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By MedHelp Editors

From Pop Warner to the NFL, football players are at risk for head injury each time they step on to the field. And with every sack, tackle or lunge for a loose ball, concern grows over the effects that concussions can have on an athlete’s physical and mental wellbeing. Brian L. Mahaffey, MD, a family practitioner specializing in sports medicine, weighed in on the risk of head injury in high school football for the November/December issue of Missouri Medicine. Dr. Mahaffey is Director, St. John’s Sports Medicine in Springfield, Head Team Physician at Missouri State University, Team Physician for the Springfield Cardinals, and recently also became Team Physician for the St. Louis Cardinals.

He talked to MedHelp about the toll the sport takes on players of all levels — and ways to better protect athletes on the field.

Q: How might head injuries affect athletes long-term?

Dr. Mahaffey: In the long-term, repetitive, multiple concussions can lead to a brain disorder that is very similar to the changes to the brain that you see with Lou Gehrig’s disease. [Editor’s note: Chronic Traumatic Encephalopathy (CTE) is a neurodegenerative disease found in some people who have sustained repetitive head injuries. CTE causes brain cell death, plaque deposits, and reductions in the weight of certain brain regions — changes similar to those seen in neurodegenerative diseases like Lou Gehrig’s disease. A study of nearly 3,500 NFL players found that professional football players are three times more likely to be affected by neurodegenerative disorders than the general U.S. population]. However, we don’t know whether there’s a cause-and-effect relationship: There’s really no science that shows the direct effect of one or multiple big concussions or head injuries. And there are so many other confounding factors that can play a role in how a person is affected by a head injury, including genetics.

The biggest issue with the research on the long-term effects of concussions is that a concussion is a subjective diagnosis — we don’t have a test that shows whether or not you have a concussion.  I saw an article where one of Junior Seau’s ex-teammates said that Seau had had 1500 concussions in his career. [Editor’s note: Junior Seau was a linebacker in the NFL who committed suicide on May 2, 2012. There was speculation that his depression might be linked to brain damage from repetitive head injuries, but the autopsy was inconclusive]. Well, I don’t know if each one of those would fit a definition of a concussion. From my understanding of the literature and what I’ve read, he never had a diagnosis of a concussion while he was in the NFL. Did he have multiple games where he didn’t feel well? I’m sure that he did. The subjective part of diagnosing a concussion makes it so hard, as a clinician, to treat patients who may have one.

In the end, I think there is a relationship between repetitive head injuries and neurological problems, but we don’t yet know exactly what that relationship is. I hope in the near future that we can get more and more evidence that points us in the right direction. That way, we can do the right thing for people who are playing the sport at all levels.

Q: Is there a link between repetitive head injuries and mood disorders, like depression? Should athletes with a family history of mental illness be particularly worried about the effects of multiple head injuries?

A: Can a head injury exacerbate or bring to life underlying mental problems? Most certainly it can. Does it lead to them? I don’t know if we can make a direct cause-and-effect statement because there are so many confounding factors. The environment someone grew up in, their family history, their genetics and all kinds of other factors play a role into mental illness. But have I seen people who were fine before sustaining a concussion, then went on to develop depression afterwards? Yes. Did they become depressed because they couldn’t play their sport for a while? That’s possible. Or is it because the head injury triggered some neurotransmitter problem that led them to develop depression? A lot of people jump to that conclusion — they had the concussion, and it led to them having this outburst of violence or committing suicide — but it may not be related at all. It’s so hard to tell by looking at the whole picture.

A lot of people are speculating on whether repetitive head injuries played a role in the Jovan Belcher incident in Kansas City [Editor’s note: According to police reports, Jovan Belcher, a linebacker with the Kansas City Chiefs, killed his girlfriend Kasandra Perkins during an argument on December 1^st, 2012. He then took his own life]. It may be 100 percent correct that he had some concussions that he didn’t tell anyone about, but we don’t know. As a nation, we want to know why horrible events happen. Well, sometimes there just isn’t an answer. It may be a correlation, but is it a direct cause? It’s hard to know.

Q: These injuries don’t just affect professional or collegiate athletes — high school football players are also at risk for head injury when they take the field.  If a high school football player gets a concussion, what  signs should parents look out for? What symptoms might hint that the injury is serious?  

A: Different players react to concussion differently. I’ve had high school athletes who’ve been knocked out in football, and within 15 minutes are completely normal and asymptomatic. And I’ve have kids who have had one or multiple concussions who couldn’t remember who their families were for a period of two or three months. That is the scary part of concussions, and that’s why we are so conservative in how we treat them.

The concussion symptom that everyone thinks about is a headache, but that’s one of about 21 or 22 symptoms: drowsiness, having trouble sleeping, acting funny, feeling strange, nausea, difficulty concentrating, visual changes — there are multiple different signs. If you think your child isn’t acting right, get them checked out by someone who specializes in treating concussions. Don’t just dismiss it as no big deal. 

For kids under the age of 18, studies indicate that, even after their concussion symptoms have gone away,  their brain function doesn’t return to a normal level for about seven more days. So that’s the number one thing I stress to parents and players: Even after you’re asymptomatic you still need to take time off from your sport for your brain to recover. You have to be very conservative and cautious. The policy that we follow at the high schools that we cover is that if you have a concussion, and it’s diagnosed on a Friday night at a football game, you’re not going to play that next Friday night because it’s within the seven day time frame.

Q: Besides head injury, what other physical impact does football have on high school athletes, and how can that impact be minimized?

A: We’ve seen the rate of stress injuries dramatically increase in preteens, young teens and even children, either because sports are a year-round process for them, or because they only focus on one sport, which puts continuous stress on the same parts of their body.

Kids are not adults — they need to have rest. It’s very important that their bodies have time to recover. The specific example I always give is of arm injuries in growing athletes. There are studies showing that the rate of injury in a teenager’s arm is dramatically higher in kids who throw competitively year-round, as compared to kids who have 3 months to recover where they rest their arm. They can go play catch as long as they’re not throwing competitively. But we’re seeing kids at younger and younger ages have major surgeries, and year-round competition dramatically increases risk of injury.

Q: What are some of the procedures or rules that should be adapted or more rigorously enforced to make football a safer sport?

A: It’s important to educate players, to teach proper techniques and to enforce the rules that are there. In both high school and college, there’s a program that the coaches follow. It’s called a “heads-up program”, and its purpose is to educate kids and coaches on proper tackling techniques. Players should tackle with their heads up — they shouldn’t be tackling with their heads. The other part of the program aims to enforce the rules that are already in place.  If there is head-to-head contact, the flag should be thrown. Those rules are there for the safety in the game. A good helmet with good support can be very helpful, but it’s not going to prevent that concussion from occurring. It can decrease the chance, but it’s the force of the brain within the skull that makes a concussion. A helmet is really there to protect from skull fractures.

There is an inherent risk in playing football and other sports like soccer and hockey, but if you use proper techniques, take care of your equipment and wear your helmet correctly, you can decrease the chance of that occurring. Can injuries still occur? Yes, they can. Yet at the same time, your children have a much higher risk of injuring themselves in a car or through a number of other activities. So while it’s great that people have an interest in and awareness of concussions, you can take the worries too far to the point that you can remove the positive aspect of the sports and what the kids are getting out of the experience in their lives.

Q: Any take-home messages for football players, and for their coaches and parents?

A: My parting message to everyone: you have to be conservative with head injuries at all ages. Winning is great, being part of the competition is great, but it’s not worth long-term injuries.

Published December 11, 2012.

See also:

• Are concussions in high school sports worth the risk?
• Is football to violent for universities to sponsor?
• Causes of headaches and treatment for headache pain
• Have a question about a head injury? Ask an expert