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Ranit Mishori, M.D., MHS

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Youth Sports Injuries: What a Headache!

Posted: 08/29/2012 9:17 am

A single rebound changed teenager Tracy Yatsko's life. It was Jan. 10, 2005. Two minutes to go till half time in a hard-played game where she -- a tenth-grade starting forward for the Tamaqua Lady Raiders of Penn Township, Penn. -- left the ground momentarily while jumping for the ball, and then, on her descent, ball in hand, the collision: the back of her skull smacking into the head of the opponent who'd been guarding her. She recalls a brief visual blackout -- less than a second -- but she didn't lose consciousness and even managed to get off another shot at the basket. Even so, feeling dizzy and nauseous, she opted for the bench for the rest of the game, just as a precaution.

Next day, though, the dizziness and nausea were still there. She attended school, finding that "I couldn't concentrate, and I just wasn't there," but after a second night's sleep, feeling better and hoping she'd weathered the worst of that head bump, she decided to suit up and start another game for the Lady Raiders. That was the breaking point. She made it through the game, but afterward, while changing in the locker room, she blacked out and fell to the ground. "I couldn't hold myself," she recalls. It was frightening, as it was now clear this was something she wasn't just going to shake off.

From that first trip to the emergency room, says her mother, Linda McCarroll, "life was never the same." Or, as Tracy puts it: "That's when everything started."

It was a concussion, and Tracy knew it, because she'd suffered one before, while still in the seventh grade. An MTBI, or Mild Traumatic Brain Injury, as it's known in the medical literature. That earlier MTBI she did shake off -- or at least the symptoms went away after 10 days or so. But "mild" can be a misleading term. Yes, there are more serious types of brain injuries, but the concussions that occur in contact sports can have effects that -- despite the "mild" label -- last a lifetime.

As Tracy has experienced for herself. Initially, she spent the rest of her junior year at home, literally on the couch. "I couldn't go to the bathroom by myself. I had to cover the windows with sheets because of the light." She has suffered constant migraines, nausea, vomiting, and had difficulty concentrating. She had to spend many days in the hospital, seeing dozens of doctors, getting all kinds of diagnostic tests. She had been on hundreds of medications, her mom says, some of them with terrible side effects. She lost many friends "because they were out having fun and I was stuck at home."

As kids return to school and embark upon a new school sport season, stories like Tracy's have put MTBIs -- as well as other sports-related injuries -- at the center of a debate that asks whether the price of getting hurt for the game is too high.

Journalists have begun focusing extensively on the toll among professional athletes, especially football players. But other experts -- including the Government Accountability Office (GAO), which held a special meeting on Capitol Hill in 2010 -- are concerned about the effects on younger athletes.

For student athletes, studies are producing alarming numbers. One estimates that between
2001 and 2009 more than 2.6 million children in the U.S. were treated for sports-related injuries. Of them, more than 170,000 suffered from traumatic brain injuries.

That sounds like a lot, but they're the tip of the iceberg, says, Dr. Dawn Comstock, of the Center for Injury Research and Policy, at Nationwide Children's Hospital in Ohio. Many injuries, she says, are never reported: "Nobody really knows how big of a burden sports-related injuries are."

Part of the story is a lack of awareness -- even now -- says sports-medicine expert Dr. Clarke Holmes, of Nashville, Tenn. "Many young athletes don't know what concussions are," he says. Many, he says, may experience a head injury, but then believe "that if they haven't lost consciousness then they should be okay."

Except that they're often not okay, a fact that may be especially important for girls to understand. Says Dr. Holmes: "There is some evidence to suggest that girls may be more likely to have concussions and that their concussions may be more severe."

Severe is certainly what Tracy's concussion turned out to be. Grade III. The worst. It's been more than seven years since that fateful game and she's still paying for it -- paying for wanting to play the game she loved. Perhaps the hardest part was being told she couldn't play sports anymore. Ever. Sports was everything to Tracy: "I was a huge athlete. I was really good in basketball and track." So when the doctor announced her sports days were finished, "it ruined my life. That's when the depression set in. I thought my life was over," she said, holding back tears even now.

Indeed, many young athletes would agree that sports are what defines them. It gives them a certain social cachet and represents real achievement, as well as embodying real-life values like teamwork and competition. Sports can also be a ticket to scholarships, higher education, and exciting careers -- if you're really that good. Tracy was that good.

That's why many athletes are reluctant to report their injury. They risk being misunderstood as weak or lacking in motivation. They fear being sidelined, losing their chance to shine, to show what they are made of. "That's just how we grow up," says Tracy today. "We grow up saying 'suck it up and get back in the game.'" Remembering the winter of 2005, Tracy says she was worried that her trainer would "sit me out of the game" if she said too much. "I kept quiet, but I shouldn't have played."

"There is no shame in being hurt," says Dr. Holmes. "If you hide an injury then you are not only hurting yourself, but also your team. Because you're out there playing and you are not 100 percent, and you can let the team down. You could miss an assignment, not know a play that you should, you could be a step slow." More importantly, he says, "You could predispose yourself to another injury, or even a second concussion."

This is an important piece of the picture. Once a concussion has occurred, the player becomes as much as four to six times more likely to suffer a second concussion. And having a second concussion, studies have shown, can be even more traumatic, resulting in permanent brain injury from the cumulative trauma.

That's why medical and athletic organizations are quite serious about when the appropriate time is to return to play. Guidelines vary, says Dr. Holmes, and each case should be looked at individually, but in general the athlete has to be completely symptom free for some time before being allowed back in the game. Depending on the initial symptoms, it can be as little as 20 minutes for a very mild first concussion with no loss of consciousness, to more than three months for a third concussion, according to some guidelines. Or it can be, as in Tracy's case, never being allowed in the game again.

The guidelines, from organizations such as the American Academy of Neurology, and the Colorado Department of Education, vary. But they all agree that athletes should take time off following an injury and that premature return to play can harbor serious consequences. As serious and catastrophic as brain herniation and death.

Unfortunately, says Dr. Comstock, not many are taking heed. According to one study she authored, 40.5 percent of high school athletes with a concussion returned to play too soon. And males -- true to stereotypes of being more "macho" --- were more likely than females to not follow these guidelines. That study, in the journal Brain Injury, also showed that during the 2007-2008 season alone, 15.8 percent of football players who suffered a concussion and lost consciousness returned to play the same day.

But it is not just the athletes themselves who are eager to put injury aside and get back in the game. Coaches and parents are as much to blame. "I see how parents can get so involved in a game," says Linda, "and sometimes coaches and parents can make the wrong decisions."

She and Tracy are trying to tell their story to anyone who would listen. Tracy even testified before a congressional committee and told her story at the Brain Injury Association of Pennsylvania. "There have been a lot of coaches who've changed the way they've coached because of Tracy," says Linda with pride in her voice. "They've been much more careful. They don't put their player back into the game if there is any injury, whether it's a head injury or it looks like they have a sprained ankle. Because of Tracy they're really thinking twice and just admiring the message that she's been putting out there."

What is a concussion?

A concussion is a brain injury caused by a bump, jolt, or blow to the head. It can happen due to a fall, or after hitting another player.

Symptoms of Concussion

Early symptoms may include: Headache, Dizziness, Confusion, Nausea, Vomiting, Vision Changes, Ringing in the ears, Sensitivity to light.

Late symptoms: Memory disturbances or loss, poor concentration, irritability, chronic migraines, sleep problems, personality changes, chronic fatigue, depression.

If you think your child had a concussion:

- Seek medical help at once. The doctor can help assess the severity and help determine when it is safe to return to play.
- Keep your child out of play until a health care professional says it is okay to go back.
- Report all concussions to your child's coach, including previous ones, or those suffered playing another sport.
- Consider baseline neuro-psychiatric testing at the beginning of the season. Repeat testing after an injury can more precisely show the degree of damage and help with rehabilitation.

A concussion can happen in any sport activity. The top offenders are contact sports. "Player-to-player contact is the number one mechanism for injury," says Dr. Comstock.

Higher injury rates, including concussions, are found in: football, ice hockey, boys lacrosse, soccer, basketball, girls lacrosse and field hockey.

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