concussions and football

Tuesday, September 30, 2014

 

The latest concussion controversy involves Shane Morris, the University of Michigan quarterback  whose head injury was unrecognized by the coaching and medical staff on the sideline and therefore was allowed to continue to play. After a few public relation gaffs, the university admitted that an error was made and instituted new procedures to address the “communication processes”. Athletic director, Dave Brandon, said that Michigan would have an athletic medical professional in the press box or video booth with the ability to talk to the medical personnel on the field and would increase communication between medical and coaching staff as to player availability.

The NCAA has a recently revised policy on concussion that addresses the issues of diagnosis, treatment and return to play. Good for the NCAA and good for Michigan but it is just window dressing for the whole head injury issue. Here are but a few of the issues that make head injuries a significant public health issue.

There is no easy way to make the diagnosis: Depending upon the research you choose to read, somewhere between 30 and 50 percent of head injuries go unrecognized and therefore unreported. The NCAA guidelines suggest that players will hide their concussion because of the invincibility of youth to fear of losing their roster spot. Studies looking at concussion rates in high school and college athletes suggest that the player did not report concussions because they were unaware that their symptoms were associated with head injury. Headache was the most commonly non-reported initial symptom. Those who had an unreported concussion were more likely to be knocked unconscious with a subsequent concussion and also have more severe post-concussion symptoms.

The diagnosis on the field needs to rely on the players and referees on the field: It is nice that Michigan has the resources to place medical personnel in the press box and have communications equipment to talk to the medical and coaching staff on the field. For all the football played in the US, from freshman and JV high school games to the Division II and III college level, virtually none will have a neurologist or head trauma specialist on the field or in the press box. Most won’t have a press box. Coaches on the sideline are too often shielded from all the action and it’s incumbent upon those on the field to be their brother’s keepers. Watching the replay of Shane Morris laying on the field after being hit, slowly getting up, stumbling and having to be supported by another player, it is clear that something is wrong. Yet, after a few seconds, he waves off help and gets into the huddle for the next play. The lineman who helped steady him and the referees on the field need to feel empowered to stop the play and have him removed.

The diagnosis of concussion on the sideline, in the ER or the doctor’s office may be also difficult to make: While it is easy to make the diagnosis of head injury when a player is knocked unconscious or is vomiting on the field or being dazed and having light sensitivity, many of the symptoms can be subtle and take hours to manifest themselves. It could be that irritability, difficulty concentrating, changing sleep patterns or headaches lead to the diagnosis. While guidelines and scoring systems exist, the only diagnosis of concussion is made clinically by symptoms alone. By definition, a minor head injury or concussion, has a normal physical exam.

Treatment of concussion is brain rest, but for how long: the first order of business is to remove the player of the game to prevent further injury. In football, that starts by having the medial staff take away the player’s helmet. There is no missed communication between the trainers and coaches when the player walks the sideline without a helmet on his head or in his hand. There is a six step program endorsed by the NCAA and the 2013 Zurich International Conference on Concussion in Sport that lays out the path for an athlete to return to play. It is interesting that while there is a presumed safe path to the football field, there is no such safe path to return to school or work.

From the NCAA: “There are no standardized guidelines for returning the athlete to school…Returning the student to school, even if the day is shortened, can be considered when the student can tolerate cognitive activity or stimulation for approximately 30 to 45 minutes. This arbitrary cutoff is based on the observation that a good amount of learning takes place in 30- to 45-minute increments… Given that most concussions resolve within three weeks of the injury, adjustments may often be made in the classroom setting without formal written plans.”

Good for Michigan, the NCAA and college football. Players will be watched from on high, yet between one third and one half of concussions will not be recognized. There is no easy way to make the diagnosis. Rest is the only treatment available. Return to play may occur within one week, yet return to the classroom may be limited to less than an hour.

With all this clarity, what direction and information does this give to players and to their parents who want their kids to play ball. It’s a reminder that institutions of higher education, like the University of Michigan, have a hard time applying science to their everyday lives.

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hip dislocation

Monday, September 22, 2014

Bo knew football. Bo knew baseball. Bo knew hip dislocation. Now Dennis Pitta knows what Bo knew…hip dislocation leads to badness. For the second time in two years, Mr. Pitta, the Baltimore Ravens tight end, dislocated his hip and required surgery to repair the damage. A year ago, the hip injury occurred while being tackled. This time, he twisted on the field and went down in a heap without being touched, the hip popping out of joint without significant trauma.

In 1991, Bo Jackson, then of the Oakland Raiders, was tackled in a playoff game and felt his hip pop out of joint. Even with having the dislocation reduced, or having it put back into place immediately, and even with surgery and rehabilitation, he developed avascular necrosis of the femoral head (the ball of the hip joint). This is a common complication of hip dislocation that occurs because of hip has been poorly structurally engineered. Some of the blood supply to the femoral head comes from arteries that have to travel across the joint from the acetabulum (the socket of the hip joint) to the femoral head. When the hip dislocates, that blood supply is lost and the potential exists that the femoral head will not get enough oxygen and nutrients from other arteries to survive. This is called avascular necrosis (a=without + vascular=blood vessels +necrosis=death) and it damage the femoral head no matter how good the treatment is or how fast the hip is repaired. Mr. Jackson underwent hip replacement surgery and was able to return for a brief time to baseball but soon his career was over.

hip xray 1

For Mr. Pitta, surgery and rehabilitation for his first hip dislocation went well and he was able to return to play football late in the season. Dislocation number two raises questions about the potential for him to return a second time.

The hip is a strong structure and it takes a significant amount of force to cause a dislocation. Aside from the bony protection of the acetabulum and the five large ligaments that help stabilize the hip joint, the angle that the femoral head enters the acetabulum provides even more stability. Most often, hips are dislocated in car wrecks, where the dashboard is driven into the knee of the driver or front seat passenger. By sitting with a bent knee the direction of the force drives the femoral neck through the back of the acetabulum, breaking that bone.

Aside from avascular necrosis and arthritis, which are long term complications, the big risk in the acute situation is damage to the sciatic nerve, the large nerve that leaves the back and runs through the buttock, behind the hip, to supply the leg. When the hip dislocates posteriorly or toward the back, it can damage the nerve in a variety of ways, from having generalized swelling inflame the nerve to specific damage done because of bony fragments injure the nerve.

Mr. Pitta required surgery again to repair the injuries and time will tell whether he will escape the complications that can plague hip dislocations. Most certainly, his second hip dislocation occurred because the structures that held his hip in place, the muscles, tendons ligaments and joint capsule had loosened. He had the bad luck to have his injury witnessed by an audience of thousands in the stadium and millions more in the television audience, but the injury could have just as likely happened in a parking lot, twisting to get out of a car or playing in the backyard with his family.

Dennis Pitta now knows what Bo knows. 20 years of medical progress still cannot guarantee perfect healing. Injury and trauma have a way of humbling those in the medical profession. Even with the best care, the body cannot always be put back together like it was before. There are complications that cannot be prevented. There are injuries that cannot be completely rehabilitated. Sometimes badness happens.

 

Xray image attribution: www.wikiradiology.com

 

 

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