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Kids playing flag football were more than twice as likely to suffer any injury during games and practices than those playing tackle football, researchers found, but when an injury occurred, it was more likely to be severe in tackle settings.

, of the University of Iowa, and colleagues conducted a cohort study of 3,794 players from grades 2-7 on youth flag and tackle teams over one season. A reported 128 injuries in sum afflicted 121 distinct players, including 65 considered severe injuries, for a rate of 2.76 injuries overall per 1,000 exposures (game or practice). This rate is in line with previous research, the authors.

While the rate was lower among tackle teams (HR 0.45 versus flag teams, 95% CI 0.25-0.80), the probability that a tackle injury would be severe was twice as high than for flag injuries (54% versus 23%).

Players with tackle-league injuries consequently missed more practice and game time due to injury. They were nearly 10 times less likely to return to a football activity on any given day because of injury, in fact (P<0.0001).

The study had a secondary goal of comparing concussion rates, but there were too few to make meaningful conclusions, the researchers said.

Overall, 3.5% of players suffered any injury forcing them to miss a practice or game during the season, Peterson said, noting the injury rates are comparable to rates in youth soccer and less than those among college football players.

"It was more common to see minor injuries in flag, which in retrospect makes sense," Peterson said. "We can say both are reasonably safe, but that flag football isn't necessarily a safer option."

The authors limited their conclusions to injury rates, Peterson said, because of several factors limiting the study, including: "The number of injuries seen in the flag football league was relatively small (13), and the number of participants in the flag league was much smaller than the number of participants in the tackle leagues (3,525 versus 269)." He said that was because "there just happens to be a lot more tackle football here than there is flag."

"For these reasons, the comparisons made between leagues are somewhat limited," Peterson said.

More study is needed before concluding anything concrete about the safety of flag versus tackle football, the authors wrote: "Future safety analyses should include looking at injury rates, severity, type of injury, lost time, and future consequences of injury."

Researchers worked with leagues in three eastern Iowa cities in what Peterson called the largest youth football study to date. They partnered with three large leagues to collect injury data during the 2015 football season. One designated adult per team was charged with inputting data after every practice or game, with researchers stipulating that any injury that caused a player to miss a football activity be recorded online. They issued a tutorial to each team reporter before the season.

Data collection ensued during the 2016 season, when researchers also collected data about injury reporting trends after implanting observers to track the teams' designated reporters. "We were worried about that," Peterson said, which is reflected in the study's noted limitations: "There may still be variability between coaches and team personnel in attendance and injury reporting. Also, 'non-medical' personnel (such as coaches) reported the injuries based on who was designated by the team."

Another limitation was families self-selecting which league to play in, with the authors postulating that parents of flag players may be more safety-focused and hence more likely to report injuries.