Head games

In a windowless room that smells of lunch meat and sweat, at the back of Luther Burbank High School in south Sacramento, several coaches break down game film. Thirty-eight young players listen from chairs and the floor, leaning on helmets and pads, as the coaches critique plays in the dark, barking out:

“Put a helmet to the hit!” “Set your hands and whip his head back.” “Run through his kneecaps!” “You gotta put a hat on him.”

In case the players miss the verbal message, on the wall next to old team photos is a poster reading, “Be the Hammer, Not the Nail.”

But the words misrepresent the changing culture of football.

With a growing body count of players suffering the crippling long-term effects of concussions and head injuries, enthusiasts of the sport are now moving the goal posts closer toward better protection of players.

The changes have started at the top, with the National Football League, and are trickling down through colleges to the high-school level—an age when adolescent brains are still developing and also more vulnerable to brain-rattling hits.

In 2009, the National Athletic Trainers’ Association reported that between 43,000 to 67,000 high school football players are concussed annually, though about half of the concussions go unreported.

The California Interscholastic Federation, the state’s governing body for high-school athletics, has also turned its attention to head injuries. In 2010, the group implemented new guidelines for high schools on how to better protect players from blows to the head.

For California—one in only 10 states to have youth concussion safeguards—this is progress. But in other ways, high-school football players, like the ones at Luther Burbank, are still as exposed to injury as they are during a blind side hit, and coaches, administrators and others are scrambling to make them safer.

“It happened to me just the other week,” Kareem Green, Luther Burbank’s senior wide receiver, cornerback and co-captain said stepping out of the school’s stuffy weight room for a breather. “I was in the backfield, and someone rang my bell. I was seeing birds and felt dizzy.”

Joining him outside the weight room, junior offensive lineman Noel Pinnock added, “It happened to me last year, too. I was sidelined, though I didn’t feel that bad … just kind of dazed.”

Dazed and confused

With such blows likened to minor car crashes, ones where the soft-tissue brain slams against the harder skull, CIF was well motivated to kickoff its new rules for managing concussions.

Modeled in part on initiatives in Washington and Oregon, the CIF guidelines announced last fall requires that players suspected of having a concussion be immediately removed from a game and have a signed medical release before they can return to play. The CIF aims to protect players from getting back on the field too soon and provides officials with more detailed instructions on how to spot possible concussions. It also provides a concussion-management course online.

“The coaches education class and the first-aid class does cover concussions, but the new online concussion course is much more complete and specifically targets coaches and parents,” Roger Blake, associate executive director for CIF said, while noting that the 20-minute online course is not required.

Even so, the guidelines are a step forward in a sport that has encouraged players to gut out an injury, and not miss too much playing time or risk losing their slot. But coaches, athletic directors and others say more can be done, both on the field and off.

“I once had a kid who tried to play a game with a broken shin,” Elk Grove’s Monterey Trail High School head coach T.J. Ewing said. “Of course, once I spotted him limping, I took him out, but budget cuts haven’t helped. Only the rich schools, or schools with boosters, can afford to have trainers.”

Cash-strapped districts, and high schools like Monterey Trail that don’t have large booster groups, are less likely to have athletic trainers equipped to spot and handle injuries. Instead, the responsibility falls to the coaches and referees, who already have multiple details to attend to during games.

“It would be very nice to have an athletic trainer,” said Dave Johnson, head coach at Union Mine High School in El Dorado County. “But our booster club would have to fund it and they are strapped now trying to help sports supplement the small budgets they get.”

Adds Luther Burbank’s head coach, John Heffernan, “a lot of the schools don’t have athletic trainers on hand.” The school pays for a trainer with the help of the district and the student body.

“I have had a handful [of players with concussions] during my time here, and if we think a player has any signs of dizziness or disorientation, we pull him for seven days, and he can’t return until he has medical clearance,” Heffernan continued, while adding that his 12 years coaching at the school and his own playing experience have helped him become more proficient in spotting possible concussions.

Heffernan and his staff have also watched the CIF’s online concussion management course, as well as related DVDs, which makes them a rarity among California coaches. So far, less than 2,000 of the roughly 68,000 coaches in California have taken the CIF course.

“We leave it in the hands of the coaches. It is up to them to take the concussion management classes,” John Smith, director of athletics for the Sacramento Unified School District, which includes Luther Burbank, told SN&R.

“I have a lot of experience and that helps keep an eye out for medical issues,” Monterey Trail’s Ewing said of his playing days at Eastern Washington University and 30 subsequent years of coaching. “You have to have an ambulance at games, but you don’t at practices and scrimmages. Just the other week we had a scrimmage against another school without a trainer on hand.”

At Nevada Union High School, athletic director Steve Pilcher said the district will soon require its coaches to complete a 30-minute online concussion course offered by the National Federation for State High School Associations.

For now, he said, “We’ve developed a head-trauma form with the assistance of our local doctors, school nurse, coaches, P.E. teachers, and other stakeholders. It is currently in the district/board approval process [and] our coaching staff is encouraged to complete the online NFHS concussion course, which is currently not required by CIF or NFHS.”

Union Mine High School’s Johnson also warns against too much hype around concussion and brain injuries.

“I think like many things that gain rapid notoriety, you have to be careful that you don’t overreact,” he said. “Obviously, a coach should never play someone who has sustained a hit and is lightheaded, seeing stars, dizzy, sick to their stomach, or has an instant headache. Unfortunately, there are a few coaches who want to win badly enough to risk serious injury just to win a game. Those coaches should not be coaching. Perhaps it is because of some of these coaches that the new rules have come into effect.”

Johnson also said such caution can extend to the medical profession.

“One of the problems, too, is that once a player goes to the doctor, many of them do not want to clear someone too early, so they double or triple the recovery time,” he explained, and added, “as a parent of sons who played in high school and college, I also understand the parental side of the issue. I would not want my sons playing if there were any doubt about their condition.”

Protect the players

At the request of the NFL, former San Francisco 49er and Stockton’s Stagg High School star, George Visger has developed his own list of ways to reduce the risk of football head injuries. He would know. After several concussions shortened his professional career, much of which he can no longer remember, Visger now has hydrocephalus, also known as water on the brain, and has brain shunts to drain excess fluid (see “Head knocker” by R.V. Scheide; SN&R Feature; November 12, 2009).

The former player now works as an environmental consultant in Grass Valley, and also advocates for improved football safety, sometimes speaking at schools and clinics. Visger’s suggestions to the NFL include better testing (concussion assessments for individuals before and after a season), education (such as having all team doctors and trainers trained in concussion diagnosis), equipment (including having oxygen treatment tanks available at all games) and techniques (such as having lineman use a two point stance).

This year, the NFL has also adopted rule changes to help protect players from injury. The first reduces distance on kickoffs—a high-speed, high-risk of injury play—and the second ends the use the use of two full-contact practices a day (some colleges have also done so).

Visger is also pleased the NFL hired a well-regarded expert, Dr. Richard Ellenbogen, to oversee head-injury issues. Prior to the NFL, Ellenbogen helped push through Washington state’s youth-concussion rules.

“We were all excited when the [former head of the NFL’s concussion committee] stepped down and was replaced by Dr. Ellenbogen,” Visger recalled. “We called the old guy [Dr. Ira Casson] ‘Dr. No,’ because he always said concussions weren’t a problem, reflecting the traditional culture of football.”

State Assemblywoman Mary Hayashi has also advocated for the protection of young athletes in California. At the moment, the CIF guidelines apply to most high-school football programs, except those not a part of the organization. This would change under her Assembly Bill 25, which would require all high schools and junior high schools to remove possibly concussed players from games.

While football is the most common cause of concussions for high-school males, head injuries also occur in such contact sports as baseball, volleyball, soccer (the leading cause of concussions for high-school girls), field hockey and wrestling.

A component also extending this protection to youth sports such as Pop Warner football teams that use high-school fields was removed from the bill just before its passage. A.B. 25 now awaits Gov. Jerry Brown to sign it into law.

“Kids believe they need to be tough and play through injuries, so they often return to play too soon,” Assemblywoman Hayashi wrote in an email. “When it comes to concussions, this kind of enthusiasm can be life-threatening.”

A.B. 25 would also require high-school athletes to submit and update annual concussion information forms.

Science of trauma

With football players now trending heavier and faster than in the past—offensive lineman, including some in high school now commonly weigh 300 or more pounds, Luther Burbank players go to about 280—medical researchers like Dr. Bennet Omalu are also increasingly turning their attention toward head injuries.

Omalu, an associate clinical professor of pathology at UC Davis Medical Center and co-director of the Brain Injury Research Institute at West Virginia University, has been ahead of the field when it comes to concussion assessments. He is believed to be the first to diagnosis brain trauma in a former player—ex-Pittsburgh Steeler center Mike Webster—after Webster’s death in 2002.

“I confirmed it to be a distinct neurodegenerative disease,” Omalu says of his work on chronic traumatic encephalopathy. “CTE is caused by trauma, [resulting in] abnormal buildup of abnormal proteins caused by repeated impacts to the head,” he adds.

As a result, the severe blows can lead to behavioral and personality changes, memory loss, mood disorders, blurred vision, pounding headaches and, in the long run, dementia, reduced cognitive ability, and increased risk of Alzheimer’s disease. Additionally, if a second concussion occurs before the first one heals, brain damage can also result in what is known as second impact syndrome.

At this point, though, CTE can only be diagnosed during autopsies.

Omalu, a Lodi resident and also San Joaquin County’s chief medical examiner, hopes to change this and in July published a study of his examination of the brains of 14 former athletes who played contact sports, including professional wrestling, professional football and high-school football. The athletes had died from suicide, drug abuse or accidents, and Omalu diagnosed CTE in 10 of the 14 athletes he examined, including one high-school football player with CTE.

“The next step is diagnosis in the living, and the next step would be treatment,” he said. “I believe we can develop drug therapies, which can prevent the buildup of tau [a primary protein that accumulates in the brains of CTE sufferers] in the brains of contact sports athletes.”

Also this year, biomedical engineers at Virginia Tech University, ranked the effectiveness of football helmets. With the help of the university’s football team, the researchers assessed how well helmets protected the head based on such factors as the angle of the hit, and the speed and distance of the tackler. For about a decade, the researchers tested each brand of helmet, based on 120 impacts per helmet (and more than a million hits overall), and plan to create a national database of their results for several sports, including football.

Still, Luther Burbank’s Heffernan points out there is no such thing as a concussion-proof helmet, adding he had a few concussions himself during his playing days at Sacramento State and the College of San Mateo.

“What’s important is that the helmet has a proper fit and there is air in it,” he said, adding that Burbank has switched to the highly ranked Schutt helmet.

Burbank defensive coordinator, Erv Kendell, also says teaching the right technique is crucial. “But it’s also about proper execution,” he said. A former football player at the University of Arizona and Sacramento State, he adds, “When I was a player, I used to love to get my nose in there and hit, so I understand where they are coming from. But we spend the first two weeks [of practice] teaching the kids to keep their heads up and their eyes up because of lot [of injuries aren’t] about poor equipment but about poor execution.”

“Helmets do not prevent CTE,” Omalu agrees. “The fundamental prevention is to avoid any activity which results in repeated blows to the head.”

But for those that do play, for now helmets are still one way to at least reduce the risk of injury.

At Monterey Trail in Elk Grove, which uses the top-ranked Riddell Revolution helmets, the Mustangs head coach, Ewing, adds he has assessed his team’s helmets on his own, saying, “We tested them out a few years ago to make sure we had better head protection.”

Ernie Cooper, head coach at Granite Bay High School, which also uses Riddell helmets, adds that some of his players buy their own head gear.

For those who cannot afford their own helmet, the price can be high for schools.

“I wish we could have ordered 100 Xeniths so all of our players could wear one,” said Josh Crabtree at Sheldon High School in Elk Grove, adding he is switching from Schutt. “But at $200 a helmet, we simply couldn’t afford to do so.”

Union Mine’s Dave Johnson also wishes he had the budget for helmets.

“We are trying to upgrade ours to a [Schutt DNA Pro Helmet] but those helmets cost about $180 each,” he said. “We would like to purchase 20-30 more, but our budgets do not allow for that large of an expenditure.”

Head and helmet

Concerns about possible head injuries were far as can be from the thoughts of the Luther Burbank Titans football team last month as players prepared to take the field during an away game at Christian Brothers High School. Instead, team members were focused on executing the plays they had spent weeks practicing in hot summer temperatures, well before the actual start of school.

Before a small crowd sitting in metal bleachers and holding colorful umbrellas to ward off the triple-digit heat, senior quarterback Reymond Norton rolled out, and in a perfectly timed pitch, tossed to the ball to sprinting running back Keith Marcus, who ran in for a touchdown. Linebacker Ngalu Tapa bursted past his blocker and spun around another to horse-collar the Christian Brothers quarterback and brought him down with one arm.

Near game’s end, cornerback Kareem Green snagged a key interception to stall a Christian Brothers drive and helped preserve the Titans’ 40-12 win.

Yes, hits to the head happened. But the effort to better safeguard players from head injuries—from the NFL to high school—remains a work in progress, and for the players, the play’s the thing.

“When you are out there, you can still get hit in the head, but you have make the play,” Green shrugged.

“I like to hit hard,” lineman added Pinnock. “They always tell you, lead with your hands and not your helmet. Aim with your shoulder, but sometimes you hit higher, that’s the way the game is.

“What are you going to do?”