It's no game: Head injuries in high school sports

Terrence Mitchell was a ferocious football player at Hillsborough High, delivering such severe hits and pain to opponents he earned the nickname T-Rex.

But one hit last season knocked the fierce competitor out cold and out of the sport for three weeks. The defensive back was chasing an opponent when he collided head-on with a teammate.

"The other cornerback ran into me," said Mitchell, now a freshman on the University of South Florida football team. "I was out."

Mitchell lay motionless for what seemed like forever. Hillsborough teammates, head coach Earl Garcia and fans watched as team doctors and trainers tended to him. Relief came, Garcia said, only when he heard a doctor say, "He's breathing."

Paramedics whisked Mitchell to the hospital. Diagnosed with a concussion, he battled painful headaches for a week and missed Hillsborough's next two games waiting for his brain to heal.

Mitchell's brain-jarring injury was extreme. Fewer than 4 percent of athletes who sustain concussions are knocked out. Other symptoms are less obvious. That's why referees will hit the football field this fall armed with a tougher national policy regarding sports-related brain injuries.

Now, perhaps thousands of the 1.1 million American high school football players could face on-the-spot ejection for "headache, dizziness, and confusion or balance problems."

Many applaud the rule's intent to safeguard against the potentially tragic consequences of sports-related concussions. Others are critical, saying referees making clinical decisions will face a backlash from angry players, fans, coaches and parents.

"When you have a head injury inside a skull, you cannot see it. You don't know if someone's behavioral episodes or memory episodes are quite frankly any different than before," said Jeff Konin, director of the University of South Florida's Sports Medicine And Related Trauma Institute, or SMART. "If you're out there only on Friday night ... it's difficult to measure."

Previously, athletes had to be unconscious or close to it before officials pulled them. Not so now, says a new National Federation of State High School Associations policy adopted by game officials across the country, including Florida.

"Our responsibility is to get the player out of the game if they show any signs of a concussion," said Greg Kaiser, a pediatric specialist and director of training for the West Coast Officials Association, which handles officiating basketball and football games in Hillsborough and Pasco counties.

Players removed with symptoms of a concussion can return to a game if a trainer or doctor on the sideline, through clinical observation, overrules the official and determines there is no concussion, Kaiser said. Players who exhibit symptoms to a health care professional at the game will not play again that night, or in subsequent games, without clearance from a physician.

"We usually have a good reception to safety issues," Kaiser said. "We're not going to send someone out of the game willy-nilly. We are going to make sure the player is safe."

Konin, who oversees certified athletic trainers at nine Hillsborough and Pasco high schools, argues that a public unfamiliar with the potentially tragic results of concussions won't know the difference. They will see a referee telling a player he's done for the night.

Teens vulnerable

Across all sports, nearly 136,000 high school athletes a year suffer concussions - many of which are mild - and show no significant symptoms, Ohio State University research shows. They are a small portion of the 1.7 million annual traumatic brain injuries in the United States, but especially worrisome because teenage brains are still maturing and growing.

Adolescent brains take longer to recover than those of adults. Symptoms can last weeks or months. Also, cognitive skills tied to learning can be delayed or stunted by head trauma.

Teens are at higher risk of serious re-injury, including a deadly condition called second-impact syndrome. Subsequent hits before full recovery can lead to catastrophic brain injuries and dementia-related behavior months or years after initial injury, said Robert Stern, co-director of the Center for the Study of Traumatic Encephalopathy at Boston University.

Dozens of former professional, collegiate and high school athletes have died as a result of such hidden injuries.

Each year, 55,000 concussions occur in high school football, roughly 5 percent of all teens who put on a football uniform.

Closer to home, a SMART Institute study at six Hillsborough County high schools found 16 football players suffered sports-related concussions in fall 2009. Thirty-five private and public high schools in the county have football programs.

In the SMART Institute study, the head injuries occurred in full-contact practices or games. But with the exception of high-profile injuries such as Mitchell's, few people read or hear about head injuries among high school players. As a result, few understand high school athletes are at a risk equal to or greater than National Football League players.

"This is not a disease of NFL players, it is not a disease of professional athletes, it's a disease of anyone who hits their head over and over again," Stern said.

NFL provides clues

Like many moms, Lisa McHale hears her sons plead to play football. Her two younger boys, Matthew and Michael, love the idea of putting on a uniform and tackling opponents, as their dad did for the Tampa Bay Buccaneers.

McHale tells them no. She is not worried her boys will get knocked out: It's about the repeated head bumps and crashes. Repetitive hits to the head, none of which were diagnosed as concussions, triggered a lethal form of dementia in Tom McHale, a former offensive tackle who died at 45.

"It hits a little too close for me," the Tampa mother said. "Their dad died from playing football."

Lisa McHale first learned repeated hits to the head were dangerous after her husband's 2008 death. She and Tom, who had played ball since junior high, thought his spiraling mental illness stemmed from a prescription drug addiction. An examination of his brain after his death revealed chronic traumatic encephalopathy, a degenerative brain disorder caused by multiple undiagnosed concussions.

"I think that people would rather not know. There's a real love affair with football. I can understand that," McHale said. "Frankly, I wish the clock could be turned back and I wish all of this weren't true. I wish football hadn't done to my husband what it did. But it did, and I can't let that go."

McHale's story is part of a growing understanding about the long-term implications of football injuries. Scientists examining NFL retirees are discovering a disproportionate number suffering from early-onset dementia and related conditions. Some worry the problems could be secretly affecting many who never played a down of football beyond high school.

Charley Hannah, a former Buccaneer whose 12-year NFL career included a Super Bowl championship with the Los Angeles Raiders, knows the game's physical and mental toll. He explains the risks to his 11-year-old son, John David Hannah, who dreams of a chance to participate but hasn't been allowed to play on a team.

"I'm not trying to force anybody to quit football. I would just love for them to know what it's doing to them so that they can make decisions for themselves," Hannah said.

McHale allows her 12-year-old to play lacrosse because she trusts that he understands the symptoms and that his coaches are equally concerned.

Without educating parents and coaches, the new high school concussion rule will backfire, she said.

Her concerns may be valid, according to a recent University of Michigan survey. Nearly two-thirds of parents of teen athletes surveyed worried their child might get a concussion playing sports. But just half knew whether their child's school had a concussion policy, such as the one being implemented nationwide this fall by high school officials.

More so, only one-third knew of the dangers of repeat concussions, according to the survey conducted for the University of Michigan's C.S. Mott Children's Hospital.

"We're coming in through the back door. People are unaware," McHale said. "Don't get me wrong, I think (the rule) is fantastic because it means somebody is looking after the players. But I don't know if it's ideal because people are going to feel forced and they are going to be angry."

Policies changing

It wasn't until news reports highlighted a series of professional athlete concussions such as Tom McHale's that the public took notice. As a result, everyone wants to investigate: state legislatures, volunteer sports groups, even Congress.

Texas, Oregon and Washington state have laws specifying when a player should be pulled from a game and return to play. Florida has no such law, deferring that and coach training issues to the Florida High School Athletic Association.

Since the new concussion rule was implemented, the association announced its coaches will take online safety training through the National Center for Sports Safety's
PREPARE program. It includes training for heat and cold illnesses, medical conditions and head, neck and facial injuries.

Online courses focused on concussions remain optional for Florida coaches.

In May, congressional hearings in Washington focused on concussions in high school sports. Testimony featured neurologists, coaches and students whose athletic and academic careers suffered after multiple concussions.

Local advocates such as Lisa McHale equate a national concussion safety policy to a national seat belt safety law.

"Any time your kid gets in a car, there is the possibility he could get in an accident," she said. "Well, do you not put him in a car? Heck no. You can't just live 30 yards from your house. You have to live life."

Questions remain

High school football is an emotional sport. It remains to be seen whether the new concussion policy - and the potential removal of players - will increase tensions.

"We're going to do what's safest for the kids," said Lanness Robinson, Hillsborough public schools' athletic director. "We can remove ourselves from the emotions of the game and not get caught up in the winning and losing. Will there be a backlash? Probably, but we are always going to err on the side of caution."

The impact may be more significant after the game, when young players suspected of having concussions go to doctors and learn whether it will be days, weeks or months before they get back in the game.

Language in the new rule is vague, stating a player can't return until cleared by a "health-care representative." In Hillsborough and Pinellas counties, players will need a doctor's clearance, but Pasco officials may interpret the rule to include medical officials who were at the game, said Phil Bell, Pasco's supervisor of athletic programs and facilities.

The best-known guidelines for returning to the game come from a sports medicine expert consortium in Zurich. It recommends athletes gradually return to activities, from light aerobic activity to noncontact drills to game day. Each step takes a minimum of 24 hours, and if symptoms return, an athlete must revert to the previous step.

The Zurich group emphasized such steps are more critical for children, recommending limited exertion in cognitive activities as well. School attendance, texting friends and even playing video games can be harmful if too much is done too soon, said the statement published last year in the Clinical Journal of Sports Medicine.

The small-step manner of recovery is the focus of the USF Concussion Center, which focuses on treatment of patients with post-concussive symptoms. The center opened last month to treat athletes and nonathletes struggling to manage the condition, said director Gianluca Del Rossi.

Hillsborough High's Coach Garcia sees a shift in awareness. Not long ago, he said, heat-related injuries were a pressing issue. Now, the new rule and media attention are bringing head injuries to the forefront. The longtime coach says there is value in recognizing and treating the symptoms of concussions, something that wasn't done when he played.

"If you got your bell rung, you got a sip of water. It was uneducated on our part," he said of playing in the late 1960s at Plant High. "This will be overkill, but I'd rather be safe than sorry."