risk reduction strategies for secondary school and collegiate football linemen. The process involved a narrative review of relevant literature, followed by iterative rounds of anonymous Delphi surveys to refine and validate the recommendations. RESULTS: A total of 20 recommendations were identified, scored, and retained for EHS risk reduction in American football linemen. Key recommendations include the education of coaches and strength and conditioning coaches on EHS risk reduction and treatment, the implementation of heat acclimatization protocols, and weather-based exercise modifications. The recommendations emphasize the importance of the avoidance of high-intensity aerobic testing during transition periods and the importance of having on-site cooling modalities. CONCLUSION: The high rates of EHS in American football linemen highlight the need for targeted risk reduction strategies. In American football, the design and implementation of workouts for linemen must differ from other players on the team. Linemen require position-specific work-to-rest ratios and tailored training programs. CLINICAL RELEVANCE: By adhering to best practices and continuously updating guidelines based on emerging evidence, the safety and well-being of American football players can be significantly enhanced. These recommendations provide a comprehensive framework for reducing the risk of EHS and improving outcomes for American football linemen.
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Stearns et al. (2026) studied Exertional heat stroke (EHS) in American football linemen. Delphi-based EHS risk reduction recommendations was evaluated on Consensus recommendations for EHS risk reduction in American football linemen. Delphi consensus procedures identified 20 recommendations to reduce exertional heat stroke deaths in American football linemen, who account for >90% of football EHS fatalities.
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