The videos, peppered around the internet, can be captivating — college football players pushing or pulling an inordinate amount of weight, their sweat and strain accompanied by heavy guitars or thumping bass. Set in weight rooms, cinderblock walls and wooden platforms adorned with the logos of major programs, these five-minute montages show young men demonstrating remarkable strength. The stirring presentation is catnip for fans and future recruits alike.

Look closer, though, and cracks start to show.

A student-athlete struggles through a squat as the barbell and his torso list to one side while the teammates encircling him shout for him to finish.

Another: Though he is performing an exercise meant to target his arms, a player’s entire body shakes violently and his back contorts as he curls a barbell laden with chains toward his chin. His teammates and coaches nod and scream.

Still another: A strength coach boasts that his primary charge is to foster mental toughness, not improve physical performance, as players are shown running stadium steps under the searing sun.

“If they can make it through our two hours in the summer …”

All of this is aimed at forging the camaraderie they will lean on when third quarters yield to fourth quarters. But the mix of machismo and mediocre form glamorized in these videos portends an issue that carries serious consequences: Some young athletes’ bodies are being pushed beyond reasonable limits as a means to harden their minds.

According to the National Center for Catastrophic Sport Injury Research, 85 college athletes died from 2000 to 2016 from indirect causes related to their sport. (Indirect causes of death, such as heatstroke and sudden cardiac arrest, occur when overexertion causes one or more of the body’s key systems to fail.) Of those 85 deaths, 40 percent were football players. And according to Scott Anderson, Oklahoma’s head athletic trainer who has published research on the subject, 23 Division I football players alone have died from indirect causes since 2000. Most of the deaths occurred after workouts or conditioning drills, including a Maryland offensive lineman who died in June.

The prevalence of catastrophic events in football does not surprise those who have examined the issue closely. Experts see the strength and conditioning field still struggling to agree on uniform professional standards. And the relatively young profession continues to be influenced by a sport whose popularity has fostered a sometimes dangerous — and persuasive — culture.

Where does the line fall between improving student-athletes’ performance and pushing them into peril? Though many strength and conditioning coaches adhere to safe practices, rooted in established exercise science, the field has never reached the type of uniform standards that could offer a definitive answer. Consequently, that discord has made it difficult for the NCAA and other athletics organizations to rely on established professional norms to offer guidance to athletics departments. The resultant environment leaves room for potentially hazardous workouts.

So, the NCAA is encouraging the field’s two widely recognized credentialing bodies to find common ground, the first step toward creating comprehensive guidelines that can better protect student-athletes. To get there, sports medicine experts say, the strength and conditioning profession needs to close its internal divide and find consensus. Even then, will better hiring and credentialing practices — and eventual baseline standards governing the conduct of strength and conditioning professionals — be enough to counter football’s long-standing customs?

Until that puzzle is solved, experts say, college athletes will remain at risk. Chuck Stiggins, executive director of the Collegiate Strength and Conditioning Coaches association and one of the profession’s most ardent defenders, says deaths and serious injuries don’t have to be training’s byproducts.

Inarguably, though, they long have.

“One death,” Stiggins insists, “is too many.”

Football fatalities

Since 2000, college football players have died of indirect causes at a rate of 2.74 per 100,000 participants, on average. Comparatively, middle school and high school players have died at a rate of 0.64 per 100,000 participants, a rate more than four times lower than that of their college counterparts. Nearly all indirect deaths occur during workouts or practices.

Source: National Center for Catastrophic Sport Injury Research Annual Survey of Football Injury Research

A 2013 paper in the American Journal of Sports Medicine found that college football players were 3.6 times more likely to die from indirect causes than their high school counterparts. And, in recent years, indirect deaths at the college level have occurred at roughly five times the rate of those who died as a direct result of playing the sport.

Athletes are most vulnerable when they return to campus from breaks over the summer and holidays. Fatalities peak in these February and August transition periods, when athletes need to gradually reacclimate to their sports’ physical rigors — a sign that some are being driven to do too much, too soon.

“They’re dying in winter; they’re dying in summer; they’re dying in August preseason,” Anderson says. “They’re not dying playing football.”

In 2015, Division I implemented legislation requiring schools to employ strength and conditioning coaches with a “nationally accredited strength and conditioning certification.” Division II took a similar path a year later, mandating a “nationally recognized” certification. (Division III already had a similar rule in place.) But those developments are dampened by language that is, by necessity, imprecise because of the field’s inability to come to consensus on how it should be regulated. A Google search for strength and conditioning coaching certification yields a slew of options, showing the industry itself has not yet settled on what a nationally accredited strength and conditioning certification means.

Amid a sea of others, two major credentialing organizations stand out. One is the National Strength and Conditioning Association, which awards credentials across several disciplines within the field. The other is the CSCCa, which launched in 2000 and is tailored specifically to strength and conditioning coaches for college and professional teams.

The NSCA and CSCCa wrote a joint letter to the NCAA in March 2017 in hopes of giving more credence to their credentials. The letter urged the NCAA to set a series of mandates: Require college strength coaches to carry a credential from a group overseen by their shared accrediting body, the National Commission for Certifying Agencies; require a minimum of a bachelor’s degree; include a continuing education component; and require first aid, CPR and automated external defibrillator certification.

The two groups that penned the letter meet those requirements. But there are many others, offering purportedly similar credentials, that don’t. The CSCCa’s specifications are particularly stringent, requiring all that was proposed in the letter in addition to a 640-hour internship overseen by a CSCCa-approved mentor, a comprehensive scientific written exam and a practical certification examination that requires creating a detailed strength and conditioning program and defending it in front of a panel of veteran strength and conditioning coaches. The NSCA requires a written test in addition to the letter’s requirements. About two-thirds of CSCCa candidates have passed those tests in recent years, and little more than half of first-time NSCA candidates pass.

The letter precipitated a meeting in June 2017 at the NCAA national office in Indianapolis, attended by leadership of the NCAA Sport Science Institute and leaders from the NSCA and CSCCa. The NCAA representatives urged the strength and conditioning coaches to follow the path of comparable health professions — such as physicians, athletic trainers, physical therapists, among others — and seek state regulation (for example, state licensure), which would require the field to precisely define itself and agree on uniform credentialing requirements. In other professions, an acknowledged single credential is a prerequisite before making a case to states for regulation.

For example, in the athletic training profession, the Board of Certification serves as the sole credentialing organization. Incorporated in 1989, the body establishes educational requirements for the profession, issues a common credential and works with state regulatory agencies to ensure credentialing standards are palatable. The NCAA, however, is not appropriately positioned to play a similar role and declare as mandatory one of the two credentials or an overarching accrediting body. The Association has not set such precedents before for athletic trainers or physicians, for instance, who are licensed by states.

“Are these individuals coaches? Or do they somehow have a performance or a medical subspecialty?” asks Brian Hainline, the NCAA chief medical officer. “They need to define themselves better, and haven’t.”

At the meeting, the strength and conditioning representatives blanched at the licensing idea. The process in each state would be too onerous, they said, particularly for coaches at major Division I programs, who often move from school to school with sport coaches. (At other levels, strength coaches tend to move less frequently, reporting to an athletics administrator rather than the coaching staff.)

The disagreement didn’t end at an impasse, though. The groups agreed to formulate comprehensive guidelines to mitigate catastrophic injury and death, with a focus on safety during conditioning sessions and transitional periods. The concept is similar to recent interassociation approaches related to concussion management and independent medical care, which set professional expectations in those areas throughout college sports. (The NCAA does not act unilaterally when publishing guidelines, instead seeking endorsement, significant contributions and feedback from key sports medicine and other medical organizations.) The conditioning guidelines could be published as soon as this year.

And the CSCCa agreed to join a third-party registry that the NSCA co-founded, which helps athletics administrators either verify credentials when making a hiring decision or determine whether current staffers’ credentials are up-to-date. A pair of recent, well-publicized incidents involved coaches whose credentials either came from other credentialing groups or were falsified. One occurred at Oregon, in which several football players developed exertional rhabdomyolysis, a preventable condition in which rapid muscle breakdown leads to kidney damage. In the other, at Kent State, a player died.

“We want to be unified as one voice so that people know that these two major organizations are on the same page,” Stiggins says, “and that health and safety is the No. 1 priority.”

Despite some initial tensions, Hainline agrees: “I think at their heart of hearts, they truly want what’s best for the athlete.”

Recent reported cases of exertional rhabdomyolysis at NCAA schools

A number of exertional rhabdomyolysis cases have caught media attention over the past decade. The condition occurs when muscle breaks down too quickly, releasing products that can damage kidneys or even cause the organ to fail. Experienced athletic trainers like Randy Cohen, associate athletics director for medical services at Arizona, note that many cases do not receive public attention, so this list is likely far from comprehensive. The incidents suggest the problem exists in many sports other than football.

72007
South Carolina swimmers

13 2011
Iowa football players

32011
Miami (Ohio) women’s soccer players

62012
Ohio State women’s lacrosse players

52012
Maine football players

12014
(at least) Ohio State women’s track athlete

12015
Louisville women’s lacrosse player

82016
Texas Woman’s University volleyball players*

32017
Oregon football players

22018
Nebraska football players

Source: Scott Anderson, Oklahoma

* An earlier version of this story incorrectly cited these as Texas women’s volleyball players. The incident referenced here took place at Texas Woman’s University, not the University of Texas.

But will the talk of credible credentialing, higher standards and other solutions stand up when crossing paths with decades of culture built around forging toughness and testing limits? Even immaculate credentialing, hiring processes and recognized standards can fall prey to simple mistakes. “You can’t legislate or credential people to do their jobs well,” says Randy Cohen, associate athletics director for medical services at Arizona.

Stiggins agrees, citing that mishaps often happen in well-regarded fields like medicine and law. “No field is perfect,” he says, stressing that his organization uses education and science to limit errors.

What that viewpoint ignores, critics say, is that injuries and deaths are not generated simply by errors or bad actors, but by an ethos that sees value in pushing athletes beyond the physical demands their sport necessitates. Work-rest ratios in conditioning drills, for instance, often far exceed those experienced during games. The public and media alike often point fingers at strength coaches when a player dies, but Stiggins insists the problems lie with traditions within sports like football. For instance, the CSCCa doesn’t condone using arduous workouts for punishment, yet punishment drills remain common throughout college football and other sports.

Many Division I college strength coaches hold one or both of the major credentials that require stringent training and education, and they strive to implement sound regimens. Still, without the backing of professional guidelines or legislated rules to validate their stance, some feel powerless to push back against sport coaches convinced that heroic workouts develop toughness and camaraderie. “It’s like the Wild, Wild West,” says Douglas Casa, chief executive of UConn’s Korey Stringer Institute, a research and advocacy group devoted to preventing sudden death in sport.

Why is the problem more pronounced in football relative to other sports? There are rational explanations: Cohen points to massive roster sizes — which often exceed 100 — and the difficulty strength coaches have in tailoring workouts to athletes who have an array of conditioning levels. The sheer number of players, Cohen says, forces strength coaches to find a middle ground that can be too strenuous for less adept athletes, but doesn’t challenge elite players.

But in his three decades in the field, Cohen also has seen strength coaches forced into difficult positions by the sport coaches who hold enormous sway over their careers. “(Strength coaches) don’t want to be the guy out there making a guy do 1,000 up-downs because he didn’t go to class,” he says. “They do what someone else wants to do because they want to keep their job.”

Stiggins says his group tries to use continuing education sessions at its annual national conference, and even direct contact with coaches holding his organization’s credential to encourage safe program design and implementation and to prepare them to resist if workouts they are ordered to oversee grow unreasonable. “I cringe in January and August, and I send email after email, and I call coaches,” Stiggins says. “You’ve got this knowledge, and you’ve got the skill. Now please, please make sure that you use good judgment and never be manipulated by any sport coach. Always make good choices.”

Mario Price, director of coaching education at the American Football Coaches Association, insists safety is a priority among its members. The group teaches football coaches about safe training practices at its annual convention and via an online library. “They’re highly engaged in these sessions,” Price says. “Those coaches are working toward implementing great programs that protect the players.”

Still, some within college athletics believe mandating that strength coaches report directly to an athletics administrator, the medical director or to student health services — rather than a sport coach — is a potential solution. Nate Moe, assistant athletics director for strength and conditioning at South Dakota State and a CSCCa board member, reports to a senior associate athletics director. And while he regularly interacts with the school’s coaching and sports medicine staffs, he does not have to seek their approval before proceeding with a workout.

His primary focus is developing strength and power, enhancing speed and agility, and making athletes more injury resistant. Mental toughness, he insists, is a mere byproduct of adhering to a meticulously designed workout program. The best way to foster a safe approach? Moe thinks it’s essential for strength and conditioning coaches to be hired by and report to a senior administrator, not a sport coach.

“Unfortunately, many sport coaches only want the yeller and screamer, or someone who looks the part but may not have the necessary training or knowledge,” Moe says. “Many people and sport coaches think if it makes them sweaty and tired, or makes them puke, then it is good. But training is not about one workout, but about a planned progression of workouts and adaptation over time.”

But the traditional structure, in which strength coaches report directly to sport coaches, remains common in the highest-profile sports, such as major Division I football.

Stacey Torman, director of athletic performance for Olympic sports at the University of Alabama at Birmingham, has been with the school for nearly three decades. Such career stability in Division I, she says, is more common for coaches like her who deal with sports other than football and basketball.

At UAB, for instance, she reports to an athletics administrator; the strength and conditioning coaches for football have a separate staff with their own weight room. They maintain relatively little contact with the veteran Torman, a CSCCa board member. She says that setup seems common across other campuses throughout the division — and is even spreading to basketball.

Altering arrangements like those in Division I in the near future, Stiggins admits, seems unlikely.

Michael Massik, executive director of the NSCA, says he hopes to see more schools creating a third branch — often dubbed sports performance — that has touchpoints with sport coaching and the sports medicine staff, but is independent of both. Some colleges already have adopted the approach, where the performance branch is home to strength coaches, nutritionists and psychologists. Greg Haff, NSCA president and a strength coach who has worked in the United States and Australia and has done consulting work in the United Kingdom, says such arrangements are increasingly common outside the United States.

“We’re seeing it more on the pro teams because they are not as necessarily constrained by budget as some of the collegiate programs,” Massik says. “We do believe that it’s going to filter down, and if you asked me what my view of the future is, that’s the future. It’s logical.”

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Strengthen Your Program

While the NCAA, leading sports medicine groups, and strength and conditioning coaching organizations develop a consensus on guidelines and recommendations, athletics departments can take steps to keep athletes safer. Which are vital? A few experts weigh in:

Enforce sound reporting structures

Joey Hannant, associate athletics director for athletic performance at Division II UNC Pembroke, reports to an athletics administrator, not a coach. He says that if a coach asks him to implement a workout he is uncomfortable with, he consults with his school’s athletic training staff or says no outright. Hannant’s close relationships with administrators in his department, including the athletics director, make him feel confident he can draw clear lines when coaches grow eager to test boundaries.

Bob Bowlsby, commissioner of the Big 12 and outgoing chair of the Division I Football Oversight Committee, says he is particularly interested in examining reporting lines for strength coaches in both of his prominent roles. “We haven’t come to any sort of closure on that,” Bowlsby says. “But I think those are the kinds of discussions that need to take place.”

Rely on data

At the University of Alabama at Birmingham, Adam Snow, a performance coach working as the sports science coordinator, has overseen the athletics department’s adoption of new technologies and data. They include tracking systems like heart rate monitors, or even simple tools like questionnaires about sleep habits and stress levels. Athletes are tested using a strength indexing tool before each workout to gauge what loads they will be able to tolerate and what might endanger them. After the test, planned workouts are amended accordingly. “It’s helping us make better decisions and helping the coaches understand the stress load (the athletes) are under physically and emotionally,” says Stacey Torman, director of athletic performance for Olympic sports at UAB.

Check credentials

Given the scattershot nature of credentialing in the field, it’s important to verify what credential a prospective or current strength and conditioning coach holds and what the requirements are to earn it. The CSCCa and NSCA are both members of a third-party registry — the United States Registry of Exercise Professionals (found at usreps.org). Strength coaches holding either credential are included on a list that schools could use to help with hiring decisions or to verify that current staff members have up-to-date credentials.

In 2012, representatives from a dozen prominent sports medicine and sports science organizations put forward a best-practices document for limiting sudden death in conditioning sessions. With Casa and Anderson as the document’s lead authors, it decried conditioning as punishment and offered guidance for proper acclimatization, credentialing standards, reporting structure and developing emergency action plans. It remains the most comprehensive paper of its kind.

The document was discussed at NCAA Committee on Competitive Safeguards and Medical Aspects of Sports meetings. Elements of the paper went on to inform safety-centric legislative proposals, but the committee never formally endorsed the document.

Subsequently, it has lacked influence.

The NCAA, CSCCa and NSCA hope they are on the path to rectifying that by building on the 2012 paper with the guidelines the groups are crafting for conditioning sessions — particularly focusing on the ever-dangerous transition periods. The work is the fruit of the summer meeting held at the NCAA national office and a step Casa and Anderson say is long overdue.

“It doesn’t have to be a bylaw; all it has to be is a standard,” Anderson says. “OK, you violated the standard of practice … your job is at stake.”

Stiggins feels the forthcoming release of an agreed-upon best practices document (in the vein of previously released interassociation documents) to NCAA members could be a landmark moment for the field. But the groups disagree on how the guidelines become athletics department gospel: Are standards of care, similar to those prescribed for athletic trainers, enough? What penalties should be imposed? Should coaches be at risk of losing their credential?

For now, consequences for negligence remain inconsistent — the credentialing groups, for instance, say they have rarely found cause to pull a credential. But the NCAA’s acknowledgment of sound guidelines, along with consensus from other leading medical groups, could be critical.

“Even if it’s not passed as policy, if (the NCAA) were to release that as best practices or recommendations, that would put a huge burden on the schools to consider those items,” Casa says.

The NCAA Sport Science Institute already has begun a more direct approach. In January, a Nebraska conditioning session left a pair of football players hospitalized for several days with exertional rhabdomyolysis. Nebraska’s new coach, Scott Frost, insisted his strength coach had tamped down the intensity of his workouts given that the student-athletes were returning from a holiday break, but Frost accepted responsibility for what transpired (though received no public censure from the school). Within days of the incident, Hainline sent a note to coaches, athletic trainers, athletics directors and other administrators throughout the NCAA membership with detailed information about exertional rhabdomyolysis and how to prevent it.

The strength and conditioning field also has begun leaning on advanced data and analytics to guide decision-making and stave off incidents like what occurred at Nebraska. Haff says the United States has been slower to adopt such evolutions, which he says are commonplace overseas. While the amount of weight someone can lift or the duration of conditioning exercises they’ve been subjected to can be cataloged easily, Haff says relying on mechanisms — such as heart rate monitors and GPS technology that tracks distance, pace and recovery — to gauge the internal load is emerging as another tool to foster safer environments.

For all the data’s benefits, Haff warns that the statistics may make strength coaches overly cautious. If they don’t push athletes to the place where they can make steady gains and adaptations, making them ill-prepared for the rigors of competition, injury rates can spike. He has seen that problem manifest while working with athletes in Australia.

Still, among some college programs that have begun integrating technology and data, the decision has had a net positive effect as strength and conditioning coaches begin to weigh both statistics and intuition — much as clinicians do — to guide their decisions. “Some of this technology stuff ... has got the coaches to inherently understand and listen to what strength and conditioning coaches and athletic trainers have been telling them for years,” says Cohen, the Arizona medical services director. “‘We’re wearing these guys out.’ And now you have numbers, and coaches, finally, some of them will look at that and say, ‘Wow.’”

The potential solutions are many: comprehensive guidelines, a detailed registry to augment hiring practices, amended reporting structures, increased transparency and documentation of workouts, and integration of data and technology. They inevitably will vary in their efficacy and impact. But in lieu of the field coming together under one umbrella, the way athletic trainers did three decades ago, this piecemeal approach may be the best recourse in the near future. Perhaps, taken together, these incremental changes will yield positive outcomes.

Only fewer deaths, fewer injuries, fewer headlines highlighting ugly exertional rhabdomyolysis incidents will demonstrate whether those approaches are enough to mitigate the risks. Only those metrics will determine if the many steps promised in the coming months and years can conquer an archaic culture and help young athletes’ bodies and minds grow stronger during difficult workouts, not succumb to them.

Hainline, for one, is hopeful: “I do see that change is happening, and I think others are seeing the necessity for that. We’ve already passed the immovable place.”