Heat-Loss Patterns in National Football League Players

as Measured by Infrared Thermography

Daniel Garza MD, Brice Rolston BA, Tyler Johnston BA, MS, Gannon Sungar BS, Jeff Ferguson BS, MS, Gordon
Matheson MD, PhD
Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford CA
San Francisco Forty-Niners, Santa Clara, CA

ABSTRACT
Various thermoregulatory mechanisms employed by the body are important for the athlete to avoid heat
illness. By employing an infrared camera to focus on the radiation of heat from a venous plexus in the face,
we were able to postulate normal and abnormal patterns of thermoregulation in National Football League
players. Shunting of blood flow to the pterygoid plexus appears to be a normal compensation for increased
body temperature generated by working muscles. Players demonstrated an increase in blood flow by infrared
measure while resting on the sidelines. Failure to adequately increase blood flow to the plexus as measured
by infrared thermography may represent a player predisposed to heat illness or a player progressing towards
heat illness.

INTRODUCTION
In high intensity athletics, heat illness can lead to a variety of negative outcomes. In addition to concerns of
decreased performance and the potential for lost practice days after a heat stress episode1,i team physicians
and trainers must also be aware of the possibility of catastrophic events. Since 1995, 33 high school, college
and professional football player fatalities have been attributed to heat stroke2.

As working muscles produce heat and core temperature increases, a variety of thermoregulatory
compensations occur to dissipate this heat to the external environment3. While the role of evaporative heat
loss through sweating is well understood, there is an increasing body of literature regarding the importance of
cooling through radiation to the external environment. This is achieved by increasing blood flow to superficial,
subcutaneous vascular beds. These capillary beds, arteriovenous anastomoses and venus plexuses, have
been shown to be effective mechanisms for heat dissipation when body temperature rises during exercise4.

Previous research has attempted to categorize and quantify heat loss in subcutaneous capillary beds using
surface thermistors and, more recently, infrared thermography5,6,7. Infrared thermography has emerged as
the preferred method, as it allows for non-invasive visualization of large, heterogeneous regions, and allows
for immediate identification of temperature changes8,9.

In this study, we utilize infrared thermography to visualize a subcutaneous venous plexus in the face, the
pterygoid plexus (Figure 1), in National Football League players. Owing to the extensive padding, body armor
and other equipment worn by players, this plexus is the most easily visualized during the post-exertion period.
Infrared images of players were collected during recovery from exertion, allowing for identification and
analysis of patterns of heat dissipation.

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Figure 1. Pterygoid plexus and ThermaCam outline.

The pterygoid plexus (left, middle) is a shallow, subcutaneous capillary bed in the face that allows for
conduction and dissipation of excess heat to the surroundings. At right, the area of interest used to generate
temperature distribution histograms in ThermaCam Researcher Pro.

METHODS
This observational study was performed during 12 National Football League games. All 53 players were
filmed on the sideline while recovering from a series of plays, yielding 1,858 images. Data were collected
using a FLIR ThermaCam EX320 with a 320x240 pixel focal plane array, fitted with a 150 x 110 telescopic
lens. Of the 1,858 images collected, 165 series were reviewed for completeness, yielding a total of 24 series
that were identified for further quantitative analysis. Two representative and one "abnormal" series are
presented in the results below.

Image collection began immediately after a player exited the field and removed his helmet, revealing the area
of the pterygoid plexus. Images were taken approximately once every minute until the player replaced his
helmet. Data on ambient conditions, game time and number of plays per drive as an approximation of
exertion were collected and correlated to each image series to provide proper context.

Image post-processing was performed using FLIR Researcher Pro software. Temperature distribution
histograms of the area of the pterygoid plexus were generated. The area of the pterygoid plexus was defined
as the area between the zygomatic arch and the angle of the mandible. The scale for qualitative image
analysis was standardized to a range of 65 to 100 °F. For each image series, the average temperature value
of the area of interest in the first image in the sequence was used as the threshold value against which
subsequent images were compared.

RESULTS
The image series in Figure 1 was taken after the 2nd offensive series (3 plays) in the 2nd half of an afternoon
game held on December 2, 2007 in Charlotte, NC. Ambient conditions: 50°F, humidity 50%, light breeze and
overcast. Approximate average temperature for the outlined pterygoid plexus region immediately post-
exertion was 78°F. At 2.65 minutes post-exertion, the histogram shows a significant upward shift, with 100%
of associated pixels above the threshold value of 78°F. In the final image of the series, at 4.53 minutes post-
exertion, 99.6% of associated pixels remain above the threshold value of 78°F.

The image series in Figure 2 taken after the 2nd defensive series (5 plays) in the 2nd half of an afternoon game
held on October 28, 2007 in San Francisco, CA. Ambient conditions: 73 °F, humidity 83%, no wind and
sunny. Approximate average temperature for the outlined pterygoid plexus region immediately post-exertion
was 87 °F. At 3.65 minutes post-exertion, the histogram shows a significant upward shift, with 99% of
associated pixels above the threshold value of 87 °F. In the final image of the series, at 11.51 minutes post-
exertion, the histogram shows a continued upward shift with 100% of associated pixels above the threshold
value of 87 °F.

The image series in Figure 3, identified as “abnormal”, was taken after the 3rd defensive series (8 plays) in the
2nd half of an afternoon game held on December 2, 2007 in Charlotte, NC. Ambient conditions: 50 °F,

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humidity 50%, light breeze and overcast. Approximate average temperature for the outlined pterygoid plexus
region immediately post-exertion was 79 °F. At 1.95 minutes post-exertion, the histogram shows only a slight
upward shift, with 55% of associated pixels above the threshold value of 79 °F. In the final image of the
series, at 6.76 minutes post-exertion, the histogram shows almost no change with respect to the first image,
with 48% of associated pixels above the threshold value of 79 °F.

Immediately post-exertion +2:41 post-exertion

+4:32 post-exertion

Figure 2. “Normal Trend” example 1.

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 Immediately post-exertion +3:21 post-exertion

+11:34 post-exertion

Figure 3. “Normal Trend” example 2.

DISCUSSION
Infrared tracking of the skin temperature of the pterygoid plexus region proved to be a useful technique for
understanding physiological heat exchange patterns in the cheek region after intense exertion. While exact
incremental measurements were not always feasible in the context of live participation, this methodology goes
a long way in lending insight into mechanisms through which the body eliminates excess heat generated
during exercise. This is particularly relevant to professional football athletes who wear shoes, gloves and
pads on their chest, shoulders, and legs, decreasing the effectiveness of many of the body’s reported
methods for eliminating excess heat.

Based on preliminary analysis of the period immediately following exertion, blood flow through the pterygoid
plexus appears to be tightly controlled in accordance with physical effort and resulting internal heat.
Specifically, in the first few post-participation minutes when the player returns to the sideline and removes his
helmet, the region of interest normally exhibits a comparatively low average temperature versus resting data
points. In the data recorded, this baseline was found to range between 73 °F and 87 °F, likely a function of
weather context, prior exertion, as well as player variability. Despite these differences in initial temperature
distribution, characteristic trends were discernable during the post-exertion period. Specifically, as evidenced
in the time series depicted in Figures 2 and 3, players typically display a period of dramatic cutaneous
temperature increase in the cheek region across the initial 0-3 minute interval following exertion. Using the

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 Immediately post-exertion
+1:57 post-exertion

+6:46 post-exertion

Figure 4. “Abnormal Trend”

initial average temperature of the region of interest as a baseline threshold, we tracked the percentage of
pixels displaying temperatures above and below this threshold across all subsequent data points. While the
timing, absolute temperature, and rate of change of temperature distribution vary between individuals and
with environmental conditions, the trend is clear.

Physiologically, the aforementioned cutaneous temperature trends reflect controlled changes in blood flow to
superficial vasculature during and immediately following exercise. As described in previous literature, this
response can be explained by the body’s constant balancing of hemodynamic demands of active muscle and
thermoregulatory demands2. While active muscle has great oxygenation and blood flow demands, during the
post-exertion recovery phase blood is preferentially shunted through superficial pathways to exchange excess
heat with the external environment. While this mechanism is well documented in various regions of the body,
here we demonstrate that it is particularly prevalent in the pterygoid plexus in the face. The documented
images and temperature histograms point to the overall effectiveness of this physiological system in
dissipating heat in professional athletes in a non-laboratory setting.

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While these trends were exhibited by the majority of the image sequences taken over the 2007/2008 season,
not all players demonstrated this rapid rise in cutaneous cheek temperature during the first minutes of
recovery. An example of an “abnormal" trend is depicted in Figure 4. In this case, the histograms of cheek
temperatures portray almost no change over the 7 minutes immediately following an 8-play drive. This was
documented as the typical recovery pattern for this player, notably deficient of any rapid rise in the
temperature of the pterygoid plexus region. Significantly, this athlete has a history of heat illness, implicating
this observed difference in vascular flow pattern a possible explanation for his inability to effectively dissipate
heat generated during intense exercise. While these conclusions are preliminary, it appears that the absence
of the body’s compensatory response of rapidly increasing blood flow to “natural radiators” such as the
cheeks may be an important corollary/ cause of heat illness and associated symptoms.

There are limitations to the study, primarily as a result of its presence in the uncontrolled setting of an NFL
game. Variables such as wind condition, ambient temperature, humidity, and sun exposure levels make it
impractical to compare players on an absolute scale. For this reason, research has focused on relative
changes in a series of images taken while a player recovers from exertion. The relative change in any given
series for a player can then be compared to other series of the same player within the same game, allowing
researchers to observe how players respond under varying levels of exertion and hydration status. Even for a
single player within a single game, however, confounds exist, as ambient conditions in San Francisco's
Candlestick Park can change drastically during a four-hour game. Additional variables based on treatments
such as use of cold towels, fans, space heaters, heated benches, etc. must also be considered and noted by
researchers. Finally, readings can be affected by distance to the player, the angle at which the image was
taken, and proper focus of the device.

At this time, while the "normal" trend of post-exertional heat dissipation through the pterygoid plexus has been
characterized across many players and situations, the "abnormal" trend has been identified based on a
limited population of players historically susceptible to heat illness. Future research should focus on
identifying and characterizing the patterns exhibited by players known to be easily susceptible to heat illness,
possibly providing predictive capability for medical and training staff, and allowing them to intervene before
athletes become symptomatic. Future work should also focus on warmer ambient environments, where heat
stress complications would likely affect a larger population.

Currently, skin temperature is not considered a reliable indicator of core temperature. Future work could
utilize infrared thermography to find anatomical areas that may better correlate to core temperature and
provide a non-invasive method of determining true core temperature.

Understanding predictable patterns of heat loss in athletes allows for further studies to characterize infrared
images of athletes suffering from heat stress. Comparison of differences in these patterns may further
delineate the physiological processes involved in heat stress and enhance the ability for early detection. In
addition, identifying the importance of the face in thermoregulation suggests further studies measuring
efficiency of cooling techniques utilizing this anatomic site.

ACKNOWLEDGEMENTS
San Francisco Forty-Niners, Dr. John York, Lal Hennegan, Craig Heller Lab

REFERENCES

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3. Johnson, JM. "Exercise and the cutaneous circulation." Exercise and Sports Science Reviews 20(1992):
59-97.

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