Tackling Head Trauma in high school football

UC San Diego professor, former La Jolla High School football coach discuss game safety

In response to a football injury at La Jolla High School last season that reportedly left a junior varsity player with a severe concussion and ongoing health issues, La Jolla Light spoke at length with two men who have close ties to the school’s football program.

Stephen Hayden, a professor of emergency medicine at UC San Diego and a father of both current and former La Jolla High football players, and Rey Hernandez, the school’s former head football coach, discussed considerations for maintaining and improving game safety at the high school level — particularly in terms of reducing head trauma.

In 2011, Hayden approached Hernandez (then La Jolla High’s head coach) about conducting a study at the school to help identify players potentially suffering from a concussion — and to catch them before their condition could worsen.

While professional teams conduct advanced baseline and computer tests on players to spot head trauma, there is rarely money for such screening at the high school level, Hayden noted.

With assistance from Ben Lowe, the school’s athletic trainer — a certified professional taught to do everything from tape ankles to spot and respond to head trauma — a UCSD screening protocol was developed and approved through the university’s Human Research Protections Program.

The protocol, which ended the year before current head football coach Jason Carter took the reins, involved using volunteer UCSD researchers to conduct an initial baseline screening of players at the beginning of the season.

Each time it was suspected a player might have a concussion, the baseline observational test was repeated and compared to the one conducted at the beginning of the season to compare differences in response and performance.

The screening, which involved freshman, junior varsity and varsity players, employed a set of cognitive tests, including simple questions such as the time and date, game score and what quarter of the game it was. A series of short-term memory tests were also conducted in which players were asked to repeat the months of the year backwards or were given a string of numbers to repeat backwards immediately, and again five minutes later.

Players’ balance was also tested by asking them to perform simple tasks, such as standing on one leg with hands on hips and eyes closed for 20 seconds. Hayden said balance is typically a precise indicator of mild brain dysfunction and/or concussion.

“If they have a true concussion, almost invariably their balance is off,” he said. “When we do repeat testing on them (weeks later) … their balance would come back.”

During the duration of the three-year study, Hayden said there were six to eight confirmed concussions observed, which he said is “extremely low” and not enough to draw any solid conclusions.

Yet, Hayden said the process of involving the boys in the study seemed to greatly raise the players’ awareness of safety issues.

“They would approach us (on the sidelines) and say, ‘I got a hard hit; I’m not feeling well. Can you check me out?’ ”

Although Hayden said most concussions are not as severe as the head trauma he’s seen during his 21 years in emergency medicine, they can range from a mild loss of balance, inability to perform simple tasks and headaches that last three or four days to more severe trauma, like that reportedly sustained last fall at La Jolla High.

Hayden said his oldest son, Connor, sustained a mild concussion after coming head-to-head with another player while returning a punt.

“He said to me the next day in school he had a little trouble seeing some of the words on the chalkboard. The teacher would write stuff up and it looked like a couple of words were missing, or he just couldn’t concentrate on them. That lasted for about two or three days and then his headaches got better. ... He missed one game, but then the following week he was 100 percent back to normal.”

Indicators of more severe brain dysfunction would include vomiting and more persistent headaches.

“There really are not very hard-and-fast, well-defined criteria that say (what a concussion is),” Hayden said. “It’s just sort of an overall clinical gestalt.”

Shear forces

Although there are products on the market to help reduce head-on impacts — including gel packs worn under or over the helmet designed to absorb kinetic energy — Hayden said there is virtually nothing that can protect a player from shear forces, or rotational impacts in which one part of the body is being pushed in one direction, and another part of the body in the opposite direction.

“It’s not necessarily the direct energy to the brain that causes the problem,” Hayden said. “It’s almost always that you hit the head a little to the side, and it snaps to the side. … There are things that you can do to reduce the direct energy that’s transmitted to the brain” such as helmet design, “but even with all of that, there’s no way to completely prevent a concussion from happening because of shear forces.”

Importance of protocols

Being able to recognize the signs of a concussion is crucial, Hayden said, because it’s the second impact — sustained while the brain is in a vulnerable state — that does the greatest amount of damage.

“If you don’t allow the brain to heal, to get back to normal, and you get a second impact while the brain is still vulnerable, that’s when we think they’re going to get much more severely injured, which leads to these long-term problems (such as) the chronic traumatic encephalopathy that (the late San Diego Chargers linebacker) Junior Seau had. … That’s what they develop over time and it’s very likely from impact after impact before the brain has had an opportunity to heal.

“On the other hand,” Hayden said, 
“just because somebody takes a hard hit, that doesn’t necessarily mean they have to come out of the game. There’s got to be some sort of a rationality to it.”

NFL injuries increase awareness

Hernandez, who coached football at La Jolla High from 1990 to 2012, said he 
has long carried a card on him listing steps to recognize and respond to a concussion. He said San Diego Unified School District (SDUSD) and high school football programs across the country have overtly stepped up their game in recent years following media scrutiny of the long-term effects of repeated head trauma sustained by NFL players.

Today, the SDUSD conducts training for coaches and assistant coaches to help them with everything from recognizing concussions to dealing with diabetic athletes and those with bee-sting allergies.

“For a long time concussions were not an issue,” he said. “It was what happened with the NFL when that started surfacing. That’s when everybody started taking notice … and scrambling to get additional certifications. … I think a lot of these coaches had to reassess — ‘What do we have to do to keep the players safe, but at the same time maintain some competitive edge on the defensive side of the ball?’ ”

Although the rules are different for high school football, teen players at times try to emulate what they see in the NFL or college ball, Hernandez said.

“You’ve got to explain to them a lot of times that the rules are different — everything from you can’t wear war paint on your face like you see the college guys doing, to you can’t wear a dark visor on your helmet. … At the pro level the kneepads are really small and the kids want to wear them like that in high school.”

Importance of trainers

Hernandez estimates that only about 30 to 40 percent of schools nationwide have athletic trainers. They are not required or paid for by the SDUSD; La Jolla High’s trainer is funded by the school’s foundation, he said.

“In our program, when we had any type of injury, unless it was a real serious one where we had to call emergency personnel, everything went through our trainer,” he said. “Most of the schools in the United States don’t have trainers, so you have coaches out there trying to handle the whole thing, and that’s where the problems begin — a lack of expertise. I know the basics about concussion protocols … but I don’t have the training that these people have in terms of going over and above that — setting a broken leg or things of that nature.”

Hernandez said the decline of the traditional huddle — which he considers a primary source of concussion detection — has also reduced the safety of the game, both at the high school and professional level.

“There’s so much fast-tempo spread offenses that are being played now that the defense doesn’t (have time to) huddle anymore … because they’re going to snap the ball at you and they’re going to be running a play,” he said. “It sped the game up.”

During a huddle, Hernandez said, “There was a little bit of personal interaction (between players). A kid would come to the sideline and say, ‘Hey coach, something’s wrong with so-and-so; he’s not lining up right, or he’s forgetting where to go. … That source of information has disappeared on the high school level.”

Hernandez said problems also occur when teams with a disproportionate number of players — or skill levels — are pitted against each other.

“In some of the tragic stories, one of the common denominators you see is programs that are small in numbers, where you might have 22 kids on the total roster,” he said. “When you’re down to those numbers, there’s obviously going to be players playing both (positions),” leading to player fatigue, in which the potential for injuries is exacerbated.

Hayden said the La Jolla High freshmen and junior varsity teams had “overall kind of small squads” last season.

“Many of the players had to play both offense and defense,” he said, noting that his son, quarterback Kenny Hayden, was frequently pulled in to play cornerback or safety or defensive linebacker.

“A lot of the boys have to play both ways just in order to be able to field a team,” Hayden said.

Hernandez also said inadequate player preparation or a too-many-cooks-in-the-kitchen coaching approach can increase risks.

In a recent, unpublished article Hernandez makes the case that a new statewide law that went into effect Jan. 1 (AB 2127) — which limits middle school and high school students to 90 minutes of full-contact football drills twice per week and bans full-contact practice during the off-season — has the potential to decrease game safety, by making inexperienced players vulnerable on the field.

“Practice scheduling decisions are probably best left up to the coaches as they are the ones who are best able to make decisions that will be tailored to meet the needs of their own individual players, while taking into consideration any special constraints that are associated with their programs,” Hernandez writes. “A one-size-fits-all approach, such as that provided by AB 2127, is probably not the best way to go about making high school football as safe as possible for the student athletes.”

Another change Hernandez notes from the time he started coaching football in the 1970s until now is the amount of private coaching students are receiving — something he said he saw a lot of at La Jolla High (and other schools), which can prove problematic.

“Back then nobody coached your kids except for yourself and your (assistant) coaches,” he said. “Kids nowadays are being coached by everybody. Personal trainers, personal coaches and elite camps … (have) made it difficult for many coaches to administer their own programs. Kids are being taught to do one thing by a personal coach and then they’re coming back to your program and maybe what they were taught there isn’t necessarily in the best interest of (your program). It doesn’t help the cohesiveness of your team and your unit.”

Despite the increased awareness of head trauma and brain injury, Hernandez maintains, “high school football isn’t anywhere near as dangerous as people are making it out to be.

“This is not the NFL. Those guys are big, and they’re fast,” he said, though noting, “you’re starting to get (high school) teams that resemble junior college teams sometimes with the number and the size of some of the kids.”

To combat injured players succumbing to potential pressure to “suck it up” for the sake of the team, Hernandez said he reminded his students that they were a family, asking, “ ‘How many of you would let one of your brothers do something that’s going to endanger their life … like suffering some type of second impact and dying from a concussion?’ … I said, ‘It’s no different with your football family. You guys are like brothers on the field, and if you see something like that that’s going on, it’s not about ratting out your teammate or your teammate wanting to stay on the field. ’ ”

Beyond physical injury, Hernandez said, psychological effects of the game caused by an increased pressure to perform, are also worth addressing.

“In many ways, high school athletes — especially the ones that look like they’re going to (get a) scholarship … or go to the next level — are being treated the way professional athletes have been treated for many years,” he said. “You’ve got high school games being televised on ESPN; kids have press conferences now to announce their signing. They’re in Sports Illustrated. There’s nothing really wrong with that per se … (but) I’ve always said this: If you are going to start treating kids like adults, you’re going to have adult problems.”

District update

According to Ursula Kroemer, SDUSD public information officer, a new district-wide concussion protocol created by SDUSD physician Dr. Howard Taras will be presented in April to associated student body teams, athletic directors and other physical education and coaching staff district-wide.

“As the medical and athletic communities continue to learn more about preventing, detecting and safely and fully recovering from injuries — especially head injuries and concussions, and at all grade levels — we will continue to review our practices so they are always best practices,” Kroemer replied, via e-mail. “We are also working with the Chargers organization to support and deepen collaboration, training and understanding with players, trainers and coaches alike.”