Football season in the South is one of the most enjoyable times of the year for many. Friday nights, cold weather (sometimes), the smell of freshly-cut grass, and the sound of “the breakdown huddle” are all too familiar. There seems to be nothing better than “boys being boys” and tackling each other to the ground to prove which team is better, tougher, and stronger. That is, until the referee whistle blares loudly, and the athletic trainers run onto the field. Someone is injured. “Oh, he just got his bell rung. Get up, shake it off!” can be heard from some of the men in the crowd. The player is motionless on the field, and suddenly the EMTs rush onto the field. The athlete that “just got his bell rung” is taken to the hospital for further evaluation. This scenario is all too familiar to me.
Concussions are one of the most common injuries in all of sports, particularly football. Understandably so, since much of football is being tackled to the ground, or tackling another player, where your head is bound to make contact with something that isn’t a soft pillow. According to Prentice (2011), it is estimated that 1.6 to 3.8 million cases of concussions occur annually in the United States, 63,000 of those occurring in high-school athletics (p. 793). Concussions, or mild traumatic brain injuries, can result in loss of consciousness, disorientation, amnesia, loss of motor coordination, and balance deficits (p. 788). Why then do we often times overlook these serious injuries and push our athlete’s back into competition as soon as possible? How are we able to properly assess these injuries well enough in high school children with the current rules and regulations in place? Is there a magic number of concussions an athlete should have before we should pull a child completely from their sport? I hope to answer these questions.
I believe, probably to every coach and proud parent’s dismay, that after an athlete is diagnosed with a concussion, they should remain ineligible to play for the remainder of that season. Even though as a Certified Athletic Trainer, this brings an athlete into my athletic training room, therefore giving me a job, I feel concussions are such an exception to that of an ankle sprain, or even an anterior cruciate ligament tear. From the mildest of concussions, to loss of consciousness spine boarding injuries, I feel that the risk is too great with the current diagnostic tools that most high schools offer. I feel this way for several reasons.
Reason number one is that several high schools do not have a Certified Athletic Trainer at every practice. To make up for the lack of medical personnel at this practice, the Alabama High School Athletic Association states in their bylaws that, “any health care professional or AHSAA certified coach may identify concussive signs, symptoms, or behaviors of a student athlete during any type of athletic activity” (p. 50). The bylaws continue on to say that “an online NFHS Concussion Course is required for all certified coaches (faculty and non-faculty). This free educational course will aid in identifying symptoms of a concussion and the procedure to follow when these symptoms are recognized.” (p. 50).
As someone who has been on many sidelines over the past six years, I cannot tell you how many coaches I have come in contact with who do not recognize these symptoms properly. This is not their fault, as the free online course does not give any individual the same assessment knowledge and skills as someone with a medical background or sports medicine degree. Without this proper knowledge, I feel that many concussions can actually become overlooked, undiagnosed, or even not really cared about. As they should, in some sense, coaches have a “winning” focus and mentality. Their first instinct is to coach a winning team, not to pause a practice to evaluate a player properly for concussion symptoms. They are not thinking about second impact syndrome possibility or symptoms that will occur one to two hours after the hard impact occurs. Players also aim to please their coach, which may also cause them to mask symptoms, and cause them to be dishonest about how they’re really feeling.
Going along with players masking their symptoms, comes the second reason why I believe players should be held out an entire season. The return to play protocol and initial assessment tools are not what I think they should be at the high school level. At most high schools I have worked at, after a concussion is suspected, the athlete must go see a doctor for medical clearance. Once the player returns to school the next day, they can technically play sports as usual. Schools with athletic trainers typically then begin a 7-day return to play protocol. This protocol lets the athlete participate in mild physical activity, moving to moderate and sport-specific activity, to full return to play. Each day during and after activity, the athlete’s cognitive and motor function are assessed. If the player shows no signs of the concussion, he may progress to the next day. Any signs and symptoms that occur during the current stage, means that the athlete must completely restart the mild activity again, repeating the 7-day protocol. What about schools that do not have an athletic trainer at every practice? Do these athletes get properly assessed? Even with athletic trainers, do athletes show honesty?
I personally feel that it would be easy for an athlete to mask their symptoms simply to return to practice or for a big game. The Standardized Assessment of Concussion (SAC) test is one of the most commonly given ways to assess cognitive and motor function after a concussion. It involves immediate memory (such as day of the week, time, the athlete’s name), delayed memory (given a series of words that the athlete must remember until the end of the test), motor function (balance and finger-to-nose test), and concentration (repeating numbers backwards in a series).
An article refers to the SAC test as a test that “only takes approximately 5 to 7 minutes to administer and was designed for use by clinicians with no neurocognitive testing experience” (Barton 2014). If this is true, and if this is the same test given every day of a player’s return-to-play protocol, then would it not be easy for an athlete to memorize the answers to this test so that he could return to play more quickly? I have administered this test several times myself, and have seen athlete’s tell me that they remembered the answers from the last test given. If they will tell their own athletic trainer this, they would certainly do this to appease a coach or parent’s request for a speedy return.
Lastly, I also feel that societal pressures can often cloud judgment in diagnosing and recovering from a concussion. There is such an expectation for high school students to attend college, that either academic or athletic excellence is the main ways to achieve that. For those that wish to excel athletically, the pressure to be noticed by recruiters and college coaches can overwhelming. Parents push their children to practice harder, longer, go to extra camps, play in travel leagues, and participate in extra workouts. While I agree that it is good to encourage our children to succeed and be the best at what they love, I would argue that there is a fine line that should not be crossed. That fine line, if crossed, could have consequences that far outweigh the benefits. The National Collegiate Athletic Association estimates that in 2016, there will be 1, 083, 617 athletes that play high school football. Of that number, only 72,788 will move on to play college football and the number covers Division I, Division II, and Division III (NCAA 2016). That is only a 6.7% chance of playing the sport beyond their senior year. Of that 6.7% that do make it, only 256 athletes are estimated to make it to the NFL draft, a 1.6% chance (NCAA 16). I feel that poses the question: Is a child’s overall mental health and best quality of life worth a 1.6% chance at a professional athletic career?
As a Certified Athletic Trainer, I have seen so many concussions. I have given the SAC test, I have referred athletes to a doctor for clearance, I have walked with them through the return to play protocol, I have seen them return to play, I have seen coaches demand to know how soon they can have their athlete back, I have seen athletes become frustrated with how slowly their brain is healing, and I have seen athletes with multiple concussions. To me, knowing the risks of sending an athlete back too soon, is a terrifying truth that I do not think many people consider. It only takes a split second, one wrong tackle, slightly imperfect technique, and one wrong step that can end an athlete’s career, and potentially life, forever. I think a person’s life is much more important than a big win against the cross-town rival.
With the lack of Certified Athletic Trainers available to every single high school, basic and simplified training of coaches to diagnose symptoms of a concussion, simplified diagnostic tools, and societal pressures of excellence in sports, we are putting athletes at risk of a detrimental situation every day. Each athlete that steps onto that field is more than a quarterback, more than the star running back, and more than a way to fulfill a dream that ended for a father when he was a boy—it is a life. It is a life with potential, and to potentially end that, is something that I feel is morally apathetic. This is why I feel that whenever a player is diagnosed with a concussion by a medical professional, that they be pulled from the sport for the remainder of the season. The risk is far too great to believe anything else.
Exec. Order No. 14, 3 C.F.R. 50 (2016).
NCAA. (2016, May 2). Probability of Competing Beyond High School. Retrieved September 02, 2018, from www.ncaa.org/about/resources/research/football.
Prentice, W. E., & Arnheim, D. D. (2011). Arnheim’s principles of athletic training: A competency-based approach (14th ed.). New York: McGraw-Hill Higher Education.
Straus, J. L. (2014, February 26). Standardized Assessment of Concussion: A Valuable Tool for Sideline Evaluation. Retrieved August 31, 2018, f