Henry David Abraham, M.D.
I was recovering from orthopedic surgery chatting with my hospital mate, Scott. I was in for skiing. He was in for football. Scott was the biggest person I had ever seen- a football lineman from a Div 1 school. His coach loved him. He came every night to boost his spirits. “Coach,” said Scott one time. “Do you think I could take up skiing?” “No, Scott,” said the coach solemnly. “Your winter sport is tobogganing.” “Huh?” said the student-athlete. “Yes, Scott. You go up a hill with six of your friends, and Scott, you’re the toboggan.”
No doubt that Scott would have made a great toboggan. He was already a great lineman. Seeing him in bed reminded me that playing football can hurt you, even though the commonest injuries are not lethal. Most are orthopedic, like knee sprains, hamstring injuries and contusions. But there are more worrisome ones. They involve the head. And of all the high school sports football has the greatest number. The chart below tells the story. Of 1219 kids with mild head injuries, football players had the most.
Mild traumatic brain injury (MTBI) is a newer way of saying concussion- head trauma that causes a change in mental status and/or unconsciousness. MTBI is always serious. In the course of a football season the chance of suffering one is about 5%. The risk is four times greater during a game than a practice. Astroturf raises the risk. Taking a hit to the top of the helmet doubles a kid’s chances for losing consciousness, but more concussions occur with front of the head impacts. High school running backs and line backers are more likely to be injured. Needless to say, the injury rates are higher in the NCAA, and still greater in the NFL.
The most disturbing observations come from studies of the brains of deceased NFL players. In selected cases the brain shows an Alzheimer’s-like condition correlating with the player’s previous mental decline. In the emerging alphabet soup of head injury, this new finding is chronic traumatic encephalopathy or CTE. But its existence is controversial because it’s extremely difficult to do controlled studies on this problem. The tragic suicide of Junior Seau, for example, does not prove that his years of football led to his death. Sadly, other people who never played football have committed suicide, too. The simple question is whether football players suicide more. They may not.
But not so fast, football fans. If you count how many times a player’s head gets hit during a season, you find the more hits, the more changes in the brain’s white matter. And after six months, the changes don’t go away. This is what a small controlled study of 15 players found. Would studying more players give the same result? We don’t know. But the average high school player in a season has between 175 and 1410 repeated head impacts. That can’t be good for you. But in this study, none of the 15 suffered an actual concussion. And even if they did, the overwhelming majority of kids who suffer MTBI have a complete recovery of mental function.
How can a parent calculate the risks and benefits to their child athletes? Some numbers can help. But apply common sense. The risks of playing in the NFL aren’t the same as those for high school kids. Take CTE, for example. The rate of high school students who appear to have developed this illness is less than seven in a million. What about other potentially lethal brain injuries? In the U.S. in 2013 there were 243 football related deaths in high school and college. Three were from brain injury. More were from heart disease. Let it be noted that the risks of death or brain injury from riding a bicycle, walking on the street, riding in a car, or swimming are greater.
There is little debate that a major head injury signals an end to playing for the year, and maybe for one’s career. One of my patients wisely called it quits after he tried out for the New England Patriots. On the first play suffered a helmet to helmet blow that knocked him out and caused a convulsion.
More difficult to answer is when and if a kid who suffered a mild concussion should be permitted to get back into the game. One expert in this field is Robert Cantu, a neurosurgeon who has also consulted with the NFL. Because recovery is the rule, so is returning to the season. The mildest cases of head trauma can return to the same game after a period of sideline examinations, once all signs and symptoms are gone at rest and during exertion. One concern is that once a kid suffers one concussion, the chances he or she will suffer a second one go up three to six times. This is a replicated finding. We don’t know why. Perhaps it reflects the child’s style of play, or a brain sensitized by prior trauma.
Numbers asides, the chance to play a sport in high school is unique. For every kid it’s a chance to pursue a dream of strength, grace, courage, and skill. Why else take the risk of skiing, skating, shooting hoops, or swinging perilously over a horizontal bar? Playing a sport is a dream of perfection. What’s so bad about that?