School of Hard Knocks

Head injuries in high school sports dwarf professional ranks

/ Author:  / Reviewed by: Joseph V. Madia, MD

There's no doubt that part of the attraction and popularity of NFL football is that the action of the game teeters on the razor thin line between competitive sport and hard-hitting violence.

Many people justify it by thinking that the men who play the game are the best athletes in the world, in prime physical condition and are paid enormous amounts of money to ameliorate the risk of injury. But at any given time, there are approximately 2,000 men actively playing in the NFL; 53 on each roster, and another 8 on the practice squad, an elite collection of talented physical specimens.

But what about the more-than one million boys playing high school football during any given school year, along with the 3 million others in youth leagues? It appears that the risk of concussion and head injury is just as severe. As many as 67,000 high school football players suffer concussions annually, and over 400,000 high school athletes suffered a concussion between 2008 and 2009--a massive number compared to the NFL and other sports where the numbers are in only the hundreds.

Sad news was made recently when Nathan Stiles, a senior football player at Spring Hill High School near Kansas City, Kansas, collapsed and died on the sidelines of a game on October 28, 2010 . He had suffered a concussion on October 1 during a game, but had been cleared to play the following week. His father, Ron Stiles, said, "He had a concussion several weeks ago from football, from that homecoming game...He had the green light to play, and I don't know exactly what all has happened there. The problem is that he definitely had the trauma."

The cause of death has yet to be released as of this writing, but it was noted that he did not suffer any apparent serious hits during the game in which he collapsed, lost consciousness and later died. “He came on the sideline and told one of my assistants, ‘My head is really hurting,’” Spring Hill football coach Anthony Orrick said. “I think then he sat down on the bench, stood up and collapsed.” Nathan Stiles never regained consciousness.

While this is an extreme example of an outcome that is only potentially related to concussions, it still gives pause and highlights the disparity of how concussions and head injuries are treated at the professional level and at the high school level. In the NFL, new guidelines mandate a full examination and clearance by a team doctor...a team doctor that is usually one of the top neurosurgeons in the area. In high school, teams and school districts don't have access to such medical expertise. In the case of Nathan Stiles, there are no rules governing when a player can return to the field, according to the Kansas State High School Activities Association. So how are concussions being treated at the high school level? Are any safety regulations in place?

It appears that if there aren't already, many regulations are about to be put in place. In Chicago, student athletes are already required to exit a game if they experience concussion symptoms. But two city Aldermen are proposing an ordinance that would prevent concussion victims from returning to practices and other activities until they visit and receive a written statement from a licensed healthcare provider trained in concussion diagnosis that they are fit to return to activity.

This seems to follow the lead of the American Medical Association, which recently put forth an official position that it supports a policy that would prohibit any young athlete who has sustained a concussion from returning to activity until the player receives a physician's note allowing participation. AMA Board Member Edward Langston, M.D. stated "Even mild brain injuries can be catastrophic or fatal. To protect the health and well-being of young athletes, it's vital a physician evaluate them and give them a clean bill of health before they return to play."

The high school athletic commissions in Texas and Florida have already begun to adopt the same policy. Collier County School District (Florida) athletic director Joe Kemper is actually hoping to have a more advanced system in place by next athletic season, by looking into purchasing the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) system that is used in the NFL and major college programs.

While it is great progress that concussion and head injury awareness are making way down to the high school level, the question still remains: is the risk worth the reward? That's a decision for students and parents to make together. But to answer that risk/reward question, consider this: eight out of every 10,000 high school football players will make it to the NFL, for career that lasts an average of 3.5 years.  The answer might make one realize that the same camaraderie, competition, and personal growth can be found on the swim team.

By Joseph V. Madia, MD

Review Date: 
November 11, 2010