Second-impact Syndrome and its Implications

During the 2015 high school football season in the United States, fourteen players died playing football or participating in football-related activities. Of these deaths, seven were categorized as what the National Center for Catastrophic Sports Injury Research, a part of the University of North Carolina, deems "direct fatalities:" deaths occurring by fatal injuries sustained during competition. The other seven deaths were categorized as "indirect fatalities," occurring during practice or conditioning but not the direct result of collisions, such as a heart attack or heat stroke. Within the direct fatalities, five were fatal head injuries, one was a broken neck, and one was a ruptured spleen.

Fortunately, deaths at the college and professional levels of football are extremely rare. In fact, only one player has ever died on field during an NFL game, Lions receiver Chuck Hughes, who suffered a heart attack on October 24th, 1971. However, there are only about 1,700 active players on NFL rosters each year, compared to what the NCAA projects to be about 73,000 NCAA players, and 1.1 million high school players. Factor in youth football, non-NCAA college teams (such as community colleges or club teams), and semiprofessional leagues, and there are millions of football players each year in the United States alone. 

Due to the small sample size of players and injuries in the NFL, catastrophic brain injuries, such as those caused by second-impact syndrome, aren't often discussed by the media or understood by people involved in or fans of the sport. By this point, pretty much everyone following football in any capacity knows the signs and long-term risks of concussion, or at least that they exist, but few know about second-impact syndrome. A couple weeks ago, I wrote about Patriots receiver Julian Edelman, who possibly played through a concussion in Super Bowl XLIX against the Seahawks in 2015. Edelman didn't miss a snap for the rest of the game after getting hit, and ended up catching the game-winning touchdown. He was praised by some media outlets for his toughness. By the reality is that, if he was concussed, he was literally one hit away from a possible death. I mean, that's kind of true in football (and a lot of things in life) all the time anyway, but sustaining a second concussion before the first one has healed can lead to rapid swelling of the brain, leading to a mortality rate of around 50%, and a near 100% chance of permanent disability, such as paralysis and/or coma. 

During a concussion, the brain, normally suspended in and protected by cerebrospinal fluid, makes contact with the skull, causing shearing forces which damage axonal tissue. This bruising leads to chemical imbalances as the brain attempts to repair itself.¹  If the brain receives a second blow before recovering from the first, these imbalances prevent the brain from regulating intracranial pressure and blood flow. Cerebral edema, the excess accumulation of fluid in the brain, leads to brain herniation, or rapid swelling; the brain essentially continues to expand, but is physically constrained by the limits of the skull, and death can occur within minutes.²

It goes without saying that in football, there's a culture of playing through injuries. But, learning about second-impact syndrome will ideally encourage players to report concussions to medical staff. In 2014, a survey of 730 NCAA football players by Harvard and Boston University revealed that for every concussion officially diagnosed, there were many other instances of suspected concussions or concussion-like symptoms that players chose not to report to medical staff. Even ignoring the long-term health concerns associated with concussions, hopefully increased awareness of the rare but often fatal condition of second-impact syndrome will incentivize players to remove themselves from games or practices when experiencing concussion symptoms, and, just as importantly, not return to play until all symptoms have dissipated.

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1 http://www.brainfacts.org/about-neuroscience/ask-an-expert/articles/2015/what-happens-in-the-brain-during-and-after-a-concussion/
2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672291/

What the Big Stories will be this NFL Offseason

More than arguably any other American sports league, the NFL has a grip on the national audience that lasts year round. Sure, it takes a back seat to the NBA and NHL in the spring, and the MLB in the early summer. Still, though, every day throughout the NFL offseason, you can find analysts and pundits on every form of media making bold predictions for the upcoming season, reporting on events within the league, or just generating interesting headlines out of nothing. At its core, though, the NFL offseason is about personnel. Especially in a league where teams start with 90 players at the beginning of training camp (which is whittled down to 53 players on the active roster by opening day), there's always buzz about who over/underperformed in the combine, what draft picks are going to different teams, and which veteran players may be traded, cut, or signed to new contracts.

In the past few years however, the biggest stories haven't just been about free-agent signings, but instead about young players deciding to leave the game early. Indeed, it seems like every year more and more NFL players are retiring "early" due to concern about the long term effects of head trauma, concern with other injuries, general disinterest in the game, or some combination of all three and/or other factors.

Now, it's hard to really define what retiring "early" is in the NFL, for many reasons. Primarily, according to the NFL Player's Association, the average career is only 3 1/2 years long, meaning that a player retiring at age 26 would technically be around retirement age, even though he might still have a lot left in the tank physically. Additionally, different positions have different expected career lengths due to disparities in the physical demands and levels of contact. A running back who is 29 would be considered pretty old by NFL standards, and yet many quarterbacks and kickers player into their late 30s. Tom Brady, for example, was named MVP of Super Bowl LI last Sunday at age 39, and hopes to keep playing for several more years.

Regardless of the subjective nature of what is "early," though, I think it's pretty commonly agreed upon that the vast majority of professional athletes play until they either A. get cut from a team or B. physically can't play anymore. So, for argument's sake, I consider someone who retired early to not fall under one of those two categories.

Around the start of this blog, I wrote an article about Chris Borland, a former all-American linebacker at Wisconsin who started for the 49ers as a rookie, who walked away from the NFL in 2015 after only one year, choosing to forgo millions of dollars and what would likely be a long, successful career due to concerns over football and TBI. Earlier today, Bengals linebacker Trevor Roach, age 24, announced his retirement from the league. Now, the Bengals organization officially stated that Roach had lost simply lost interest in the game, and I'm not saying that he retired for the same reasons as did Chris Borland. But in addition to citing a dwindling interest in the game, lost time with family, and desire to start a new career, Roach also commented to media, "I've seen guys play for 10 years and have their bodies beat up and I didn't want to do that."

Calvin Johnson

Now it's one thing for younger, emerging players to leave the sport when less of their life has been built around it, and their legacy within it is not as strong. It was and is quite another when one of the best players in the entire NFL decides to retire while still in great shape and at the top of his game. But that's exactly was Lions receiver Calvin Johnson did last offseason after nine years in the league. Now, nine years is a long NFL career compared to the average. But in that nine year span, no player had more receiving yard or receiving touchdowns than did Johnson. In fact, he set the NFL single-season record with 1,964 receiving yards in 2012. Still a borderline hall of fame candidate now, most agree that he would have been in the discussion for the greatest NFL receiver of all time had he played around five more years and put up decent numbers. Yet he retired at age 30, citing concerns over his long-term health. Now, he didn't point to head injuries specifically as the cause for his decision, but they were certainly a factor; he said in an interview, "I don't know how many [concussions] I've had over my career, you know, but I've definitely had my fair share." Johnson's statement is especially concerning because he never was listed with a concussion on an NFL injury report in any of his 9 seasons, which calls into question the reports' integrity (I've discussed this topic in a previous post on De'Anthony Thomas).


So, anyway, this offseason we'll obviously see a handful of big name players retire after long careers and years of wear-and-tear on their bodies. But what I think the more interesting stories will be, and I'm certain that there will be a few of them, are the younger guys who will follow the precedent set in the past few offseason of players retiring early in order to look out for their long-term health.

Two Years Ago: The "Julian Edelman Rule"

The New England Patriots are almost undisputedly the most dominant football team of the new millennium. Currently, they have three certain future hall-of-famers in their organization, Tom Brady, Rob Gronkowski, and Bill Belichick, and they have countless other players year-in and year-out who seem to rise to the team's standards and find ways to win consistently. In fact, many analysts and fellow coaches have argued that Patriots head coach Bill Belichick's most valuable traits as a coach are his ability to scout valuable players that might otherwise fall under the radar in the NFL, and his ability to fit players into specific niches within his playbook that highlight their specific strengths. One such example is wide receiver Julian Edelman.

A 5'10 running quarterback coming out of Kent State, most NFL scouts believed that Edelman lacked the size and passing accuracy to be able to succeed as a professional. Though he put up great rushing stats in college, Kent State saw two losing seasons with him at the helm, and the school's football program generally isn't regarded as terribly competitive or though to be in possession of future NFL talent. Edelman was picked near the end of the 2009 NFL draft, drafted 232nd out of 256 selections, and had to make the transition to a completely new position in wide receiver while also adjusting trying to make the Patriots roster and adjust to the NFL game. Fast forward five years late to the 2013-2014 season, and Edelman was the top receiver for the one of the best teams in the league, leading the Patriots in receptions, receiving yards, and receiving touchdowns. The following season, a little over two years ago, Edelman was starting in Super Bowl XLIX and caught what became the game-winning touchdown (shown below) as the Patriots squeezed out a close victory against the Seahawks, 28-24.

Several minutes earlier in the game, however, Edelman had taken a blow to the head around the 47 yard line by Seahawks strong safety Kam Chancellor. Edelman was visibility shaken on the helmet-to-helmet hit (which, by the way, went unpenalized), and although he got up and kept running after contact, he was visibly off balance after the hit, and ended up falling to the grass and taking a few seconds on the ground before jogging back the huddle. It was the kind of hit that you'd think would send medical staff running out onto the field immediately, but they didn't. In fact, Edelman remained in the game for the rest of that offensive drive, and he didn't miss any plays during the next drive, which ended in him catching the go-ahead touchdown.

Seeing a player take such a big hit in the most popular game of the year (here's a link to a video of the hit) and not be removed from play yielded countless different reactions from analysts and fans across the country during the game and in the following days. The sports website Bleacher Report called the incident "NFL's Nightmare." The New Yorker said that watching Edelman play through a possible concussion was "unsettling."

Like I said with the Matt Moore discussion a few weeks ago, I'm not here to speculate on whether Edelman indeed suffered a concussion on that play or not. I think it's very likely that he did, but he took the NFL concussion tests performed by team training staff and an independent neurologist in between the Patriots two offensive drives, and he passed them. The main problem with this situation was that everyone in the stadium and watching across the world knew that Edelman got rocked on that play, and yet no one did anything to stop the game. There was no immediate medical evaluation, no time out called, no commercial break, nothing.

Let's assume for a moment that Edelman did suffer a concussion on that hit. The chances of him or any player removing himself from the game in that situation are near zero. For one, it's the Super Bowl. It's the moment that every player on that field has been working towards for literally his entire life. No one accidentally makes an NFL roster. No one accidentally makes it to the Super Bowl. So, for better or for worse, they're willing to take the risk in order to remain in the game. Moreover, the Patriots were running a hurry-up offense, meaning that they were trying to get the next play off as soon as possible after the previous play was over in order to conserve time and wear the opposing defense out, so Edelman didn't have the opportunity to get a sub in between plays. Finally, if he did suffer a concussion on that hit, adrenaline might have prevented him from feeling immediate symptoms or from thinking about removing himself from play.

I'm not saying that Edelman doesn't have any fault here. If did indeed suffer a concussion, then the fact that he continued to play literally put his life in danger by increasing his chances of Second-impact syndrome, which is rapid/often fatal swelling of the brain that occurs when a second concussion is sustained before the first one has healed. But the bigger problem is that Edelman and other players shouldn't be the ones choosing whether they're removed from play. Because they're not going to remove themselves, especially in the fourth quarter of the biggest game of their lives. The real problem was that no training staff ran onto the field after that play. The real problem was that no independent neurologist on the sideline notified a member of the Patriots coaching staff that the game should be stopped. The real problem is that none of the referees on the field felt that Edelman needed further evaluation after he stumbled to the ground.

The silver lining to this situation is that, likely due to the media outcry after the game, the NFL incorporated a new rule last year which allows independent concussion spotters, who sit in the media box and have a bird's eye view of the game, to be able to radio officials on the field and call a medical time out, which stops the game but does not penalize either team. The Boston Globe nicknamed this new ability the "Julian Edelman Rule," because hopefully it will prevent what happened with Edelman from happening again.

With Super Bowl LI coming up in just a couple days, Julian Edelman and the Patriots will be back to face the Falcons. Over a hundred million people will be watching, and if the NFL really wants to demonstrate that it's committed to player safety, it should be adamant to stop the game whenever a player shows symptoms of a head injury.

Bo Jackson, and What I See as the Future of Football

Earlier this week Bo Jackson, one of the greatest multi-sport athletes of all time, said that he "would never have played football" had he known the risk of head injuries and CTE that are inherent to the game.

Jackson was a true renaissance man within sports. At Auburn University, he ran track, played baseball, and won the Heisman trophy as a running back. He was drafted first overall by the Los Angeles Raiders in 1986, and played both for the Raiders in the NFL and the Kansas City Royals in Major League Baseball simultaneously for four years, until a hip injury prematurely ended his football career. His MLB career continued on for several more years after he recovered from the injury. To this day, he is the only athlete to ever named an All-Star in both the MLB and NFL.

Bo Jackson's comments are significant because they allude to a trend that I foresee happening within the next couple decades: due to increasing awareness of the dangers of head injuries, the best male athletes in the United States will start gravitating towards sports other than football. Jackson was an exceptional athlete, but there are quite a few players currently in the NFL who played other sports at high levels as well. Tight ends Jimmy Graham and Antonio Gates, two of the best players at their position right now and potential hall-of-famers in the future, both played basketball in college. Tom Brady, Colin Kaepernick, Russell Wilson, and Jameis Winston, all current starting NFL quarterbacks, each got selected in the MLB draft at one point. Football is such a versatile sport that its players can succeed in one of the numerous other sports played in the United States.

Therefore, the stark changes in levels of participation will start from the ground up. I think parents, especially of younger kids but even of high schoolers, will be less likely to let their children play football. Thus, the talent pool will somewhat diminish for college programs, and while I don't think the number of players participating will decrease (at least at the Division 1 level), the level of performance will go down because, again, the best athletes will play other sports. This change will extend to the NFL as well.

I've been meaning to write something on where I see the future of football being 15, 20 years down the line. That might not seem like a long amount of time, but the average NFL career is only four years, and outside of quarterbacks and kickers, you have a team of virtually entirely different players every five years or so, let alone every decade. But anyway, eventually, I think football is going to be like what boxing in the US is now. It'll still exist, it'll still be a sport that draws huge crowds and pays large chunks of money for its athletes. It'll still be shown on mainstream television, it'll still be talked about on talk radio and by the water cooler. But it won't be a mainstream sport. It won't be one of the "Big Four," like it is now (for those unfamiliar with the term, the big four refers to the four major professional sports in the United States: football, baseball, basketball, hockey). Kids won't grow up dreaming about catching a touchdown pass in the Super Bowl in the same way that they'd dream about hitting a shot in the NBA finals or a home run in the World Series.

Like boxing is now, football will largely be seen as too barbaric for kids to play. Older high school kids and college-aged students might do it on the side on club teams, but it won't be an official high school or NCAA sport, just like boxing isn't. The kids who do want to seriously pursue football, like many who pursue boxing in the past and nowadays, aren't gonna be ones who see themselves going to college or getting a normal job. They're not gonna plan on having a nice, long, healthy life after their sports careers are over. They're most likely going to be kids who have no desire for anything in the world except to play professional football, and might likely come from poverty or other hardships where football seems like the only way out. This story might seem like a stretch, but the rags-to-riches narrative is one that is already extremely common in the NFL today.

Of course, there are reasons to believe I'm wrong. Maybe scientific advancements with helmet technology, concussion prevention, concussion treatment, and/or CTE treatment will save the game. Obviously, those developments would be nothing short of amazing. But I'm not counting on that, at least not in the short run.

The main reason to believe that I'm wrong about the future of football is that many people either don't understand the risks of head injuries in football, or have some other reasons to ignore the risks if they do understand them. At the risk of getting too political, it reminds me a lot of the climate change "debate." The jury is in on whether preventable human activities contribute to the warming of our planet: they do. But people act like it's still a discussion because either they don't understand climate change, don't care, or have some vested economic interest that incentivizes them to deny science. The same exact thing holds true with football and head injuries.

Thus, I acknowledge that such a big cultural change might not happen so quickly, and it might not happen in a linear fashion. Shoot, we just elected a president who denies the severity of both climate change and of concussions (see the article I wrote back in October on that issue here). It's a gradual process. But look at all the progress that's been made on the concussion crisis. 5 years ago, if an NFL player took a hit to the head and left a big game to get medically evaluated, he would be torn apart by fans and by the media. But today, if a player takes a shot and isn't removed from play, the media is all over it. Just look at what happened this year with Cam Newton, what happened a couple weeks ago with Matt Moore. Overall, that development makes me optimistic.

Matt Moore

One of the most discussed plays in the Steelers' 30-12 routing of the Dolphins this past wild card weekend is the hit on Dolphins QB Matt Moore, a backup who replaced starter Ryan Tannehill after Tannehill went down on December 11th with an ACL/MCL sprain.

In the second quarter, Moore took a huge hit to the neck/jaw area by Steelers linebacker Bud Dupree. I would try to describe the hit, but you might as well just see the film to understand it.

Although Moore allegedly didn't lose consciousness after the hit, he was on the ground talking to training staff for at least a couple minutes. He was able to walk to the Miami sideline and underwent the NFL's concussion protocol, only to return one play later. Yes, after that hit, Moore returned to the field and finished the rest of the game.

Now, a lot of people online are debating whether the concussion protocol was truly followed to its fullest extent in Moore's case. Today, the NFL announced it is reviewing whether the concussion protocol was properly followed. It will do so in conjunction with the NFL Player's Association (NFLPA), and the review will reportedly feature a review of the film and interviews with the parties involved in the incident.

I'm not here to speculate on that issue, for a few reasons. When asked about the hit during a postgame press conference, Moore stated, "[I] needed a second there. So got checked out, felt fine, was really more my jaw than anything else. Felt good, came back in, was fine." Of course, only Moore knows whether he's telling the truth or not, but the point is that we truly don't know, so there's no point in speculating. Additionally, Moore was attended to a decent period of time. Yes, he only missed one play, but a few minutes had already passed in the time between when he first began to be evaluated, to when the play he missed started. Lastly, it seemed like Moore ran out onto the field himself, rather than being pushed by a doctor or coach. 

Just to clarify, none of those reasons are good, and of course I think that Moore should have been taken out for way more time, if not for the rest of the game. But I'm trying to point out that arguing over whether the concussion protocol was properly followed is futile, because we don't have enough evidence.

What I am here to discuss, however, is the reaction to Moore's return by the media. Moore was heralded as brave, tough, a hero. And I do think it's laudable that, assuming he didn't suffer a concussion, he was able to return from such a big hit. But it's problematic that he's being praised for doing so. As I often write, the media and public has to understand that a concussion isn't like other injuries.

Playing through a hamstring strain or a broken hand certainly takes toughness and maturity, and I'm all for celebrating that kind of resilience, especially in a playoff game. Playing through a concussion, however, is life threatening. Again, I'm not claiming that Moore did that. But when reporters on mainstream sports media, like ESPN, are applauding Moore for returning to the game, it sends the wrong message to fans, players, and coaches at all levels. If anything, players who suffer concussions and remove themselves from play on their own volition, those are the ones who should be heralded.

We need a culture change in order to solve this concussion crisis. We need increased awareness, better understanding, and proper execution. Reactions like that of many sports media stations on Sunday reveal how there is still much work to be done in that regard.

Tom Savage and Lessons for Concussion Protocol

Anyone who's been following the NFL this season has probably seen the disappointment of many fans and analysts in Houston Texans QB Brock Osweiler. Coming off of his role as a backup to Peyton Manning as the Broncos marched to a Super Bowl 50 victory, Osweiler signed a now somewhat infamous four year, $72 million contract with the Texans before this season, making him one of the highest paid players in the league.

Osweiler, who only had 7 career starts before signing his contract, has certainly underperformed thus far, leading the Texans to an 8-6 record as a starter in one of the easiest divisions in the NFL. He also is near the bottom in both passing yards and passing touchdowns, rating 27th in those categories at the end of the regular season. Long story short, Osweiler wasn't getting it done, so Bill O'Brein decided to pull him in a week 15 matchup against Jacksonville, where Osweiler had 2 interceptions and didn't put up a single point against a subpar opponent in two quarters of play. So, the Texans, with strong support from the home crowd at NRG Stadium, put in backup quarterback Tom Savage, a third year player out of the University of Pittsburgh who no career starts prior to this season.

Tom Savage enjoyed some success, leading the Texans to a win both against Jacksonville when he replaced Osweiler, and then again the following week against Cincinnati. However, in week 17 facing Tennessee, Savage took a shot early in the 2nd quarter on a QB sneak, as was removed from the game by officials to be evaluated for a concussion. However, Savage cleared the concussion examinations, and briefly returned to action later in the second quarter. However, he apparently experienced concussion symptoms when returning to the field, and at halftime was ruled out for the remainder of the game. Today, four days later, he remains in the NFL's concussion protocol, and is unlikely to start in this week's AFC wild card matchup against Oakland.

Initially, I was disappointed that Savage returned to the game at all, but after thinking about it, I realized that the league really did do everything it needed to; Savage was watched by one of the league's concussion spotters up in the press box, and the spotter contacted an official down on the field who removed Savage from the game. We no reason not to believe that he was evaluated thoroughly by team doctors, and was probably symptom free when he returned to the game.

The real lesson here, though, is that even if a player returns to the field after passing concussion protocol, officials and team staff should keep a special eye on the player for the remainder of the game, because concussion symptoms can often take time to develop. Especially, under the adrenaline-fueled atmosphere of a game, a player might not experience symptoms for minutes, hours, or even days after the initial hit. We've seen this situation before this season; back in November, Colts QB Andrew Luck completed the matchup against the Titans, but reported concussion symptoms well after the game, and missed his team's Thanksgiving day game against Pittsburgh.

Understanding that symptoms do not always develop immediately after a concussive hit is a next level that the NFL's concussion protocol can incorporate in order to properly protect players. Overall, concussions are difficult to diagnose, because they're an invisible injury barring loss of consciousness, balance problems, or a few other symptoms, so responsibility falls on players as well to report symptoms that develop late. But it's a two way street, and the concussion protocol could possibly include checkups at the end of each quarter and at the end of the game if a player is evaluated but then returns to play.

Rashaan Salaam's Death Officially Ruled Suicide

I wrote a more detailed post about Rashaan Salaam and his recent death a few weeks ago, but I wanted to write a brief follow up in response to new information on the situation. The Boulder County coroner's office formally ruled former running back Salaam's death a suicide earlier today. The autopsy revealed that Salaam shot himself in the head, and was under the influence of alcohol and marijuana at the time of death.

In observance of Salaam and his family's Muslim faith, his family declined to have his brain examined for the degenerative disease CTE. Nevertheless, his brother stated that Rashaan had "all the symptoms" of the disease, including memory loss, problems with vision, and depression.