A Tough Week for the NFL Concussion Protocol

Week 10 of the NFL season, which concluded this past Monday, included several different incidences which all highlighted failures and limitations of the NFL's concussion protocol.

In the Atlanta Falcons' matchup against the Dallas Cowboys, Falcons running back Devonta Freeman left the game with a concussion in the first quarter after taking a hard hit helmet-to-helmet hit from Cowboys linebacker Anthony Hitchens. On the surface, the concussion protocol was followed well in this case-- Freeman was noticeably dazed after the tackle and was removed from play by referee Ed Hochuli, and after medical evaluation Freeman was determined to be out for the remainder of the game and placed in the protocol. But the concerning claims came from Carolina Panthers' linebacker Thomas Davis, who tweeted during the Falcons-Cowboy's game that Freeman had suffered a concussion in the week 9 matchup between the Falcons and Panthers.

Davis deleted the tweet soon after, but he confirmed his sentiments in a press conference earlier today. Freeman left that game in the fourth quarter after taking a hard hit from Panthers safety Kurt Coleman. Like the hit from Hitchens, Coleman's hit went unpenalized, although Coleman subsequently received a $24,309 fine from the League. However, Freeman was not placed in concussion protocol and although he was on the Falcon's week 10 injury report leading up to last Sunday's game, he was listed as having issues with his knee.

Obviously Thomas Davis isn't a doctor and isn't qualified to determine whether Freeman suffered a concussion against the Panthers and, if so, how that injury may have affected him in the Cowboys game. But Davis' concern is certainly telling, especially because Freeman missed two weeks back in August of this year with a concussion as well.

On Luke Kuechly

Earlier today, Carolina Panthers star linebacker and team captain Luke Kuechly was officially ruled out of this upcoming Sunday's matchup against the Chicago Bears with a concussion. On October 12th, during last week's Thursday night matchup between the Panthers and the Philadelphia Eagles, Kuechly took a hard hit to the neck area from the Eagles guard Brandon Brooks. Take a look at the play below.

While the hit that Kuechly took eight days ago was definitely hard, it certainly wasn't out of the ordinary-- the Eagles ran the ball with LeGarrette Blount to the left, and Brooks pulled and led with his shoulder/bicep as he blocked Kuechly and gave Blount room to run. But it's a particularly concerning sight to see Kuechly go down in this scenario, not just because of his leadership hall-of-fame level talent that the Panthers defense relies on, but due to his recent yet lengthy concussion history and his reaction to a hit that would leave most players getting right back up unscathed.

Kuechly missed 3 games during the 2015 season and six games during the 2016 season recovering from concussions. He became a media talking point last November, when he was concussed in a Thursday night game against the Saints and left the field on a cart as he was tearing up and seemed disoriented.

Besides, Kuechly is a linebacker, which is arguably the most dangerous position on the football field in terms of head injuries. It combines the sheer frequency of hits to the head that linemen experience with the acceleration and awkward angles at which hits to the head occur to defensive backs, meaning it gets the worst of both force and frequency.

Having had three concussions in the past three years, Kuechly is never going to be the same player again. Even if he never suffers another concussion. Because he's always going to hesitate. He's always going to be paranoid. He's always going to think twice before making a move on the football field. And not only is that going to hurt how effective he is as a player, but when you take that split second to tense up or second guess yourself, that's when you're most likely to get hurt playing this game. Especially at the NFL level. Some players can do it. I don't condone it at all, but there are players who have lengthy concussion histories and still play. For example, De'Anthony Thomas, a receiver and kick returner for Kansas City, suffered a concussion in November 2015 and missed the final eight games of the Chief's season. But he's really a gadget player who only touches the ball three or four times a game, during which he'll make a very obvious effort to go down or get out of bounds before he gets hit. There are plenty of similar cases across the league. But the point is that it's one thing to risk getting a concussion as a receiver, where your job is to avoid getting hit during the occasional instances where you're thrown the ball, but it's quite another when in Kuechly's position, where your job is to find the player with the ball and hit him as hard as you can every single play. 

I think NFL coaches needs to start putting more emphasis on a player's concussion history when making personnel moves. It makes no sense that teams sign guys who have become concussion prone not only from a moral and medical standpoint, but just in terms of their abilities to stay healthy throughout the duration of the season. Teams stay away from guys who've had three ACL tears, broken their clavicles twice, etc. The same mentality should come with players who've had concussions-- it's just better decision making for all involved.

Why The NFL Concussion Protocol Should Include Time Requirements

In the past few seasons in the NFL, the term "concussion protocol" has become immensely popular; theoretically medical protocol, the phrase is now likely uttered at some point nearly every game by announcers and fans.

In the NFL, after a player suffers a concussion in practice or in a game, he is placed under the "concussion protocol," a system of evaluations designed to determine when a player is ready to return to play. This system is what is known in sports medicine as a "graduated exertion protocol:" a player starts by resting and recovering until he can pass basic and cognitive tests, then moves to aerobic exercise, then strength training, then non-contact football drills, then full-contact practice. Should the player be feeling normal and healthy after all of these steps, he is then evaluated by an independent neurological consultant, a neurologist not directly affiliated with an NFL tram, before he is "cleared" from the concussion protocol and allowed to rejoin the active roster.

As is true with nearly any injury, the healing process for concussions is not linear--

The actual language from the NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol on time states that "Each player and each concussion is unique. Therefore, there is no set time-frame for return to participation or for the progression through the steps of the graduated exercise program set forth below. Recovery time will vary from player to player." The NFL is correct that each brain injury is different, and that's an important concept to remember. But it's not why there's no set time-frame in the protocol. There's not set time-frame because the NFL wants the ability to bring back any given player at any given time, regardless of his health status. 

Should the NFL Amend/Eliminate the Preseason?

It goes without saying that playing football, especially at the NFL level, is a pretty high-risk activity. It's a sport where the discussion about injuries doesn't start in "if," but "when." The NFL generally rewards this high risk with high rewards-- million dollar contracts, fame, glory, community impact, all of that. But there's also a large portion of the NFL season that for most players presents a high-risk situation with very little reward, very little purpose: the preseason. Before the start of every 17-week-long regular season (which consists of 16 weekly games and one bye week), each team plays four preseason games, a full length exhibition matchup where the final score has no bearing on the team's ranking or seeding during the regular season or in playoffs.

Like in any other game, injuries occur in the preseason, and this year has seen what seems like an abnormally large amount of them. For example, Spencer Ware, Julian Edelman, Ryan Tannehill, and Cameron Meredith, four superstars in the NFL, have all endured season-ending injuries without even getting to play in a regular season game. Odell Beckham Jr, too, one of the most talented and popular players in the NFL, took a hard hit to hit to the leg and suffered an injury on August 21st.

If the NFL really wants to start demonstrate that it's willing to make sacrifices that will actually benefit player safety in and of itself, rather than player safety to avoid negative PR or lawsuits, it should consider shortening or even completely eliminating the preseason altogether. You can only take so many hits in the NFL, only play so many games before your body is going to break down. The NFL understand this concept, as both the intensity and frequency of training camp practices has been gradually dulled down in the past decade in order to keep players safe. But having a long preseason just needlessly puts players in dangerous situations. By comparison, the NBA allows a maximum of 8 preseason games for each team, about 10% the amount of games played in the regular season. The NHL allows a maximum of 9 games, a bit over 10% of the regular season schedule. So for the NFL, the highest league of the most violent major sport in the United States, to add an extra 25% with four games to a regular season that is already grueling makes no sense.

Back several decades ago, when some NFL players had other jobs outside of football or when players didn't have the opportunities to stay connected the football that modern technology affords, I can see an argument for having a long preseason to allow players to brush off the cobwebs and get into football shape again. But nowadays, when players workout year round, when it's easy to study the playbook and watch film from your own couch, when there's numerous optional practices in April and May known as organized team activities (OTAs), a lengthy preseason is unnecessary.

The main argument, though, is that preseason games are necessary for evaluating talent and finding your starters, backups, and determining which players will ultimately be traded or released. After all, each team starts with 90 players to start training camp, and their rosters must be whittled down to only 53 active players by the end of the season. While this argument isn't wrong per se, it's just not necessary. I mean, coaches and scouts at this level know how to evaluate talent, and in the grand scheme of things, past performances in important games and in daily practices are much more telling than how a player performs on a random Tuesday night preseason game. The NCAA doesn't have preseason football (besides maybe an intrasquad scrimmage), for example, and I doubt that Jim Harbaugh or Nick Saban struggle to set their opening day depth charts as a result. Plus, NFL teams already do joint practices with other teams, which gives the chance to see different looks and skillsets.

Many proponents of preseason (not that there are many of them) will also argue that football is unique in that players need to experience "live action" and acclimate to the physical contact of a game before the season actually gets going, and I agree to some extent. But this goal can be achieved through just one or two preseason games; it certainly doesn't require four. And plus, so long as every team is playing the same amount of exhibition matches, they'll all be on the same level anyway going into the regular season, so even if less preseason would tarnish the quality of the first regular season game or so (which I highly doubt it would), at least all teams would need to make the same acclimations. Overall, the preseason is just an unnecessary hazard, and whatever minuscule excitement comes from seeing an uncompetitive game is drowned out by a fear of players getting hurt.

Odell Beckham, Jr.

John Urschel Announces Retirement from NFL

On Thursday, July 27th, Baltimore Ravens interior offensive lineman John Urschel announced his retirement from the NFL. Urschel, who was entering his fourth season in the NFL, was the most likely candidate to win the starting center spot on Baltimore's offensive line this season. His decision came as a shock to many, as at age 26 Urschel is in the prime of his career, and the announcement of his retirement came very late in the offseason-- according to the Baltimore Ravens' statement on Urschel's retirement, Urschel called head coach John Harbaugh to inform him of his decision before 6:30 AM on the morning of the first full day of training camp practices for the 2017 season.

Urschel is much more than just a football player, and even among NFL fans he was likely as well known for his achievements off the field than those on it. He earned a bachelors degree in Mathematics from Penn State, graduating with a 4.0 GPA, and he's currently a doctoral candidate in Applied Mathematics at the Massachusetts Institute of Technology. While at Penn State, he also earned an masters degree and worked as lecturer in the mathematics department, teaching Calculus and Geometry; according to his curriculum vitae, through his time at Penn State and MIT Urschel already has a half-dozen publications to his name. Urschel is also a competitive chess player, and was named to Forbes Magazine's "30 under 30" for outstanding young scientists. All this while also being a team captain and three-year starter at Penn State, as well as contributing to the Ravens offensive line unit for the past three years.

Now, although a lot of major news outlets are claiming that Urschel retired due to concerns about CTE, neither the official statement from the Ravens organization nor Urschel's retirement post on Twitter mention the risk of CTE as a determining factor in Urschel's decision. Urschel and Harbaugh publicly cited three reasons for Urschel's retirement: his desires to invest more time in his coursework and research at MIT, spend more time with his fiancé, and prepare himself for fatherhood (he and his fiancé are expecting his first child in December). Of course, those are all reasons enough to retire from professional football themselves, but the timing of Urschel's decision has left many speculating about its connection to a study published two days prior on Tuesday the 25th, in which researchers at Boston University reported that they'd found evidence of CTE in the brains of 110 out of 111 deceased NFL players.

I don't know that Urschel will ever comment further on why specifically he's choosing to retire, but it's clear that concern over football's long-term ramifications has been in his mind for at least the past few years. In a 2015 article that he wrote for The Player's Tribune, Urschel stated: "Objectively, I shouldn’t [play football]. I have a bright career ahead of me in mathematics. Beyond that, I have the means to make a good living and provide for my family, without playing football. I have no desire to try to accumulate $10 million in the bank; I already have more money in my bank account than I know what to do with.... I play because I love the game...  I’ve fallen in love with the sport of football and the physical contact associated with it." 

But it's clear that something changed in Urschel's mind this week, and his action continue to demonstrate a recent trend of NFL players retiring earlier in their careers, forgoing fame and millions of dollar in order to look out for their future health. Particularly in the case of players like Urschel, who devote large amounts of time and mental energy to passions outside of football, I'm sure that more and more players will continue to walk away from the game before they're forced out of it. At the same time, though, some players such as Tom Brady of the New England Patriots and Aaron Rodgers of the Green Bay Packers have expressed their desires to play into their 40s. It'll be interesting to see if more players begin to retire early from football in coming seasons, and what research will continue to come out on CTE. 

New NOCSAE Regulations Aimed at Absorbing Rotational Forces

A few weeks ago, the Kansas City Star reported that the Kansas-City area National Operating Committee on Standards for Athletic Equipment (NOCSAE) will begin to include the measurement of rotational forces in its football helmet standards starting in June of next year. The NOCSAE is a nonprofit that sets testing standards for helmets in various contact sports including football, hockey, and lacrosse. The organization itself does not certify helmets, but helmet manufacturers certify their products to meet the NOCSAE standards. Currently, the NFL, NCAA, and governing bodies for high school sports require that helmets used meet NOCSAE standards, and thus the regulations established by the NOCSAE completely dictate the direction of research and development in new helmet technologies.

Riddell's Air Bladder Design

The design and technology of football helmets has been constantly evolving since football developed into its (somewhat) contemporary form at the beginning of the 20th century. At that time, leather helmets were used by some players, but helmets didn’t become mandatory in college football until 1939 and in the NFL until 1943. In 1940, the John T. Riddell Company was formed in Chicago and developed the first football helmets made of molded plastic shells rather than of leather, and gradually innovations such as the chin strap and the facemask gained popularity as well. In 1970, Riddell filed a US patent for “Energy Absorbing and Sizing Means” for football helmets, which introduced the technology of air bladders in football helmets, a structure which is still used today. Before that point, the interior of football helmets simply consisted of foam padding, similar to what you would find in many contemporary lacrosse or hockey helmets. But with development of air bladders that sit behind this foam padding, which can be inflated or deflated easily using a small pump, helmets could be tailored to form a unique fit for every individual head. Theoretically, a football helmet that fits well is so tight that if someone were to grab a player's facemask and move it side to side, the player’s entire head would move as well, rather than the interior of the helmet brushing about his scalp. Now the padding in football helmets is extremely dense and a truly skin-tight fit is really uncomfortable, so I suspect that many players don’t fit their helmets as tightly as they should, especially at the high school and youth levels.

While I’m sure there’s been an understood relationship between football and head injuries for as long as the game has existed, it’s important to recognize that football’s “concussion crisis” is a relatively new phenomenon. Concussions were rarely talked about 10 years ago, let alone 45 years ago when the development of the air bladder system formulated the technology that is still used in helmets today. And therein lies the problem with contemporary helmets: they’re designed to prevent catastrophic head injuries (ie skull fractures), but don’t actually do much to prevent concussions. Because concussions are internal injuries, where a blow to the head causes the brain, suspended in cerebrospinal fluid, to slosh around and receive axonal damage by bumping into the interior walls of the skull, a hard protective layer around the head doesn’t do a lot to prevent these injuries. Think about an egg. Let’s say you created some sort of hard layer to put an egg in that would protect the shell. If you dropped the egg on the floor, you might prevent the shell from cracking, but you’re not going to be able to prevent the yolk inside of the egg from moving around.

Medical professionals and helmet manufacturers alike recognize this problem. Many months ago, I wrote a post on how every football helmet has a warning sticker on the back of it. Different manufacturers use slightly different language in their warnings, but they all concede that no helmet can prevent brain injuries. This problem is especially true in the case of hits to the head that cause rotational forces, because again, it’s the internal movement of the brain that causes concussions, not necessarily the amount of blunt force applied to an area. Dr. Frank Conidi, a professor of neurology at the Florida State University College of Medicine and director of the Florida Center for Headache and Sports Neurology, stated in 2014 that “biomechanics researchers have long understood that rotational forces, not linear forces, are responsible for serious brain damage including concussion, brain injury complications and brain bleeds.”

Therefore, for all the advancements made in helmet technology in the past few decades, there are really only a couple that I can think of that actually help disperse rotational forces, and they’re both arguably not that significant. The first is that modern helmets are actually rounder than they were in the 1970s and 1980s. As you can see in the picture of Mike Ditka below, helmets used to be more in the shape of an oval, similar to how the human head is shaped.

However, the more spherical two objects are, the less surface area will come in contact between them should they collide. So theoretically, rounder football helmets are safer because direct the surface area of helmet-to-helmet can be diminished a bit, especially if hits are coming at odd angles. The second thing is something I don’t know if I’d call an “innovation,” because it’s been around for decades, and it’s difficult to argue not only whether it’s deliberate or not, but also if it’s even true, especially because I’ve never seen a study confirm or even attempt to confirm this belief. But regardless, some people also believe that the glossy finishes on football helmets reduces friction between helmets that collide, and thus disperses rotational forces more than matte finished helmets would. Whether there’s any veracity in that claim, I’m not sure. But I can see the logic.

But anyway, the question for the future of football helmet technology is what can done to absorb rotational forces. Like I said earlier, theoretically with the air bladder system, the fit of the helmet is so snug that the entire head of a player would move if his facemask would move. And clearly, that might not be the best system for reducing rotational forces. There are currently a couple helmet companies that already have produced helmet models constructed with rotational forced in mind. One is the company Xenith. Their helmets don't use air bladders, and instead fit the helmet with a web system that tightens or expands using the chinstrap, which is connected to the interior structure of the helmet. One of the their models, the Xenith X2, is pictured on the right. The shell of the helmet can rotate independently of the white web that surrounds the player's head, theoretically helping to disperse the rotational forces that impact the head. Xenith helmets certainly aren't the most popular in the NFL, but you'll definitely see them occasionally and their popularity has definitely grown in the past few years. Another company, VICIS, a startup based in Seattle, is also developing a helmet with the idea of dispersing rotational forces. Their helmet design, called ZERO1, also doesn't use an air bladder. The outer layer of their helmet consist of many columns which can both compress and also move laterally, therefore absorbing forces from any angle. More uniquely, the shell of the helmet isn't perfectly rigid like that of other helmets, and instead gives a big to further absorb impact and disperse force. Check out the video below to learn more about the ZERO1. These helmets are still being tested and developed, but it'd be pretty cool to see them at the NFL, NCAA, and high school levels in coming years. Overall, hopefully the new NOCSAE tests will incentivize even more helmet companies to develop technology aimed at absorbing and dispersing rotational forces.

Michael Oher Still in Concussion Protocol

As far as the different positions go, offensive tackles certainly don't have the same star power as do positions like quarterback, running back, or middle linebacker. Many committed fans probably couldn't even identify which position on the offensive line that tackles play, let alone name who their favorite teams' starting tackles are. But Michael Oher, left tackle for the Carolina Panthers, is probably one of the most famous offensive linemen in the league, not just for his 8 year NFL career or for his role on the 2013 Baltimore Ravens team that won the Super Bowl, but for the movie The Blind Side, which was a semi-autobiographical account of Oher's experiences growing up in foster care and with periods of homelessness, his eventual adoption by Leigh Anne and Sean Tuohy, and his academic and athletic achievements that enabled him to receive an athletic scholarship to the University of Mississippi. 

However, talk of Oher sort of disappeared early on in the 2016 season, as he played in only the first three games of the season before being ruled out before week four with a concussion. Oher missed the next two months of the season, and was placed on injured reserve on November 25th, 2016. On March 24th of this year, Panthers general manager Dave Gettleman stated that Oher is still in the league's concussion protocol, making it six full months since he was placed in the protocol in week four. On March 30th, the Charlotte Observer reported that Panthers head coach Ron Rivera stated, "I believe he's going to play," referring to getting Oher back in the lineup for the 2017 season.

Even putting all concerns about long-term health aside, I can't imagine why any coach or front office person would keep a player on their roster that has been in concussion protocol for six months. Obviously every brain injury is unique and it's impossible to predict someone's path of recovery or long-term prognosis, but if a player has been unable to pass concussion protocol (which consists of neuropsychological evaluation which tests cognitive and balance functions, and then moves to a graduated increase of physical activity from light aerobic activities, to football-specific workouts, to non-contact drills, to full-contact practice) for six months, the chances that he's all-of-a-sudden going to get healthy in time for next season, and, more importantly, that he'll stay healthy throughout the following year, is extremely unlikely. And what baffles me the most is that this situation happens way more often than it should, where a good player enters concussion protocol for a prolonged period time (like months), but then returns the following year only to eventually re-enter the concussion protocol once again. This exact situation happened with Steelers tight end Ladarius Green, who I wrote an article about in December. You'd think that NFL teams would stop taking chances on these guys given the risks involved. And again, here I'm only talking about the financial and logistical risks of signing a player who might not be able to play in every game, not the larger question of whether a player with a history of concussions should at some point be blacklisted (either formally or informally) from being signed by teams in the future.

Answering that bigger question is a bit tougher, and it depends on a lot of different variables at play. In the case of Oher, I don't think it could be more obvious that he should hang up the cleats. I mean, the guy is 30 years old, he's been in the NFL for eight years, he's a multimillionaire, he's a Super Bowl champion, he had a movie made about his life that was nominated for an Academy Award. What else does he need to prove? A player who is 23, has only been in the NFL for one year and is still trying to make a name for himself and make enough money where the past 8+ years he's invested in football might seem financially worthwhile, maybe I could see his reasoning for wanting to keep trying to get healthy and play another year (of course, I certainly would certainly advise him against it, but I'm just saying I understand his argument). But it makes no sense for Oher to stick around or for the Panthers to take a chance on him by keeping him for the 2017 season, because he's already had a long career, and he's at the age where he's deteriorating as a player anyway, concussion issues or not.

Now, I don't think it would be right for the NFL to ever literally force a player to retire over concussion issues, for a few reasons. One, there's a 100% injury rate in the game of football. It's unfortunate, but it's a reality that players obviously understand and experience every year. And more recently, I think an increasing amount of players also understand the symptoms of concussions and the risks of concussions on long-term health. But another important thing to consider is that if the NFL were to ever force players to retire due to concussions, it would strongly discourage players from reporting concussions to medical staff and/or teams from reporting concussions to the media out of fear of a player's career being cut short (the irony here should be pretty obvious).

I think a good solution might be a shift in the perception of signing or resigning players with a known history of prolonged concussion symptoms. To discuss Ladarius Green again, I guarantee the Steelers organization knew about the concussion history he had with the Chargers when they decided to sign him as a free agent. In fact, they probably discussed it at length before making a decision on his contract. But they decided that it wasn't significant enough to avoid signing him, even though he was healthy for only six games in the 2016 season. A big shift should come from the media as well. I mean, there's many different non-directly-football-related reasons that teams choose not to sign players, and much of this reasoning comes due to perceived media reaction. For example, most teams avoid signing players with histories of off-the-field incidents such as DUIs, assault charges, domestic violence, among other things. While I'd like to think that the decision to not sign these players is because NFL teams care about having players with high standards of conduct, a large incentive for these decisions more likely comes from the perceived impact it will have on a team's PR. You would think that if the media viewed signing a player with a history of concussions as a negative action by NFL teams, and if situations like what happened with Green or what is currently happening with Oher received more media scrutiny, they'd be less likely to do it.