Introduction
Football has been at the forefront of discussions of sports-related injuries for decades. A high priority has been made by football leagues of all levels to make the game safer for its athletes, specifically in regards to head injury and concussions.  One suggestion is to encourage participation in non-tackling alternatives, especially in younger athletes.  A potential alternative is flag football, which utilizes many of the same rules as traditional football, but incorporates a belt carrying flags which must be removed for a ball carrier to be considered “down”.  Another alternative is TackleBar™ football.  This alternative maintains the same rules as traditional football, including use of protective equipment along with a harness holding foam bars.  A ball carrier is “down” when a player “wraps up” the carrier with normal tackle form and removes the foam bar rather than tackling the carrier to the ground.  In order to assess the relative safety of these, a literature review was performed to analyze overall injury rates and compare to open source data for TackleBar™.
Methods
Articles were searched for on ebscohost using the terms “injury”, “football” and “rates”.  Matches were analyzed and used for comparison if they recorded athletic exposures (AE), defined as one player participating in one game or practice, and defined an injury as occurring during sport participation, needing attention from coach, athletic trainer, or physician, and requiring loss of playing time.  Independent analysis of open source data from TackleBar™ football injury reporting was done and compared to articles meeting the criteria.
Results
Five articles met all criteria.  Two reported the concussion rates of 100 high school tackle football teams over 5 years, 0.82 per 1000 AE (N= 3,528,790 AE’s) and 1.0 per 1000 AE’s (N= 2,517,207). Others followed youth, high school, and collegiate tackle football leagues over the course of a single season.  These found youth injury rates to be 2.25 and 2.6 per 1000 AE’s (N= 142,536, and 44,164), high school rates to be 4.74 and 4.36 per 1000 (N= 860,202 and 431,242), and college to be 3.21 and 8.61 1000 AE’s (N=315,723 and 401,932).  One article reported on youth flag football, and found the rate of injury to be 5.77 per 1000 AE’s (N= 2252).  Youth TackleBar™ football was found to have an overall injury rate of 0.31 per 1000 AE’s (N= 15,910)
Discussion
Flag football had the highest injury rate among youth leagues at 5.77 per 1000 AE’s compared to ~2.5 for tackle and 0.31 for TackleBar™, which produced the lowest injury rate of any competition level and form of football assessed.  Limitations of this study include ascertainment bias in data collection methodology and relatively smaller numbers for TackleBar™.

Injury Rates in Football and Football Alternatives