You can see a broken bone on an X-ray, the swelling from a sprained ankle.
Physicians and athletic trainers know roughly how long those injuries take to heal.
A concussion is the hardest injury not only to diagnose, but to manage. And it’s become increasingly apparent that long-term health problems can arise from even what’s thought to be one mild concussion.
“There’s probably no bigger issue right now than concussion management in the field of sports medicine,” said Josh Fullmer, Colorado Mesa’s head athletic trainer and assistant director of athletics for sports medicine. “It’s just the elephant in the room at this point, that’s what everybody’s talking about, what everybody’s focusing on.”
Data compiled by the NCAA from 2004-2014 shows wrestlers have the highest rate of concussion during competition, with 3.2 concussions per 1,000 athlete-exposures.
Football is second with three concussions per 1,000 athlete-exposures.
Diagnosing a concussion is the first of several complicated steps in concussion management.
Every one of the myriad of symptoms varies from athlete to athlete. There’s no definitive test, no X-ray or MRI that can show a concussion has occurred. If Fullmer or a member of his staff even has an inkling one of the players has been concussed, he or she is removed from practice or the game.
“We have to go off of what their symptoms are, our gut feeling sometimes,” Fullmer said. “A student-athlete gets hit and is acting a little goofy but they’re saying I’m perfectly fine, and we go through the balance testing and cognitive testing and they check out, technically they’re cleared to play, but sometimes they’re just not right.
“That’s when that gut feeling comes into play. Obviously if there’s a question one way or another, we’re gonna hold you out and assume the worst and not going to risk it.”
Not worth the risk
Last fall, CMU quarterback Sean Rubalcaba was involved in a helmet-to-helmet collision during the second game of the season. As he was scrambling and going to the ground, a Midwestern State University defender hit Rubalcaba in the side of the head, leading with his helmet.
Rubalcaba stayed on the ground for a few moments and was checked on the sideline by medical personnel. He did not return to the game.
He passed the sideline concussion exam, but that “gut” feeling came into play and the Mavericks weren’t willing to risk his health. Rubalcaba returned to practice the next week after passing concussion protocol.
CMU football coach Russ Martin said afterwards that no game was worth risking a player’s health, and that’s the stand the athletic department maintains in all sports. Fullmer said there’s been no pushback from any coach since he’s been at Mesa about any injury, especially suspected concussions.
As more and more studies are done on concussions, long-term effects and how best to treat head injuries in sports, it’s gotten a little easier to manage them, because guidelines have been mandated. Still, there’s no way to definitively know if the brain has completely healed from a concussion and there will be no long-term effects.
“I tell my students all the time, you can look at an X-ray and you know if a bone is broken. We know it’s 4-6 weeks and they’ll be back,” Fullmer said. “Concussion management is nowhere near that easy. We have to really rely on the student-athlete and their honesty.”
CMU requires student-athletes to sign a form pledging to be forthcoming with all medical information.
Baseline tests required
The NCAA requires every student-athlete to take baseline tests, called SCAT3, before they are allowed to practice or play. If a concussion is diagnosed, several steps must be taken before they are cleared to return to practice.
The SCAT3 provides medical history and behavior of the student-athlete when healthy. A history of prior concussions warrant the ImPACT computerized test.
“That’s probably the most common baseline computer test out there,” Fullmer said. “It’s not feasible to baseline (ImPACT) test every student-athlete.”
The ImPACT test must be given with minimal distractions, so you can’t put 30 or 35 student-athletes in a computer lab at once. Every student-athlete who has had a concussion or has a learning disability, ADHD, dyslexia or a history of migraines or frequent headaches is ImPACT tested.
The baseline tests are compared with post-concussion tests to help determine whether the concussed student-athlete has recovered to his or her “normal” neurological status.
In 2011, Western Orthopedics and Sports Medicine, which treats CMU athletes, hired Dr. Danny Mistry, who is the Mavericks’ primary care physician.
A concussion management specialist, Mistry helped develop concussion management protocols for CMU and School District 51. He’s also a member of the Concussion Task Force in Grand Junction, which provides educational programs and guidelines for concussion management, with financial backing from Community Hospital.
As CMU athletes go through the post-concussion protocol, they must be cleared by Mistry or another physician before they return to play.
Mistry knows he might not be popular when he tells an athlete he or she isn’t cleared to compete after a concussion, and he’s OK with that.
“Please be patient,” Mistry said. “Attention to detail is important. The brain has a remarkable power of healing, and an integrated approach to concussion management is key.”
Some athletes need only a few days to recover and clear concussion protocol. Others can take several days, weeks or months. There’s no way to predict recovery time for the brain.
Along with concussion protocol, the NCAA has made other, more subtle rule changes to help recognize concussions.
One of those is no longer allowing football players to wear tinted visors. The reason? Officials on the field need to be able to see the players’ eyes.
Always on the lookout
On the sideline, Fullmer and his staff are always on the lookout. He and at least one assistant trainer move up and down the sideline of football games, intently watching players get up from tackles.
“We’re watching very carefully at the end of every play, watching as the players unpile and get up. Are they kind of woozy or are they moving around coming off the field? Are they able to run effectively?” Fullmer said.
“A lot of it is knowing our athletes. There are some that are goofy and can’t balance worth a darn to begin with and there are some that do very well. We’re looking for some of those things as a team changes.”
Because of the sheer number of players and the amount of contact involved, Fullmer said football has the most concussions at CMU, but they can, and do, occur in nearly every sport. Coaches are trained to help spot symptoms, and the same caution is taken and protocol followed in every sport.
Trainers are at every practice and game, always keeping an eye on athletes, especially when they hit the floor or ground or make hard contact with another player.
Headers, slide tackles or diving to make a save in soccer can produce concussions. Basketball and volleyball players can hit their heads on the wood court diving for a ball, running into another player or getting elbowed in the head.
An errant tennis shot that hits a player in the head can cause injury — there’s no limit to what it takes for the brain to be jarred into the skull.
If athletes, parents, coaches and medical personnel are patient and follow protocol to the letter, Mistry said, the chances of long-term effects are minimized. He wants athletes to achieve their goals, but reminds them they need their brains to live.
“The steps are very clear, no symptoms, normal exams, normal brain function testing, no academic adjustments, because return to learn is as important, if not more important, and then a graded return-to-play protocol as described in international guidelines, the Zurich guidelines,” Mistry said.
“It’s not rocket science. People get better when you pay attention to detail. There is no question.”
Athletes have asked Fullmer how many concussions they can withstand before they can’t play again. His answer: It could be one, it could be several. There’s no way to know.
He just knows you can’t be too careful.
“With the second-impact syndrome that can happen and actually take someone’s life, it’s a significant thing,” Fullmer said. “It’s frustrating for us because there’s no Band-Aid we can put on their forehead that says concussed or not concussed.”