Keep long-term well-being of student-athletes at the center of our priorities
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Any direct force to the head or a force that causes the brain to shift or rotate may damage brain cells and surrounding structures. The damage may be mild and not recognized by athletes, coaches or team physicians. It also can be moderate or severe with loss of consciousness.
In all cases, team physicians must be honest and recognize concussions represent brain injury. As team physicians for many sports, orthopedic surgeons must must know the serious nature of concussions, especially in youth.
Professional sports organizations have dedicated millions of dollars to improved concussion management, including the development of the NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol. However, support for managing the condition in youth sports remains the collective voluntary priority of team physicians, coaches, parents and athletes.
Recent research has shown the rate of concussions in youth has steadily increased. Boys are more likely to sustain a concussion overall. However, in sports where boys and girls participate equally, such as soccer, the incidence is higher in girls. Unfortunately, the overall prevalence of concussions is most likely underreported due to a lack of certified athletic trainers in U.S. high schools and limitations in concussion management training for athletic trainers and others who support youth sports.
Traumatic brain injury
Concussions must be recognized as a traumatic brain injury, no matter how mild or inconsequential the symptoms. Many professional and collegiate programs have established sports-related concussion management protocols. However, significant gaps in education and concussion management of youth sports leagues expose children to risks for brain injuries related to concussions.
It is essential for professional, legal and personal reasons that orthopedic surgeons who cover sporting events at any level be current on sports-related concussion management protocols. In 2010, Oregon enacted OAR 581-022-0421, which requires Oregon school districts to implement sports-related concussion management protocols for student-athletes. Max’s Law, as it is also known, was passed after a high school quarterback had a concussion during a football game then, without a further medical assessment, started the next game and collapsed at halftime due to massive bleeding in his brain leading to a severe and permanent brain injury.
If a program does not exist within the sport covered, then the team physician is responsible for concussion management by default. The Oregon Concussion Awareness and Management Program is an excellent template for setting up a sports-related concussion program.
Education
Recognition of concussions begins with educating participants in youth sports, including coaches, trainers, school administrators, teachers, parents, athletes and physicians. Everyone should be aware that any alteration in brain function represents a brain injury, and symptoms may not reflect the severity of damage with a first-time assessment. Few athletes lose consciousness with a concussion. The most likely signs and symptoms are confusion, forgetfulness, memory loss, non-descript headache and poor mentation. Recognition is critical as youth athletes are more susceptible to second injuries, which can result in severe long-term deficits or even death.
If athletes have been involved in a collision or exhibits any signs or symptoms of concussion, then they must be removed from play until medically cleared, even when they made it to the sidelines or players’ bench on their own. This is often an unpopular decision in competitive sports and emphasizes the importance of educating everyone involved in the athlete’s life. If the team physician is knowledgeable and competent with concussion assessment on the sidelines, then he or she may allow the athlete to continue participation after appropriate testing. Pre-participation evaluation of cognition, balance and documentation of the athlete’s history of concussions can facilitate the process. However, this information is often incomplete or absent for most youth athletes.
Questions about well-known facts can also help discover memory deficits. Neurocognitive tests, such as the Sports Concussion Assessment Tool, Fifth Edition (SCAT5) for athletes aged 13 years or older and Child SCAT5 for children aged 5 to 12 years, should be part of the assessment to determine return to sport.
Computerized neurocognitive testing with Immediate Post-Concussion Assessment and Cognitive Testing has become a more common component of concussion management. Youth athletes with signs and symptoms of concussion should not return to competition on the same day and must be referred for a complete concussion evaluation by a specialist. Athletes should be monitored closely by legal guardians until seen by a concussion management specialist, preferably within 3 days of injury. The assessment results must be communicated to all shareholders in the athlete’s well-being before a final decision about return to sport is made.
Medical decisions
The determination to return to sports and school activities is a medical decision. Student-athletes may struggle with academic and light recreational activities when recovering from concussion. Therefore, a gradual return to full preinjury performance may require concessions, such as more time for tests or schoolwork, adaptive physical education participation, and the ability to retake tests or other performance measures.
As the health care providers for student-athletes, orthopedic surgeons must remember the importance of education in sports-related concussion management. When concussion is suspected, no matter how minimal the symptoms, youth athletes must be removed from play and competition, monitored for signs and symptoms, and seen by a specialist.
If we accept the responsibility of being team physicians – voluntary or compensated – then we must have a solid working knowledge of sports-related concussion management. We must keep the long-term well-being of the student-athlete at the center of our priorities.
- References:
- Chun BJ, et al. Sports Health. 2021;doi:10.1177/1941738120932570.
- https://cbirt.org/sites/cbirt.org/files/resources/max%27s_law.pdf. Accessed June 6, 2023.
- https://static.www.nfl.com/image/upload/v1665264248/league/moexjmdzy2kvjtqsdpbx.pdf. Accessed June 6, 2023.
- Max’s Law: Concussion Management Implementation Guide for School Administrators. Available at: https://www.oregon.gov/ode/educator-resources/standards/physicaleducation/Documents/ocampguide.pdf. Accessed June 6, 2023.
- Jildeh TR, et al. JBJS Reviews. 2020;doi:10.2106/JBJS.RVW.20.00055.
- Theadom A, et al. Neuroepidemiology. 2020;doi: 10.1159/000505424.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Healio | Orthopedics Today. He can be reached at Healio | Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.
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